SubstanceAbuseandMentalHealth

Center for Substance Abuse Treatment 

Substance Ab

Treatment an

Domestic Vi

Treatment Improvement Protocol (TIP

25 
Blue Lines FPO

(for spine positioning)

Substance Abuse Treatment and Domestic Violence CSAT (TIP)

25
Substance 

Abuse 

Treatment and 

Domestic 

Violence 

Treatment Improvement Protocol (TIP) Series 

25 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment

'LSOI'LIVV]6SEH

Rockville, MD 20857 
Acknowledgments 

This publication was prepared under contract 

number 270-95-0013 by the Knowledge 

Application Program (KAP), a Joint Venture of 

The CDM Group, Inc., and JBS International, 

Inc., for the Substance Abuse and Mental Health 

Services Administration (SAMHSA), U.S. 

Department of Health and Human Services 

(HHS). Sandra Clunies, M.S., ICADC, served as 

the Contracting Officer’s Representative. 

Disclaimer

The opinions expressed herein are the views of 

the consensus panel members and do not 

necessarily reflect the official position of 

SAMHSA or HHS. No official support of or 

endorsement by SAMHSA or HHS for these 

opinions or for the instruments or resources 

described are intended or should be inferred. 

The guidelines presented should not be 

considered substitutes for individualized client 

care and treatment decisions. 

Public Domain Notice

All material appearing in this report is in the 

public domain and may be reproduced or 

copied without permission from SAMHSA. 

Citation of the source is appreciated. However, 

this publication may not be reproduced or 

distributed for a fee without the specific, written 

authorization of the Office of Communications, 

SAMHSA, HHS. 

Electronic Access and Printed Copies 

This publication may be ordered for free from 

SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov. Or, please call 

SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español). The document can be 

downloaded from the KAP Web site at 

http://kap.samhsa.gov. 

Recommended Citation

Center for Substance Abuse Treatment. 

Substance Abuse Treatment and Domestic Violence.

Treatment Improvement Protocol (TIP) Series, 

No. 25. HHS Publication No. (SMA) 12-4076.

Rockville, MD: Substance Abuse and Mental 

Health Services Administration, 1997. 

Originating Office 

Quality Improvement and Workforce 

Development Branch, Division of Services 

Improvement, Center for Substance Abuse 

Treatment, Substance Abuse and Mental Health 

Services Administration, 1 Choke Cherry Road, 

Rockville, MD 20857. 

HHS Publication No. (SMA) 12-4076

First Printed 1997 

Revised 2000, 2002, 2003, 2005, 2008, and 2012
iii

Contents 

What Is a TIP?............................................................................................................................................................ v 

Editorial Advisory Board.......................................................................................................................................vii 

Consensus Panel ...................................................................................................................................................... ix 

Foreword.................................................................................................................................................................... xi

Executive Summary and Recommendations .................................................................................................... xiii

Scope of the TIP................................................................................................................................................... xiii 

Summary of Recommendations........................................................................................................................ xiv 

Supplemental Materials ...................................................................................................................................xviii 

Chapter 1—Effects of Domestic Violence on Substance Abuse Treatment....................................................1 

Defining the Problem .............................................................................................................................................2 

Identifying the Connections..................................................................................................................................3 

A New Way of Thinking........................................................................................................................................7 

Chapter 2—Survivors of Domestic Violence: An Overview .............................................................................9

Entering the Treatment System ............................................................................................................................9 

Treatment Planning for the Survivor Client .....................................................................................................11 

Issues for Children of Survivors .........................................................................................................................17 

Summary................................................................................................................................................................19 

Case Scenario: Profile of a Survivor ...................................................................................................................20 

Chapter 3—Batterers: An Overview.....................................................................................................................25

Perspectives on Substance Abuse and the Batterer Client..............................................................................25 

Profiling Batterers.................................................................................................................................................26 

Treatment Issues for the Substance-Abusing Batterer.....................................................................................32 

Chapter 4—Screening and Referral of Survivors and Batterers in Substance 

Abuse Treatment Programs.............................................................................................................................

 

.37 

Screening................................................................................................................................................................37 

Methods of Screening for Domestic Violence: Survivors................................................................................38 

Screening for Domestic Violence: Batterers ......................................................................................................42 

Screening for Presence of Child Abuse..............................................................................................................44 

Referral...................................................................................................................................................................45 
Contents 

iv

Appendix G—Field Reviewers ...........................................................................................................................149

Treatment Concerns for Survivors and Batterers.............................................................................................48 

Chapter 5—Legal Issues .........................................................................................................................................51

Federal Law ...........................................................................................................................................................51 

Local Laws: Civil Protection and Restraining Orders .....................................................................................53 

Other Legal Issues ................................................................................................................................................54 

Communicating With the Legal System............................................................................................................59 

Dealing With the Police .......................................................................................................................................60 

Conclusion .............................................................................................................................................................61 

Chapter 6—Linkages: A Coordinated Community Response.........................................................................63 

Systemic Reform ...................................................................................................................................................64 

Community-Based Linkages ...............................................................................................................................65 

Identifying Critical Linkages, Barriers, and Opportunities ............................................................................68 

Establishing a Linkage Relationship ..................................................................................................................68 

Other Linkage Strategies......................................................................................................................................76 

Examples of Effective Community-Based Linkages ........................................................................................77 

Coordination of Care............................................................................................................................................79 

Appendix A—Bibliography...................................................................................................................................81

Appendix B—Federal Confidentiality Regulations ..........................................................................................95 

Types of Programs Covered by the Regulations ..............................................................................................95 

Federal Confidentiality Laws..............................................................................................................................96 

Rules Governing Communication of Information ...........................................................................................99 

Five Other Exceptions to the General Confidentiality Rule..........................................................................107 

Other Requirements ...........................................................................................................................................111 

Conclusion ...........................................................................................................................................................111 

Endnotes ..............................................................................................................................................................111 

Appendix C—Instruments ...................................................................................................................................115

Abuse Assessment Screen (English Version)....................................................................................................116 

Encuesta Sobre El Maltrato (Spanish Version)..................................................................................................117 

Danger Assessment ............................................................................................................................................119 

The Psychological Maltreatment of Women Inventory (PMWI)..................................................................121 

The Revised Conflict Tactics Scale (CTS2) (for Couples) ..............................................................................123 

Appendix D—Sample Personalized Safety Plan for Domestic Violence Survivors.................................127

Personalized Safety Plan....................................................................................................................................128 

Telephone Numbers I Need to Know: .............................................................................................................133 

Appendix E—Hotlines and Other Resources for Domestic Violence and Related Issues....................

Hotlines.... ...................

...135

...................................................................................................................................... ...135 

General Resources ..............................................................................................................................................136 

Other Services .....................................................................................................................................................139 

Appendix F—Resource Panel..............................................................................................................................147 
v

What Is a TIP? 

Treatment Improvement Protocols (TIPs) are 

developed by the Center for Substance Abuse 

Treatment (CSAT), part of the Substance Abuse 

and Mental Health Services Administration 

(SAMHSA) within the U.S. Department of 

Health and Human Services (HHS). Each TIP 

involves the development of topic-specific bestpractice guidelines for the prevention and 

treatment of substance use and mental 

disorders. TIPs draw on the experience and 

knowledge of clinical, research, and 

administrative experts of various forms of 

treatment and prevention. TIPs are distributed 

to facilities and individuals across the country. 

Published TIPs can be accessed via the Internet 

at http://kap.samhsa.gov. 

Although each consensus-based TIP 

strives to include an evidence base for the 

practices it recommends, SAMHSA recognizes 

that behavioral health is continually evolving, 

and research frequently lags behind the 

innovations pioneered in the field. A major goal 

of each TIP is to convey "front-line" information 

quickly but responsibly. If research supports a 

particular approach, citations are provided. 

Editorial Advisory Board 

Karen Allen, Ph.D., R.N., C.A.R.N. 

President of the National Nurses Society on 

Addictions 

Associate Professor 

Department of Psychiatry, Community 

Health, and Adult Primary Care 

University of Maryland 

School of Nursing 

Baltimore, Maryland 

Richard L. Brown, M.D., M.P.H. 

Assistant Professor 

Department of Family Medicine 

University of Wisconsin School of Medicine 

Madison, Wisconsin 

Dorynne Czechowicz, M.D. 

Associate Director 

Medical/Professional Affairs 

Treatment Research Branch 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Rockville, Maryland 

Linda S. Foley, M.A. 

Former Director 

Project for Addiction Counselor Training 

National Association of State Alcohol and 

Drug Directors 

Washington, D.C. 

Wayde A. Glover, M.I.S., N.C.A.C. II 

Director 

Commonwealth Addictions Consultants and 

Trainers 

Richmond, Virginia 

Pedro J. Greer, M.D. 

Assistant Dean for Homeless Education 

University of Miami School of Medicine 

Miami, Florida 

Thomas W. Hester, M.D. 

Former State Director 

Substance Abuse Services 

Division of Mental Health, Mental 

Retardation and Substance Abuse 

Georgia Department of Human Resources 

Atlanta, Georgia 

Gil Hill 

Director 

Office of Substance Abuse 

American Psychological Association 

Washington, D.C. 

Douglas B. Kamerow, M.D., M.P.H. 

Director 

Office of the Forum for Quality and 

Effectiveness in Health Care 

Agency for Health Care Policy and Research 

Rockville, Maryland 

Stephen W. Long 

Director 

Office of Policy Analysis 

National Institute on Alcohol Abuse and 

Alcoholism 

Rockville, Maryland 

Richard A. Rawson, Ph.D. 

Executive Director 

Matrix Center 

Los Angeles, California 

vii
Editorial Advisory Board 

viii

Ellen A. Renz, Ph.D. 

Former Vice President of Clinical Systems 

MEDCO Behavioral Care Corporation 

Kamuela, Hawaii 

Richard K. Ries, M.D. 

Director and Associate Professor 

Outpatient Mental Health Services and Dual 

Disorder Programs 

Harborview Medical Center 

Seattle, Washington 

Sidney H. Schnoll, M.D., Ph.D. 

Chairman 

Division of Substance Abuse Medicine 

Medical College of Virginia 

Richmond, Virginia 
ix

Consensus Panel 

Co-Chairs 

Patricia Anne Fazzone, R.N., D.N.Sc., M.P.H., 

C.S. 

Assistant Professor 

School of Nursing 

Kansas University Medical Center 

Kansas City, Kansas 

John Kingsley Holton, Ph.D. 

Site Director 

Maternal and Child Health 

School of Public Health 

Harvard University 

Chicago, Illinois 

Beth Glover Reed, Ph.D. 

Associate Professor 

School of Social Work and Program 

in Women’s Studies 

University of Michigan 

Ann Arbor, Michigan 

Workgroup Leaders 

Larry Bennett, Ph.D. 

Assistant Professor 

Jane Addams College of Social Work 

University of Illinois at Chicago 

Chicago, Illinois 

Vivian Brown, Ph.D. 

President and Chief Executive Officer 

PROTOTYPES 

Culver City, California 

Candace M. Shelton, M.S., C.A.D.A.C. 

Clinical Director 

Guiding Star Lodge 

Indian Rehabilitation, Inc. 

Phoenix, Arizona 

Kimberly Smith-Cofield, M.Ed. 

Executive Director 

Casa Myrna Vasquez, Inc. 

Boston, Massachusetts 

Carey Tradewell, M.S., C.A.D.C. III 

President and Chief Executive Officer 

Milwaukee Women’s Center, Inc. 

Milwaukee, Wisconsin 

Oliver J. Williams, Ph.D. 

Associate Professor 

Graduate School of Social Work 

University of Minnesota 

Minneapolis, Minnesota 

Panelists 

Roland Byrd, C.C.D.C., M.A. 

Counselor 

Montana Chemical Dependency Center 

Montana State Department of Public Health 

and Human Services 

Butte, Montana 

Lonnie Hazlewood, M.S.H.P. 

Managing Partner 

Austin Stress Clinic, Ltd. 

Austin, Texas 
Consensus Panel 

x

Judy Howard, M.D. 

Professor of Pediatrics 

Developmental Studies Program 

Department of Pediatrics 

School of Medicine 

University of California at Los Angeles 

Los Angeles, California 

Kate Malliarakis, C.N.P., M.S.M., N.C.A.D.C. II 

American College of Nurse Practitioners 

Arlington, Virginia 

Jan Mickish, Ph.D. 

Executive Director 

Colorado Domestic Violence Coalition 

Denver, Colorado 

Brenda Miller, Ph.D. 

Deputy Director 

Research Institute on Addictions 

Buffalo, New York 

Beth E. Richie, Ph.D. 

Associate Professor 

Program in Public Health 

Hunter College 

City University of New York 

New York, New York 

Eric D. Wish, Ph.D. 

Director 

Center for Substance Abuse Research 

University of Maryland at College Park 

College Park, Maryland 

Diane Zainhofsky 

Executive Director 

Abused Adult Resource Center 

Bismarck, North Dakota 
xi 

Foreword 

he Treatment Improvement Protocol (TIP) 

series fulfills the Substance Abuse and 

Mental Health Services Administration’s 

(SAMHSA’s) mission to improve prevention and 

treatment of substance use and mental disorders 

by providing best practices guidance to clinicians, 

program administrators, and payers. TIPs are the 

result of careful consideration of all relevant 

clinical and health services research findings, 

demonstration experience, and implementation 

requirements. A panel of non-Federal clinical 

researchers, clinicians, program administrators, 

and patient advocates debates and discusses their 

particular area of expertise until 

they reach a consensus on best practices. This 

panel’s work is then reviewed and critiqued by 

field reviewers. 

The talent, dedication, and hard work that TIPs 

panelists and reviewers bring to this highly 

participatory process have helped bridge the gap 

between the promise of research and the needs of 

practicing clinicians and administrators to serve, 

in the most scientifically sound and effective ways, 

people in need of behavioral health services. We 

are grateful to all who have joined with us to 

contribute to advances in the behavioral health 

field. 

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

Peter J. Delany, Ph.D., LCSW‐C, RADM, USPHS

Director

Center for Substance Abuse Treatment  

Substance Abuse and Mental Health Services Administration   

   

T 

xiii

Executive Summary and 

Recommendations 

toward a more integrated delivery system that 

can provide the appropriate holistic care to their 

clients who suffer from both of these complex, 

intertwined problems. 

Scope of the TIP 

Domestic violence is the use of intentional verbal, 

psychological, or physical force by one family 

member (including an intimate partner) to 

control another. This TIP focuses only on men 

who abuse their female partners (batterer 

clients) and women who are battered by their 

male partners (survivor clients). Child abuse 

and neglect, elder abuse, women’s abuse of men, 

and domestic violence within same-sex 

relationships are important issues that are not 

addressed in depth in this document, largely 

because each requires separate comprehensive 

review. Other patterns of domestic violence 

outside the scope of this TIP are abused women 

who in turn abuse their children or react 

violently to their partners’ continued attacks and 

adult or teenage children who abuse their 

parents. 

Researchers have found that one fourth to 

one half of men who commit acts of domestic 

violence also have substance abuse problems 

(Gondolf, 1995; Leonard and Jacob, 1987; Kantor 

and Straus, 1987; Coleman and Straus, 1983; 

Hamilton and Collins, 1981; Pernanen, 1976) and 

that a sizable percentage of convicted batterers 

S ubstance Abuse Treatment and Domestic 

Violence is one of the most ambitious 

documents in the Treatment Improvement 

Protocol (TIP) series. The Consensus Panel 

responsible for developing this TIP aimed to 

open a line of communication between two 

fields that have worked largely in isolation from 

each other, despite the considerable overlap in 

their client populations. Because both the 

domestic violence and substance abuse 

treatment fields are relatively young and new to 

each other, neither has yet consistently 

implemented programs that facilitate 

interagency coordination and cooperation. Basic 

differences in philosophy and terminology have 

also blocked the collaborative care that the 

Consensus Panel considers critical for treating 

substance-abusing clients who are survivors or 

perpetrators of violence. 

This TIP primarily represents the views of 

domestic violence experts. Panel members 

combined their hard-won experience working 

with survivors and perpetrators of domestic 

violence with research literature from both 

disciplines to create an integrated knowledge 

base about substance abuse and domestic 

violence and to outline a system of integrated 

care. For some providers, implementing the 

collaborative model of service delivery 

described in the TIP may prove untenable at this 

time. It is the Panel’s hope, however, that the 

suggestions presented will help providers move 
Executive Summary and Recommendations 

xiv

were raised by parents who abused drugs or 

alcohol (Bureau of Justice Statistics, 1994). 

Studies also show that women who abuse 

alcohol and other drugs are more likely to be 

victims of domestic violence (Miller et al., 1989). 

The primary purpose of this document is to 

provide the substance abuse treatment field 

with an overview of domestic violence so that 

providers can understand the particular needs 

and behaviors of batterers and survivors as 

defined above and tailor treatment plans 

accordingly. This requires an understanding not 

only of clients’ issues but also of when it is 

necessary to seek help from domestic violence 

experts. The TIP also may prove useful to 

domestic violence support workers whose 

clients suffer from substance-related problems. 

As the TIP makes clear, each field can benefit 

enormously from the expertise of the other, and 

cooperation and sharing of knowledge will pave 

the way for the more coordinated system of care 

discussed in Chapter 6. Future publications will 

examine those aspects of the problem that 

concern such special populations as adolescent 

gang members, the elderly, gay men and 

lesbians, and women who batter. The first of 

these is an upcoming TIP that addresses the 

connections between substance abuse and child 

abuse and neglect. 

Summary of 

Recommendations 

Because there has been so little study of the 

connections between the two fields, 

recommendations in this TIP are largely based 

on the clinical experience of Consensus Panel 

members. Studies, mostly in the domestic 

violence field, are cited when appropriate. 

Chapter 1 establishes the connections 

between substance abuse and domestic violence. 

While there is no direct cause-and-effect link, 

the use of alcohol and other drugs by either 

partner is a risk factor for domestic violence. 

The Consensus Panel concludes that failure to 

address domestic violence issues among 

substance abusers interferes with treatment 

effectiveness and contributes to relapse. 

Therefore, the Panel recommends that substance 

abuse treatment programs screen all clients for 

current and past domestic violence, including 

childhood physical and sexual abuse. When 

possible, domestic violence programs should 

screen clients for substance abuse. (Screening 

instruments and techniques for identifying 

domestic violence appear in Chapters 2, 3, and 4 

as well as Appendix C.) 

Screening, Referral, and 

Treatment of Survivor Clients 

And Batterer Clients 

Chapters 2 and 3 provide an overview of, 

respectively, survivor clients and batterer 

clients, each of whom present complex 

treatment challenges. Chapter 4 builds on this 

information and discusses screening and referral 

in more detail. Though Chapters 2 and 3 serve 

primarily to introduce these populations and 

their specific problems, recommendations for 

treatment do appear in those discussions. To 

provide a clearer picture of the process, 

therefore, recommendations from Chapters 2, 3, 

and 4 are presented below to follow each type of 

client chronologically through screening, 

referral, and treatment. 

Survivors 

 If a client believes that she is in immediate 

danger from a batterer, the treatment 

provider should respond to this situation 

before addressing any other issues and, if 

necessary, should suspend the screening 

interview for this purpose. The provider 

should refer the client to a domestic violence 

program and possibly to a women’s shelter 

and to legal services. 

 To determine if a woman is a victim of 

domestic violence, look for physical injuries, 
Executive Summary and Recommendations 

especially patterns of untreated injuries to 

the face, neck, throat, and breasts. Other 

indicators may include a history of relapse or 

noncompliance with substance abuse 

treatment plans; inconsistent explanations for 

injuries and evasive answers when 

questioned about them; complications in 

pregnancy (including miscarriage, premature 

birth, and infant illness or birth defects); 

stress-related illnesses and conditions (such 

as headache, backache, chronic pain, 

gastrointestinal distress, sleep disorders, 

eating disorders, and fatigue); anxietyrelated conditions (such as heart palpitations, 

hyperventilation, and panic attacks); sad, 

depressed affect; or talk of suicide. 











Always interview clients about domestic 

violence in private. 

Ask about violence using concrete examples 

and hypothetical situations rather than 

vague, conceptual questions. 

In framing screening questions, it is 

extremely important to convey to the 

survivor that there is no justification for the 

battering and that substance abuse is no 

excuse. Questions such as, “Does he blame 

his violence on his alcohol or drug use?” or, 

“Does he use alcohol (or other drugs) as an 

excuse for his violence?” serve the dual 

purpose of determining whether the client’s 

partner may be a substance abuser while 

reinforcing to her that substance abuse is not 

the real reason for his violence. 

Though addictions counselors can be trained 

relatively easily to screen clients for domestic 

violence, once it is confirmed that a client has 

been or is being battered, domestic violence 

experts should be contacted. Violence 

assessment requires in-depth knowledge and 

skill and should be conducted by a domestic 

violence expert. 

Providers should be alert to the possibility 

that the mother of a child who has been or is 

being abused by her partner is also being 

abused herself. 















The provider should contact a forensics 

expert to document the physical evidence of 

battering. 

Once the client has entered substance abuse 

treatment, a treatment plan that includes a 

relapse prevention plan and a safety plan 

(see Appendix D) should be developed. 

Survivors appear to benefit by participating 

in same-sex treatment groups that do not use 

confrontational techniques. 

Survivors can be asked to sign a “no-contact 

contract” agreeing not to communicate with 

their batterers for the duration of treatment. 

Referrals should be made whenever 

appropriate for psychotherapy and 

specialized counseling. Even so, staff 

training in this area is important so that 

treatment providers can respond effectively 

in a crisis. 

Should a client decide to relocate to another 

community, she should be referred to the 

appropriate programs within that 

community. 

Because batterers in treatment frequently 

harass their partners by circumventing 

program rules and threatening them by 

phone, by mail, and by sending messages 

through other, approved visitors, telephone 

and visitation privileges should be carefully 

monitored for identified batterers and 

survivors in residential substance abuse 

treatment programs. 

Batterers 





A discussion of family relationships is an 

element of all substance abuse screening 

interviews. Use this component of the 

interview to address the issue of domestic 

violence with male clients. 

To initially gauge the possibility that a client 

is being abusive toward his family members, 

the interviewer can ask whether he thinks 

xv
Executive Summary and Recommendations 

xvi

violence against a partner is justified in some 

situations, using a third person example. 











Ask specific, concrete questions (e.g., “What 

happens when you lose your temper?”). 

Define violence (e.g., “When you hit her, was 

it a slap or a punch?”, “Do you take her car 

keys away?”, “Damage her property?”, 

“Threaten to hurt or kill her?”). 

Once it has been confirmed that a client is a 

batterer, the provider should contact a 

domestic violence expert, either for referral 

or consultation. Treatment providers should 

collaborate with a batterers’ program to 

ensure that an assessment of dangerousness 

is performed. 

Be direct and candid; avoid euphemisms 

such as, “Is your relationship with your 

partner troubled?” Instead, talk about “his 

violence” and keep the focus on “his 

behavior.” 

Become familiar with batterers’ excuses for 

their behavior: 

♦ Minimizing: “I only pushed her,” “She 

bruises easily,” “She exaggerates.” 

♦ Citing good intentions: “She gets hysterical 

so I have to slap her to calm her down.” 

♦ Use of alcohol and drugs: “I’m not myself 

when I drink.” 

♦ Claiming loss of control: “Something 

snapped,” “I can only take so much,” “I 

was so angry, I didn’t know what I was 

doing.” 

♦ Blaming the partner: “She drove me to it,” 

“She really knows how to get to me.” 

♦ Blaming someone or something else: “I was 

raised that way,” “My probation officer is 

putting a lot of pressure on me,” “I’ve 

been out of work.” 





In asking screening questions, substance 

abuse treatment providers must be careful 

not to enable a batterer to place the blame for 

the battering on the victim or the drug. 

Domestic violence staff sometimes interview 

the batterer’s partner in order to obtain 

salient information about his dangerousness 

to himself, his partner, and others. This type 

of collateral interviewing is quite different 

from that practiced in the substance abuse 

treatment setting and should only be 

performed by someone with specialized skills 

and expertise in domestic violence. 











Treatment providers should try to ensure the 

safety of those who have been or may 

become a perpetrator client’s victims, in 

particular his partner and children, during 

any crisis that precedes or occurs during the 

course of his treatment. 

Treatment providers should mandate that 

batterers in treatment sign a “no-violence 

contract” that states that the client will, 

among other stipulations, refrain from using 

violence both inside and outside the 

program. 

Treatment providers should elicit the 

following information about the relationship 

between the substance abuse and the violent 

behavior: 

♦ Exactly when in relation to substance 

abuse the violence occurs 

♦ How much of the violent behavior occurs 

while the batterer is drinking or on other 

drugs 

♦ What substances are used before the 

violent act 

♦ What feelings precede and accompany the 

use of alcohol or other drugs 

♦ Whether alcohol or other drugs are used 

to “recover” from the violent incident. 

After identifying the chain of events that 

precede or trigger violent episodes, provider 

and client should together formulate 

strategies for modifying those behaviors and 

recognizing emotions that contribute to 

violent behavior. 

Providers should be alert to signs that 

batterer clients are misinterpreting the 12-

Step philosophy to justify or excuse 

continued violence. Another danger is that 
Executive Summary and Recommendations 

xvii

they will call their victims “codependent” in 

order to shift blame for the battering onto the 

woman. 

 Referrals to self-help aftercare groups like 

Batterers Anonymous (BA) groups should be 

made only after the client has completed a 

batterers’ intervention program and has 

remained nonviolent for a specified period of 

time. 

Screening for Child Abuse 

 During the initial screening of a client, the 

Consensus Panel recommends that the 

interviewer should attempt to determine 

whether the client’s children have been 

physically harmed and whether their 

behavior has changed (e.g., they have 

become mute or they scream or cry). 

 Inquiries into possible child abuse should not 

occur until notice of the limitations of 

confidentiality as defined in Title 42, Part 2, 

of the Code of Federal Regulations has been 

given and the client has acknowledged 

receipt of it in writing. Clients also must be 

informed that mandated reporters, a 

category that includes substance abuse 

treatment providers, are required to notify a 

children’s protective services (CPS) agency if 

they suspect child abuse or neglect. 

 The substance abuse treatment provider 

should not perform an assessment of 

children for abuse or incest; this function 

should be performed by personnel with 

special expertise. The treatment provider 

should, however, note any indications of 

whether abuse of children is occurring in a 

client’s household and pass on what he or 

she finds to the appropriate agency. 

Indications of child abuse that can be gleaned 

in a client interview include: 

♦ Whether CPS has been involved with 

anyone who lives in the home 

♦ Children’s behaviors such as bedwetting 

and sexual acting out 

♦ “Special” closeness between a child and 

other adults in the household 

♦ The occurrence of “blackouts”: Batterers 

often claim blackouts for the period of 

time during which violence occurs. 

 If a treatment provider suspects that the 

child of a client has been a victim of violence, 

he or she must refer the child to a health care 

provider immediately. If it appears that the 

parent will not take the child to a doctor 

(who is required by law to report the 

suspected abuse), the provider must contact 

home health services or CPS. 

 The treatment provider must assess the 

impact on a survivor client of reporting 

suspected or confirmed child abuse or 

neglect and develop a safety plan if 

necessary. 

Legal Issues 

Chapter 5 discusses the Federal, State, and local 

regulations that bear upon domestic violence, 

particularly the 1994 Violence Against Women 

Act (VAWA). Also covered are issues such as 

restraining orders, duty to warn, the legal 

obligation to report threats and past crimes, and 

confidentiality. 

 Substance abuse treatment providers should 

be familiar with relevant Federal, State, and 

local regulations as well as with the legal 

resources available to victims of domestic 

abuse. 

 Treatment providers must fulfill their legal 

obligation to report domestic violence and 

suspected child abuse and neglect. 

 Treatment providers should never discuss 

their clients with lawyers, law enforcement 

officers, or anyone else without the client’s 

permission. Only certain types of subpoenas 

and warrants (discussed in Chapter 5) 

require that records be turned over. 
Executive Summary and Recommendations 

xviii

 Treatment providers should coordinate their 

efforts with domestic violence workers to 

ensure that clients avoid problems under the 

provisions of “welfare reform” (The 

Personal Responsibility and Work 

Opportunity Reconciliation Act of 1996).

Establishing Linkages 

Chapter 6 recommends linkages between 

substance abuse treatment programs and 

domestic violence programs and among other 

agencies as well. A model for systemic reform is 

provided in addition to suggestions for 

implementing community-based systems of 

coordinated care. 

Systemic reform 

 Treatment providers and domestic violence 

support workers should foster a new way of 

thinking about linkages on the systems level. 

Both fields would benefit from a coordinated 

system that could address the multiple social 

service needs of substance-abusing victims 

and perpetrators of violence. 

 A new mechanism should be developed at 

the State level to coordinate planning among 

disparate agencies based on client needs 

assessments; devise financing strategies that 

would allow for blended funding and strive 

for equitable allocation of resources among 

agencies; and establish a vehicle for resolving 

any problems that emerge in the course of 

providing integrated services. 

 Linkages should address needs for housing, 

child care, emotional and physical safety, 

health and mental health care, economic 

stability, legal protection, vocational and 

educational services, parenting training, and 

support and peer counseling, among others. 

 The services provided should be holistic, 

flexible, collaborative, coordinated, and 

accountable.

 Linkages should address needs for housing, 

child care, emotional and physical safety, 

health and mental health care, economic 

stability, legal protection, vocational and 

educational services, parenting training, and 

support and peer counseling, among others. 

 Federal and State policymakers should 

consider a series of demonstrations designed 

to test the feasibility of changing the current 

system to institutionalize a formal 

administrative structure for promoting and 

supporting collaboration and linkages 

among social service programs.

Community linkages 

 In the absence of systemic reform, substance 

abuse treatment providers, domestic violence 

experts, and legal or other relevant 

professionals should plan treatment 

collaboratively. 

 A legal professional or legal service is the 

best resource for resolving problems that 

pertain to individual clients’ involvement in 

the justice system and may be the best 

resource for information and guidance 

regarding VAWA. 

 Initial meetings between organizations trying 

to establish linkages should include 

discussion of the origins of both communities 

in order to help each understand the other’s 

beliefs and attitudes. 

 The choice of outcomes to measure must be 

made carefully: The definition of success 

must be palatable to funders and third party 

payers as well as experts in the field. 

 Credentialing processes for substance abuse 

treatment providers should assess their 

ability to screen for violence and create a 

safety plan, as well as their knowledge of 

legal issues related to domestic violence. 

Supplemental Materials 

The TIP also includes resources to help 

providers implement the recommendations in 

the TIP. Appendix B explores how the Federal 
Executive Summary and Recommendations 

xix

confidentiality regulations affect treatment 

decisions for batterer and survivor clients. 

Appendix C is a collection of instruments to 

screen for domestic violence and to assess a 

batterer’s dangerousness. Appendix D 

reproduces a safety plan that a provider can use 

with survivor clients, and Appendix E lists 

national programs and hotlines concerning 

domestic violence. 
1

1 Effects of Domestic Violence on 

Substance Abuse Treatment 

separate comprehensive review. Other patterns 

of domestic violence outside the scope of this 

TIP are abused women who in turn abuse their 

children or react violently to their partners’ 

continued attacks and adult or teenage children 

who abuse their parents. 

The primary purpose of this document is to 

provide the substance abuse treatment field 

with an overview of domestic violence so that 

providers can understand the particular needs 

and behaviors of batterers and survivors as 

defined above and tailor treatment plans 

accordingly. This requires an understanding not 

only of clients’ issues but also of when it is 

necessary to seek help from domestic violence 

experts. The TIP also may prove useful to 

domestic violence support workers whose 

clients suffer from substance-related problems. 

As the TIP makes clear, each field can benefit 

enormously from the expertise of the other, and 

cooperation and sharing of knowledge will pave 

the way for the more coordinated system of care 

discussed in Chapter 6. Future publications will 

examine aspects of the problem that concern 

such special populations as adolescent gang 

members, the elderly, gay men and lesbians, and 

women who batter. The first of these is an 

upcoming TIP that addresses substance abuse 

by victims of child abuse and neglect. 

D omestic violence is the use of 

intentional emotional, psychological, 

sexual, or physical force by one family 

member or intimate partner to control another. 

Violent acts include verbal, emotional, and 

physical intimidation; destruction of the victim’s 

possessions; maiming or killing pets; threats; 

forced sex; and slapping, punching, kicking, 

choking, burning, stabbing, shooting, and killing 

victims. Spouses, parents, stepparents, children, 

siblings, elderly relatives, and intimate partners 

may all be targets of domestic violence (Peace at 

Home, 1995). (See Figure 1-1.) 

This Treatment Improvement Protocol (TIP) 

focuses on heterosexual men who abuse their 

domestic partners and on women who are 

abused by men, because these individuals 

constitute a significant portion of the population 

seeking substance abuse treatment. Though 

domestic violence encompasses the range of 

behaviors above, the TIP focuses more on 

physical, or a combination of physical, sexual, 

and emotional, violence. Therefore men who 

abuse their partners are referred to throughout 

as batterers; women who are abused are called 

survivors. Child abuse and neglect, elder abuse, 

women’s abuse of men, and domestic violence 

within same-sex relationships are important 

issues that are not addressed in depth in this 

document, largely because each requires 
Chapter 1 

2

Defining the Problem 

In the United States, a woman is beaten every 15 

seconds (Dutton, 1992; Gelles and Straus, 1988). 

At least 30 percent of female trauma patients 

(excluding traffic accident victims) have been 

victims of domestic violence (McLeer and 

Anwar, 1989), and medical costs associated with 

injuries done to women by their partners total 

more than $44 million annually (McLeer and 

Anwar, 1987). Much like patterns of substance 

abuse, violence between intimate partners tends 

to escalate in frequency and severity over time 

(Bennett, 1995). “Severe physical assaults of 

women occur in 8 percent to 13 percent of all 

marriages; in two-thirds of these relationships, 

the assaults reoccur (Dutton, 1988)” (Bennett, 

1995, p. 760). In 1992, an estimated 1,414 

females were killed by “intimates,” a finding 

that underscores the importance of identifying 

and intervening in domestic violence situations 

as early as possible (Bureau of Justice Statistics, 

1995). 

Source: Casa Myrna Vazquez, Inc. Adapted from the Domestic Abuse Intervention Project 

by Elba Crespo-Gonzalez. Developed for Casa Myrna Vazquez, Inc., and sponsored by the 

Boston Health Start Initiative, 1993. 
Effects of Domestic Violence 

3

An estimated three million children witness 

acts of violence against their mothers every year, 

and many come to believe that violent behavior 

is an acceptable way to express anger, 

frustration, or a will to control. Some 

researchers believe, in fact, that “violence in the 

family of origin [is] consistently correlated with 

abuse or victimization as an adult” (Bennett, 

1995, p. 765; Hamberger and Hastings, 1986a; 

Kroll et al., 1985). Other researchers, however, 

dispute this claim. The rate at which violence is 

transmitted across generations in the general 

population has been estimated at 30 percent 

(Kaufman and Zigler, 1993) and at 40 percent 

(Egeland et al., 1988). Although these figures 

represent probabilities, not absolutes, and are 

open to considerable interpretation, they 

suggest to some that 3 or 4 of every 10 children 

who observe or experience violence in their 

families are at increased risk for becoming 

involved in a violent relationship in adulthood. 

Identifying the 

Connections 

Researchers have found that one fourth to one 

half of men who commit acts of domestic 

violence also have substance abuse problems 

(Gondolf, 1995; Leonard and Jacob, 1987; Kantor 

and Straus, 1987; Coleman and Straus, 1983; 

Hamilton and Collins, 1981; Pernanen, 1976). A 

recent survey of public child welfare agencies 

conducted by the National Committee to 

Prevent Child Abuse found that as many as 80 

percent of child abuse cases are associated with 

the use of alcohol and other drugs (McCurdy 

and Daro, 1994), and the link between child 

abuse and other forms of domestic violence is 

well established. Research also indicates that 

women who abuse alcohol and other drugs are 

more likely to become victims of domestic 

violence (Miller et al., 1989) and that victims of 

domestic violence are more likely to receive 

prescriptions for and become dependent on 

tranquilizers, sedatives, stimulants, and 

painkillers and are more likely to abuse alcohol 

(Stark and Flitcraft, 1988a). Other evidence of 

the connection between substance abuse and 

family violence includes the following data: 

 About 40 percent of children from violent 

homes believe that their fathers had a 

drinking problem and that they were more 

abusive when drinking (Roy, 1988). 

 Childhood physical abuse is associated with 

later substance abuse by youth (Dembo et al., 

1987). 

 Fifty percent of batterers are believed to have 

had “addiction” problems (Faller, 1988). 

 Substance abuse by one parent increases the 

likelihood that the substance-abusing parent 

will be unable to protect children if the other 

parent is violent (Reed, 1991). 

 A study conducted by the Department of 

Justice of murder in families found that more 

than half of defendants accused of 

murdering their spouses⎯as well as almost 

half of the victims⎯had been drinking 

alcohol at the time of the incident (Bureau of 

Justice Statistics, 1994). 

 Teachers have reported a need for protective 

services three times more often for children 

who are being raised by someone with an 

addiction than for other children (Hayes and 

Emshoff, 1993). 

 Alcoholic women are more likely to report a 

history of childhood physical and emotional 

abuse than are nonalcoholic women 

(Covington and Kohen, 1984; Miller et al., 

1993; Rohsenow et al., 1988; Hein and 

Scheier, 1996). 

 Women in recovery are likely to have a 

history of violent trauma and are at high risk 

of being diagnosed with posttraumatic stress 

disorder (Fullilove et al., 1993). 
Chapter 1 

4

The Societal Context 

Clearly, substance abuse is associated with 

domestic violence, but it is not the only factor. 

As discussed above, witnessing or experiencing 

family violence during childhood is a risk factor 

as is a history of childhood aggression. Another 

factor that must be acknowledged is societal 

norms that indirectly excuse violence against 

women (tacit support for punishing unfaithful 

wives, for example, or stereotyped views of 

women as obedient or compliant) (Kantor and 

Straus, 1987; Reed, 1991; Bennett, 1995; Flanzer, 

1990). 

The overt or covert sexism that contributes to 

domestic violence also bears on connections 

between violence and substance abuse. 

Manifestations of that sexism vary across social 

classes and cultural groups: Some groups more 

than others accept domestic violence or 

intoxication as a way of dealing with frustration 

or venting anger. Though they range from 

subtle to blatant, sexist assumptions persist and 

are reflected by society’s different responses to 

domestic violence and substance abuse among 

men and among women. 

For example, substance abuse treatment 

providers have observed that society tolerates a 

man’s use of alcohol and other drugs more 

readily than a woman’s. They note that 

batterers often blame a woman they have 

victimized for the violence, either implicitly or 

explicitly, and other people, including police, 

judges, and juries, often accept this argument. 

Research suggests that intoxicated victims are 

more likely to be blamed than sober victims and 

that aggression toward an inebriated victim is 

considered more acceptable than aggression 

toward a sober one (Aramburu and Leigh, 1991). 

At least one other research team (Downs et al., 

1993) argues that sexist attitudes may in fact 

contribute to the alcoholism of some women. 

“The alcoholic woman,” they write, “may 

internalize previous negative stigmatization and 

subsequently use alcohol to cope with negative 

feelings resulting from the stigma. Conversely, 

the partner may use the woman’s drinking as a 

rationale to label her negatively” (p. 131). 

Attitudes toward rape are another example 

of how this rationalization works. Even when 

alcohol or other drugs are not involved, women 

victims frequently are assumed to have 

provoked their rapists by the way they behaved 

or dressed. This widely accepted misperception 

is often internalized and accounts for the guilt 

and shame that many rape victims experience. 

Not surprisingly, some victims of rape and other 

violence report using alcohol and other drugs to 

“self-medicate” or anesthetize themselves to the 

pain of their situations. 

The Connection Between Substance 

Abuse and Domestic Violence 

Though experts agree there is a connection 

between the two behaviors, its precise nature 

remains unclear. One researcher writes, 

“Probably the largest contributing factor to 

domestic violence is alcohol. All major theorists 

point to the excessive use of alcohol as a key 

element in the dynamics of wife beating. 

However, it is not clear whether a man is violent 

because he is drunk or whether he drinks to 

reduce his inhibitions against his violent 

behavior” (Labell, 1979, p. 264). 

Another expert (Bennett, 1995) observes that 

[I]f substance abuse affects woman abuse, it 

does so either directly by disinhibiting normal 

sanctions against violence or by effecting 

changes in thinking, physiology, emotion, 

motivation to reduce tension, or motivation to 

increase interpersonal power (Graham, 1980). 

Despite its popularity, the disinhibition model 

of alcohol aggression is often discredited 

because of experiments that have found 

expectation of intoxication a better predictor of 

aggression than intoxication itself (Lang et al., 

1975). 

An alternative to disinhibition, is ‘learned 

disinhibition,’ or expectancy of a drug and 

violence relationship ... Drug and alcohol use 

occur in a cultural context in which behavior 
Effects of Domestic Violence 

5

can be attributed to ‘I was loaded’ 

(MacAndrew and Edgerton, 1969). (p. 761) 

Within this theoretical framework, the 

societal view of substance abusers as morally 

weak and controlled by alcohol or other drugs 

actually serves some batterers: Rather than 

taking responsibility for their actions, they can 

blame their violent acts on the substance(s) they 

are abusing. Although drugs or alcohol may 

indeed be a trigger for violence, the belief that 

the violence will stop once the drinking or drug 

use stops is usually not borne out. The use of 

alcohol or other drugs may increase the 

likelihood that a batterer will commit an act of 

domestic violence⎯because it reduces 

inhibitions and distorts perceptions, because 

alcohol is often used as an excuse for violence, 

and because both alcohol abuse and domestic 

violence tend to follow parallel escalating 

patterns⎯but it does not fully explain the 

behavior (Pernanen, 1991; Leonard and Jacob, 

1987; Steele and Josephs, 1990). The fact remains 

that nondrinking men also attack their partners, 

and for some individuals, alcohol actually 

inhibits violent behavior (Coleman and Straus, 

1983). 

Batterers⎯like survivors⎯often turn to 

substances of abuse for their numbing effects. 

Batterers who are survivors of childhood abuse 

also frequently say that they use drugs and 

alcohol to block the pain and to avoid 

confronting that memory. It is a selfperpetuating cycle: Panel members report that 

batterers say they feel free from their guilt and 

others’ disapproval when they are high. 

The Impact of Violence on 

Substance Abuse Treatment 

Though it cannot be said that substance abuse 

“causes” domestic violence, the fact remains that 

substance abuse treatment programs see 

substantial numbers of batterers and victims 

among their patient populations and 

increasingly are compelled to deal with issues 

related to abuse (Flanzer, 1993). 

As substance abuse treatment programs have 

grown more sophisticated, the treatment offered 

patients has become more comprehensive and 

more effective. Questions about vocational, 

educational, and housing status; coexisting 

mental disorders; and presence of human 

immunodeficiency virus (HIV) and other 

infectious diseases are routinely raised during 

the assessment process. Treatment providers 

now recognize the importance of addressing 

issues that affect clients’ patterns of substance 

abuse (and vice versa) so that these issues do not 

undermine their recovery. Today, mounting 

evidence about the varied associations between 

domestic violence and substance abuse attests to 

the need to add violent behavior and 

victimization to the list of problems that should 

be explored and addressed during treatment. 

Based on their clinical experience, members of 

the Consensus Panel who developed this TIP 

conclude that failure to address domestic 

violence issues interferes with treatment 

effectiveness and contributes to relapse. 

Practitioners in both fields must be attuned 

to the connections between the two problems. 

By sharing knowledge, substance abuse 

treatment providers and domestic violence 

workers can understand the complexity of the 

problem, address their own misperceptions and 

prejudices, and better serve individual 

clients⎯as well as lay the foundation for a 

coordinated community response. Building 

bridges between the fields requires an 

understanding of the way each problem can 

interfere with the resolution of the other and of 

the barriers posed by the two fields’ differing 

program priorities, terminology, and 

philosophy. 
Chapter 1 

6

Barriers To Addressing Domestic 

Violence in the Treatment Setting 

Battering, victimization, and 

treatment effectiveness 

Battering and victimization undermine 

substance abuse treatment in both direct and 

indirect ways. Consensus Panel members report 

that a substance-abusing woman often finds that 

her abusive partner becomes angry or 

threatened when she seeks help, and his 

violence or threats of violence may push her to 

drop out of treatment. Panel members have also 

seen a violent partner sabotage a woman’s 

treatment by appearing at the program and 

threatening physical harm unless she leaves 

with him or by bullying or manipulating her to 

use alcohol or other drugs with him. Another 

variation on this theme occurs when a woman 

manages to continue in treatment, a violent 

episode occurs, and, as part of “making up,” is 

persuaded to take alcohol or other drugs. 

Although these patterns occur in nonviolent 

relationships as well, the threats of physical 

harm, withholding of financial support, or abuse 

directed toward children can lead survivors to 

resort to using substances to buffer their 

distress. For this reason, recovery from a 

substance use disorder may not be possible 

unless client survivors improve their selfesteem, sense of competence, and ability to 

make sound decisions. Survivors must get to 

the point where they can recognize and take 

advantage of their options and alternatives 

before they can replace their substance use with 

positive coping strategies. 

When batterers enter treatment, their 

partners also may subvert their efforts to 

achieve sobriety. Some batterers are less violent 

and easier to handle when they are drunk or 

high. If a batterer is more violent when sober or 

abstinent, his partner may encourage drinking 

or taking drugs. “Enabling” is actually a safety 

measure in these cases. Another complicating 

factor is some women’s perception that they are 

responsible for their partners’ substance abuse, a 

perception that often is reinforced by their 

partners, friends, and family. In the same way 

that they hold themselves culpable for their 

battering, those women believe that their “bad” 

behavior prompts their partners’ use of alcohol 

or other drugs, a position that abusers exploit to 

rationalize their continued substance abuse. 

Program priorities, terminology, 

and philosophy 

The problems of substance abuse and domestic 

violence intersect in destructive ways; 

furthermore, differences in priorities, 

terminology, and philosophy have hampered 

collaboration between providers in the two 

fields. For substance abuse, attaining abstinence 

is a key goal; for domestic violence programs, 

ensuring survivors’ safety is of paramount 

concern. While both goals are valid, the reality 

is that they may be difficult to balance. The 

problem for substance abuse and domestic 

violence staff then lies in the perception that one 

goal invariably must be selected to the exclusion 

of the other for a program to preserve its 

identity and thereby carry out its mission. 

A heightened awareness of the two 

problems, however, reveals that programs can 

forego an “either/or approach,” shift priorities 

to accommodate a client’s situation, and still 

retain program identity and orientation. A 

female substance abuser’s living arrangements, 

for example, may be so dangerous that regular 

attendance at treatment will be impossible until 

safety issues are resolved. In this case, 

substance abuse treatment could be temporarily 

postponed and then reinitiated after a more 

secure environment can be achieved. 

Conversely, some survivors remain in traumatic 

relationships because of their addiction. Their 

batterer is their supplier, and they endure the 

intolerable in order to feed their habit. Delaying 

development of a safety plan until the drug 

problem is addressed could be a more effective 
Effects of Domestic Violence 

7

strategy under those circumstances. Adjusting 

priorities on a case-by-case basis does not 

undermine a particular program’s philosophy; 

instead it recognizes the need for flexibility in 

responding to individual client needs. 

Differences in terminology pose another 

potential barrier to effective networking. 

Domestic violence programs try to avoid 

negative language by using such positive terms 

as empowerment to encourage battered women to 

move forward and build a new life. Denial, 

enabling, codependency, and powerlessness—terms 

widely used in the substance abuse field to 

describe typical client behaviors and aspects of 

recovery—strike some domestic violence 

workers as stigmatizing, repressive, and counter 

to appropriate goals for violence survivors. 

Increasingly, substance abuse is considered a 

brain disorder that deserves treatment in much 

the same way as hypertension and diabetes do. 

In contrast, domestic violence counselors tend to 

distance themselves from medical models that 

imply that survivors are “sick” when, in fact, 

they have been battered by someone else. To 

forestall divisions between the two fields, 

etiological differences must not only be 

recognized, but accepted as legitimate. 

Other features of substance abuse treatment 

that have posed problems for domestic violence 

programs and have inhibited collaboration 

between the two fields are the largely male 

clientele, the emphasis on family involvement, 

and the use of confrontational group therapy. 

Some domestic violence professionals worry 

that the male orientation in many substance 

abuse treatment programs makes these 

programs irrelevant to the realities of women’s 

lives, insensitive to their needs, and inapplicable 

to the issue of domestic violence. They also 

believe that enlisting the help of family 

members and significant others in the treatment 

process can, in the case of violent partners, 

endanger the survivor. Likewise, domestic 

violence professionals who work with survivors 

consider the confrontational techniques used by 

some substance abuse treatment providers to 

overcome denial and resistance to treatment as 

“bullying” and inappropriate. 

Although there is some validity to these 

characterizations (as well as to the claim that 

domestic violence staff are uninformed and 

naive about substance abusers and the 

manipulative behaviors they sometimes 

employ), education, communication, and crosstraining can help to overcome barriers between 

substance treatment and domestic violence 

programs. Increased understanding within both 

disciplines will equip practitioners to address 

the particular problems of substance abusers 

who are victims or perpetrators of domestic 

violence. 

A New Way of Thinking 

The disagreements between experts in the fields 

of substance abuse and domestic violence can 

inhibit the exchange of essential information to 

the detriment of the client’s recovery. This TIP 

represents an initial effort to bridge that gap. In 

the chapters that follow, experts in the 

respective arenas share their understanding 

about the impact of domestic violence on 

batterers and survivors. In addition, this TIP 

provides suggestions for screening and 

assessing for past and current experience with 

domestic violence, offers ideas for intervening 

with survivor and perpetrator clients, and 

summarizes legal and ethical issues that 

substance abuse providers should consider 

when working with this population. In addition 

to presenting guidelines to improve client 

outcomes, the information included in this 

document is intended to begin a dialogue 

between domestic violence and substance abuse 

treatment staff about the larger issue of systemic 

reform. Currently, domestic violence and 

substance abuse treatment function as parallel 
Chapter 1 

8

programs within the overall social services 

system. 

In the short term, the ideas presented in this 

TIP should enhance the responses of both 

programs to the problems of domestic violence 

survivors and batterers who are also substance 

abusers. However, to effect lasting change and 

reduce morbidity, people working in both fields 

must accept the fact that the two problems often 

exist together, must recognize the importance of 

a holistic treatment approach, must be willing to 

set aside concerns about “turf,” and must learn 

to collaborate effectively on the client’s behalf. 

Impediments to systemic reform are scattered 

throughout substance abuse and domestic 

violence programs and in the public and private 

funding organizations supporting them. The 

insistence on identifying a single problem as 

primary or the need to conceal a problem in 

order to receive services can complicate 

admission to treatment, interfere with the 

development of appropriate treatment plans, 

and ultimately derail progress. In the 

concluding chapter of this TIP, Chapter 6, the 

Panel offers ideas for forging systemwide 

linkages that exemplify a new, collaborative 

way of thinking about problems and their 

solutions. This chapter builds on the practical 

suggestions described in earlier chapters to 

create a blueprint for a system of coordinated 

care. Such a unified system would be better 

equipped than the current fragmented one to 

interrupt the cycle of violence, fear, 

intimidation, guilt, and relapse to substance 

abuse that jeopardizes clients’ recovery.
2 Survivors of Domestic Violence: 

An Overview 

9

family members or continually harass, stalk, and 

possibly kill her often inhibit victims from 

leaving (Rodriguez et al., 1996). If the batterer is 

also the victim’s drug supplier, that further 

complicates the situation. Assuming all these 

issues can be resolved, the effects of continual 

abuse and verbal degradation can be so 

inherently damaging to self-esteem that the 

survivor may believe that she is incapable of 

“making it” on her own. 

Entering the 

Treatment System 

Crisis Intervention 

When a client presents for substance abuse 

treatment and informs staff that she is a victim 

of domestic violence, treatment providers 

should focus on 

1. Ensuring her safety: Whether a client is 

entering inpatient or outpatient treatment, 

the immediate physical safety of her 

environment must be the chief concern. If 

inpatient, security measures should be 

intensified; if outpatient, a safety plan (which 

may include immediate referral to a domestic 

violence or battered women’s shelter) should 

be developed. In both cases, staff should be 

cautioned about the importance of vigilantly 

guarding against breaches in confidentiality. 

T his chapter presents an overview of those 

issues likely to affect survivors of 

domestic violence seeking treatment for 

substance abuse. Its purpose is to help 

substance abuse treatment providers 

understand the impact of this experience on the 

treatment and recovery process and appreciate 

the differences in approach between the fields of 

substance abuse and domestic violence as they 

affect the survivor, so that treatment programs 

can respond more appropriately to this client 

group. The primary focus of substance abuse 

treatment services is to initiate the recovery 

process and reinforce the skills needed to stay 

sober or abstinent, while domestic violence 

programs seek to interrupt the cycle of violence 

and help the survivor client access the 

information and resources she needs to increase 

her safety and to develop and implement a 

safety plan. Holistic care is impossible if a 

treatment provider cannot understand the 

profound effect of domestic violence on a 

survivor. 

The battered woman lives in a war zone: She 

rarely knows what will trigger an abusive 

episode, and often there is little, if any, warning 

of its approach. She spends a great deal of time 

and energy trying to read subtle signs and cues 

in her partner’s behavior and moods in order to 

avoid potential violence, but she is not always 

successful. Financial constraints and fear that 

the batterer will act on his threats to harm 
Chapter 2 

10

2. Validating and believing her, and assuring her 

that she is believed: Reinforcement of the 

counselor’s belief of a survivor’s 

victimization is a critical component of 

ongoing emotional support. Affirming the 

survivor’s experience helps empower her to 

participate in immediate problem solving 

and longer term treatment planning. 

3. Identifying her options: Treatment providers 

should ask the survivor to identify her 

options, share information that would 

expand her set of available options, explore 

with her the risks associated with each 

option, and support her in devising a safety 

plan. 

These three goals remain important for a 

survivor throughout treatment. Other needs 

that must be addressed immediately are 

 Stabilizing detoxification (including 

withdrawal symptoms, if any). 

 Evaluating and treating any health concerns, 

including pregnancy. The latter is especially 

important for a survivor client because 

batterers often intensify their abuse when 

they learn their partner is pregnant (Hayes 

and Emshoff, 1993; Stark et al., 1981). 

Injuries should be documented for any future 

legal proceedings that might occur. 

 Attending to immediate emotional and 

psychological symptoms that may interfere 

with the initiation of treatment, such as acute 

anxiety and depression. 

Once survivor clients’ physical safety and 

symptoms have been addressed, treatment 

providers can obtain the information necessary 

to design a treatment plan. 

Obtaining a History 

A number of issues unique to domestic violence 

survivors must be considered by substance 

abuse treatment providers who work with these 

clients. Chief among these is the need to 

uncover the extent of the client’s history of 

domestic violence. The survivor client’s current 

substance abuse problems must be placed in the 

context of whatever violence and abuse she may 

have experienced throughout her life, both 

within her current family and in her family of 

origin. Childhood sexual abuse has been 

associated with a higher risk for 

“revictimization” later in life (Browne and 

Finkelhor, 1986). (See Chapter 4 for a discussion 

on how to elicit information regarding domestic 

violence.) 

Studies have found a higher incidence of 

substance abuse among women who were 

victims of childhood sexual abuse and sexual 

assault (Ryan and Popour, 1983; Reed, 1985). 

Data suggest that substance abuse often begins 

at an early age and may become part of a selfdestructive coping style that is sometimes seen 

in incest victims (Harrison et al., 1989; Conte 

and Berliner, 1988; Briere, 1989). It is not 

unusual for the abuser to foster the child’s 

initiation into alcohol and drugs in order to 

make the child more compliant. 

A discussion of substance abuse in the 

client’s history should cover her current use, her 

treatment history, and alcohol or other drug use 

in her family of origin. In addition, patterns and 

frequency of alcohol or other drug use by her 

batterer are key to understanding the 

relationship of substance abuse to the violence. 

Substance abuse counselors should be aware 

that survivors often are reluctant to disclose the 

extent of violence in their lives. Often a 

survivor’s denial that violence occurs is so 

pervasive that it has become an integral element 

of her psyche. And, especially if violence 

existed in her family of origin, she may simply 

consider it a normal part of an intimate 

relationship. 

At the same time, it is important to recognize 

that many survivors consciously keep the fact or 

extent of their battering concealed for good 

reasons, such as fear for themselves, their 

children, or other family members. When a 
Survivors of Domestic Violence 

11

battered woman leaves her abuser, her chances 

of being killed increase significantly (Wilson, 

1989; Casanave and Zahn, 1986; Rasche, 1993; 

Dutton-Douglas and Dionne, 1991). 

Furthermore, the batterer may be the primary 

source of income, so his incarceration could 

leave her destitute (Rodriguez et al., 1996). 

Instruments for uncovering domestic violence 

appear in Appendix C. 

Treatment Planning for 

The Survivor Client 

Treatment providers can best serve clients by 

establishing strong linkages to domestic 

violence referral and intervention services and 

by employing staff who are thoroughly familiar 

with local and State laws regarding domestic 

violence and with the unique needs of the 

domestic violence survivors. Ideally, counselors 

should be able to refer to those services and staff 

members when domestic violence is suspected 

and call on them for consultation as needed. If a 

client denies a history of domestic abuse but the 

treatment provider still suspects it is possible, 

additional attempts to discuss it with the client 

should be made and documented. Once the 

client has entered treatment, a treatment plan 

that includes guarantees of safety (see Appendix 

D) and a relapse prevention plan should be 

developed. Considerations specific to domestic 

violence survivors should be integrated into 

each phase of the treatment plan. 

Safety From the Batterer 

In the early stages of the survivor’s treatment, 

the substance abuse counselor should help her 

develop a long-term safety plan either by 

referring the client to or employing domestic 

violence service providers. If substance abuse 

counselors have been well trained in this area, 

they can work with clients to develop such a 

plan as part of intake. 

One of the purposes of screening is to assess 

the degree to which the survivor is in physical 

danger. Screening for this purpose should be 

conducted early in the treatment process. 

However, domestic violence and safety issues 

do not always arise in the early stages of 

treatment of these clients. Thus substance abuse 

treatment providers are wise to be prepared to 

develop a safety plan whenever the need 

becomes known or acknowledged. (See Chapter 

4 on screening and assessment for a discussion 

on assessing danger and lethality and Appendix 

C for an example of a danger assessment 

instrument). In this regard, it is also important 

to remember that the client’s sobriety may 

threaten the batterer’s sense of control. In 

response, he may attempt to sabotage her 

recovery or increase the violence and threats in 

order to reestablish control. It is important to 

address this issue in treatment and to help the 

client minimize her risk of harm so that she can 

continue to comply with her treatment plan. In 

addition, although involving the family in 

counseling is usually a precept of successful 

substance abuse treatment, couples and family 

therapy may be dangerous for domestic violence 

survivors and should be undertaken cautiously, 

if at all. 

It is also important for the substance abuse 

provider to assess the degree to which an 

addicted client’s drug problem is tied to the 

abusive partner: Her batterer may be her 

supplier. A survivor client who relies on a 

batterer to obtain or administer drugs may have 

a difficult time remaining in treatment or 

avoiding the batterer. A batterer who 

understands his partner’s addiction may simply 

wait for the victim to resurface. The treatment 

provider should be alert to the possibility that a 

survivor client may sabotage both her treatment 

and her safety in the service of her addiction. 
Chapter 2 

12

Physical Health 

Domestic violence survivors often present with 

acute injuries and long-term sequelae of 

battering as well as the physical health problems 

more commonly associated with substance 

abuse (e.g., skin abscesses and hepatitis). Cuts 

and bruises from domestic violence tend to be 

on the face, head, neck, breasts, and abdomen 

(Randall, 1990). The body map in the Abuse 

Assessment Screen (see Appendix C) can help 

identify these injuries. Abdominal pain, 

sleeping and eating disorders, recurrent vaginal 

infections, and chronic headaches are also 

common among survivors (American Medical 

Association, 1992; Beebe, 1991; Stark et al., 1981; 

Randall, 1990). While it may be necessary to 

attend to pressing legal and financial concerns 

before chronic health problems can be 

addressed, medical staff should be available to 

assess the client’s most immediate physical, 

emotional, and mental health needs. 

When a woman presents for treatment with 

obvious signs of or complaints about physical 

battering or sexual abuse, staff should consider 

enlisting a forensic expert to help the survivor 

client obtain proper medical documentation of 

her injuries. Forensic medicine programs have 

been employed successfully in pediatric 

populations (Corey Handy et al., 1996), and are 

now being expanded to include adult victims of 

abuse. Forensic examiners are medicolegal 

experts (e.g., nurses, emergency room 

physicians, and forensic pathologists) specially 

trained to evaluate, document, and interpret 

injuries for legal purposes (Corey Handy et al., 

1995). They can assess whether an injury is 

consistent with events as described by the victim 

or perpetrator client, information especially 

valuable when the victim is unable to accurately 

recount the circumstances surrounding her 

injuries because she was using alcohol or other 

drugs at the time of the assault. Forensic 

examiners frequently are called to testify in 

court and may be viewed as a valuable asset in 

any court proceeding relating to the assault 

(Corey Handy et al., 1995). 

Other health concerns that need attention 

early in treatment include screening and care for 

pregnancy, HIV infection, and other sexually 

transmitted diseases (STDs). Battered women 

are at extraordinarily high risk for STDs because 

they are frequently unable to negotiate the 

practice of safe sex with their partners and are 

often subjected to forced, unprotected sex. They 

also may have been forced by their partners to 

share needles. Not only do STDs and pregnancy 

require immediate medical attention, but they 

can also be triggers for more battering. 

One of the coping mechanisms used by many 

survivors is the repression of physical 

sensations, including physical pain. Often the 

survivor’s awareness of physical pain and 

discomfort resurfaces only when the traumatic 

effects of the abuse have been relieved. An 

increase in a client’s somatic symptoms is also 

common as emotional issues surrounding her 

victimization begin to emerge. Such a 

newfound awareness can be confusing and 

frightening for the survivor, and it is important 

to ensure that this awareness is addressed both 

in her medical care and through 

psychotherapeutic counseling. 

Psychosocial Issues 

Shift of focus and responsibility 

to the abuser 

A key aspect of treatment for substance abuse is 

encouraging the client to assume responsibility 

for her addiction. For a survivor client, it is 

critical at the same time to dispel the notion that 

she is responsible for her partner’s behavior. She 

is only responsible for her own behavior.

The survivor client must realize that she does 

not and cannot control her partner’s behavior, 

no matter what he says. Treatment should help 

move her toward becoming an autonomous 

individual who is not at the mercy of external 

circumstances. Concrete steps to ensure her 
Survivors of Domestic Violence 

13

safety or, if she decides to leave the batterer, to 

set up a new life will do more toward this end 

than anything else. As she frees herself from the 

violence, she will feel more independent. A 

counselor can help reinforce the client’s view of 

herself as capable and competent by eliciting 

information about her efforts to address the 

violence, even if they were unsuccessful. A 

counselor can point out that her efforts reflect 

determination, creativity, resourcefulness, and 

resilience, many of the same qualities that will 

equip her to take responsibility for her substance 

abuse. 

Improving decisionmaking skills 

Poorly developed decisionmaking skills is a 

problem for many substance abusers. When a 

client is a battered woman, that inadequacy may 

be compounded by the domestic abuse 

(American Medical Association, 1993). For some 

battered women, every aspect of their lives has 

been controlled by the batterer, and a “wrong” 

decision (as perceived by the batterer) may have 

served as another excuse to batter her. The 

paralyzing effect of being battered for making 

independent decisions must be overcome as the 

survivor begins to exercise choices without fear 

of reprisal. Thus one of the first steps in the 

process of empowering the survivor client is to 

help her develop, strengthen, focus, or validate 

her decisionmaking skills. 

For a proportion of domestic violence 

survivors, decisionmaking is a new skill that 

must be acquired for the first time rather than a 

lost skill that must be relearned. Exploring her 

own wants, needs, and feelings, although an 

unfamiliar and sometimes uncomfortable 

process, can be a stepping stone to making 

larger and longer term decisions. It is important 

for the treatment provider to avoid 

underestimating the importance to the survivor 

of making even seemingly mundane decisions, 

such as what to wear or when to eat. 

Like most substance abusers, the survivor 

client must examine those areas of her life that 

will either support or undermine her recovery. 

Like others in treatment, she must disengage 

from drug-using friends, and she will need 

support as she begins the task of making new 

social contacts who support her recovery. 

Reevaluating relationships with partners 

who support and encourage drinking or drugtaking is another therapeutic task for those 

undergoing substance abuse treatment. In a 

pattern that parallels the experience of many 

survivors of domestic violence, female substance 

abusers are often introduced to and supplied 

with drugs by male partners. Among the 

myriad reasons for continuing use are to 

maintain a relationship, to please a partner, or to 

share a common activity. Since safety poses 

such a serious problem for survivor clients, 

reevaluating ties to her significant other in the 

context of her goals for recovery requires careful 

consideration. For many of these women, 

recovery will not be possible without separation 

from their partners—a reality that may be 

extremely difficult for them to acknowledge, 

accept, and translate into action. Furthermore, 

because of the toll that the battering has taken 

on many survivor clients’ belief in their ability to 

make decisions, they are likely to need 

additional help in evaluating and identifying 

sources of stress in their relationships. Despite 

the time and effort involved in working through 

this issue, however, it is not uncommon for 

survivor clients to change their views about 

which relationships feel safe as they begin to 

make choices that support recovery. 

When working with some survivor clients, 

substance abuse treatment providers may have 

to discard traditional notions about the wisdom 

of making major life decisions, such as moving, 

early in the course of treatment. For a domestic 

violence survivor who fears being pursued by a 

batterer, relocation to another community may 

be a priority. As part of treatment, the stress of 

uprooting herself and her children and the 

accompanying risk of relapse must be weighed 
Chapter 2 

14

against safety issues. Should a client decide to 

move, every effort should be made to refer her 

to appropriate resources and supportive services 

within the new community. 

Ensuring emotional health 

Posttraumatic stress disorder 

Posttraumatic stress disorder (PTSD) is a 

psychiatric diagnosis described in the Diagnostic 

and Statistical Manual of Mental Disorders, Fourth 

Edition (DSM-IV) (American Psychiatric 

Association, 1994). The first diagnostic criteria 

are being “exposed to a traumatic event in 

which . . . (1) the person experienced, witnessed, 

or was confronted with an event or events that 

included actual or threatened death or serious 

injury, or a threat to the physical integrity of self 

or others [and] (2) the person’s response 

involved intense fear, helplessness, or horror” 

(American Psychiatric Association, 1994, pp. 

427–428). Other criteria include recurrent 

nightmares, difficulty sleeping, flashbacks, 

hypervigilance, and increased startle 

responses—symptoms shared by many battered 

women (Walker, 1991; Douglas, 1987; 

Follingstad et al., 1991; Woods and Campbell, 

1993). One study of 77 battered women in a 

shelter found that 84.4 percent of them met the 

PTSD criteria in the DSM-IV (Kemp et al., 1991). 

Though the DSM-IV states that the disorder is 

“more commonly seen in association with an 

interpersonal stressor (e.g., childhood sexual or 

physical abuse, domestic battering, being taken 

hostage, incarceration as a prisoner of war or in 

a concentration camp, torture)” (p. 425), some 

domestic violence support workers have been 

reluctant to acknowledge PTSD among survivor 

clients. Their fear is that thus labeling the victim 

moves the onus for the violence from the abuser 

to the victim and provides another excuse for 

the batterer’s behavior (e.g., “she’s crazy”). A 

treatment provider, however, must be aware of 

the possibility that a survivor may be suffering 

PTSD and must make the appropriate referral. 

Emergence of trauma from 

childhood abuse 

Many survivor clients also suffered abuse as 

children (Browne and Finkelhor, 1986). 

Emotional and psychological trauma from 

childhood abuse is often repressed and may 

surface once the client is in a safe setting, such as 

an inpatient substance abuse treatment facility. 

The emergence of this memory can be an 

overwhelming experience, and treatment 

providers should not attempt to address it 

before the survivor is ready or if program staff 

are unprepared to handle the results. If the 

issue surfaces in a group setting, the substance 

abuse counselor should allow the survivor client 

to express her emotions initially. Thereafter, 

however, a client should be referred if possible 

to a therapist with special training in treating 

victims of childhood abuse. 

Life event triggers 

Recovering substance abusers are trained to deal 

with relapse triggers—events or circumstances 

that produce cravings and predispose them to 

resume their use of alcohol or other drugs. A 

potential trigger for relapse can be something as 

seemingly benign as walking through a 

neighborhood where the recovering individual 

once purchased drugs. A domestic violence 

survivor is vulnerable to an additional set of 

triggers—situations or experiences that may 

unexpectedly cause her to feel the fear and 

victimization she experienced when being 

battered. Such life event triggers may cause the 

client to relapse and should be addressed 

directly by counselor and client. Examples of 

life event triggers are sensory stimuli (sights, 

sounds, smells); the close physical proximity of 

certain people, particularly men; or situations 

that trigger unpleasant memories (such as 

witnessing a couple arguing). They also include 

stressful situations that evoke trauma responses 

and recreate the sense of victimization (Craine et 

al., 1988). Such triggers may push these feelings 

to the surface many years later, after the 
Survivors of Domestic Violence 

15

survivor is out of the abusive relationship; some 

disappear over time, but others may always be 

present to some degree. Counselors should help 

patients identify these stressful situations and 

rehearse alternative responses, just as they 

should for substance use triggers. 

Increased stress with abstinence 

Survivors of domestic violence usually 

experience strong emotional reactions when 

they stop abusing alcohol or other drugs, which 

may have been a form of self-medication. They 

may be flooded by formerly repressed emotions 

and physical sensations. Abstaining from 

substance abuse, which often helps a survivor 

repress her responses, may also eradicate her 

ability to psychologically dissociate (distance 

herself emotionally so she does not “experience” 

feelings) from what was happening during the 

abuse. This dissociation may have provided her 

with an effective coping mechanism that 

allowed her to function on a day-to-day basis, 

despite the abuse. Its elimination may give rise 

to somatic symptoms, such as headaches or 

backaches, as formerly blocked physical 

sensations and experiences reenter her 

awareness. 

Another issue for the survivor upon 

becoming abstinent may be the freeing of time 

and energy formerly spent procuring alcohol or 

other drugs, leaving her feeling empty or 

directionless and with too much time to dwell 

on her life situation. Other problems may 

surface as well. In the Panel’s experience, eating 

disorders as well as other kinds of obsessivecompulsive behavior tend to reemerge after 

substance abuse ceases. Treatment providers 

should be alert to this possibility and prepared 

to refer survivor clients for specialized help 

(such as a local eating disorders program or 

chapter of Overeaters Anonymous). 

Perceptions of safety 

Paradoxically, the very concept of “safety” may 

itself seem “unsafe” to a survivor of domestic 

violence. As one survivor expressed it, “The 

minute you (think you) are safe, you are not 

safe.” For these clients, feeling safe from the 

perpetrator, even if he is dead or incarcerated, is 

equated with letting one’s guard down and 

making oneself vulnerable to attack. Survivors 

tend to be hypervigilant and are accustomed to 

always being on guard. The substance abuse 

treatment provider needs to understand and 

respect the domestic violence survivor’s concept 

of and need for safety. Helping a client rebuild 

a more appropriate general level of trust is an 

important long-term therapeutic goal. 

Medications 

For some survivors, anxiety, depression, suicidal 

thoughts, and sleep disorders are severe enough 

to require medication during their treatment for 

substance abuse. In such cases, it is of utmost 

importance to strike a balance between the need 

for medication and the avoidance of relapse. On 

the one hand, the recurrence of the physical and 

emotional sequelae of abuse may tip a survivor 

into emotional trauma; on the other hand, 

however, the client may risk relapse with the 

possible misuse or abuse of the medication. 

Physicians should weigh carefully the risks and 

benefits of prescribing drugs to battered women 

for symptom relief. For battered women who 

use or are dependent on alcohol or other drugs, 

the drug may affect their awareness, cognitive 

reasoning, or motor coordination, which can, in 

turn, reduce their ability to protect themselves 

from future incidents of physical abuse. A 

thorough medical and psychological assessment 

should be conducted by a trained clinician 

experienced in addiction medicine before any 

psychoactive medications are prescribed. As 

with other medicated substance abusers, regular 

monitoring and reassessment of symptoms are 

essential. 
Chapter 2 

16

Later Postabstinence Issues 

Practical concerns overwhelm many survivors 

of domestic violence after they become 

abstinent. These include resolution of legal 

problems, housing, transportation, employment 

or supported vocational training, and child care, 

among others. Linkages with other programs 

and agencies become extremely important in 

meeting these clients’ needs. (See Chapter 6 for 

a discussion of the importance of forming 

collaborative relationships.) In addition, there 

are some special concerns that merit particular 

attention when working with survivor clients. 

“Welfare to Work,” “Workfare,” and other 

initiatives designed to rapidly move welfare 

recipients into employment may prove 

especially problematic for these clients. Both 

Panel members and reviewers described the 

inordinate pressure survivors experience when 

they are compelled to accept several new 

responsibilities at the same time. Panel members 

recommended developing, if possible, a 

schedule for the graduated assumption of 

responsibilities. Field Reviewers concurred and 

observed that providers should plan on 

providing extra support during this crucial 

postabstinence period. 

In addition, survivor clients are likely to need 

education or reeducation about meeting sexual 

needs without drugs or alcohol. Referral to or 

staff training by experts in this area is 

recommended to ensure that this topic is 

approached sensitively. In addition, classes in 

healthy nutrition are a useful adjunct to 

treatment for survivor clients as for other 

substance abusers. 

Social functioning 

Although a strong family or friendship support 

system can be invaluable to substance abusers as 

they reenter the mainstream from the drug 

culture, the domestic violence survivor who is 

recovering from substance abuse may find it 

especially hard to reestablish ties, make new 

friends, or, in some cases, build a completely 

new life for herself. Social isolation is common 

among domestic violence survivors, as batterers 

curtail their victims’ contacts with friends and 

family members. While a survivor client will 

likely need help and advice about creating a 

new nondrug, nonviolent social milieu, 

treatment providers should be careful not to 

make decisions for her, but rather support her in 

finding new activities and pastimes. Many 

women who are victims of domestic violence are 

surprised to discover that they have a 

continuum of choices, especially in social 

situations: The idea of enjoying a party without 

getting intoxicated, for example, may not have 

occurred to a survivor in the past. 

Parenting 

Parenting is an issue for many substance abusers 

but may be a special challenge for survivor 

clients. The time spent in treatment initially 

may provide a respite from the concerns of 

parenting for many mothers, and the 

resumption of child care may be a source of 

additional stress. Some children become 

extremely needy after separation from their 

mother, and their demands could trigger a 

relapse or provoke an episode of violent 

behavior on her part. 

An additional stressor may be the fact that 

some children are not supportive of their 

mother’s choices. For example, they may not 

like her decision to separate from her abusive 

partner. They may pressure her, become 

depressed, act out, and try to coerce her into 

going home. This can create extreme conflict as 

the survivor client struggles to act in the best 

interests of her children. To further complicate 

the situation, it is not uncommon for older 

children (particularly boys) to ally with the 

batterer and become verbally or physically 

abusive to their mother. 

To handle these issues effectively, a 

postabstinent domestic violence survivor may 

need to learn new parenting skills that take into 
Survivors of Domestic Violence 

17

account the realities of her status as a domestic 

violence survivor. These clients and their 

children commonly have a great deal of 

suppressed rage; handling frustration and anger 

is a crucial life skill that must be addressed 

directly in treatment. If treatment providers 

have not been trained in anger management and 

violence prevention, survivor clients should be 

referred to domestic violence support programs 

for these services. 

Financial and legal concerns 

Discussing the realities of everyday living and 

plans for the future that may increase the client’s 

chances of a successful recovery is essential to 

the design of an effective treatment plan. 

Treatment providers should explore with the 

client her plans for future education and 

employment and should have information 

available about a variety of options. Through 

linkages with other agencies, the treatment 

provider can also help the client develop 

realistic plans for addressing any legal issues 

that may be unresolved and are interfering with 

recovery. 

Relapse prevention 

Domestic violence survivors who are newly 

abstinent may feel overwhelmed by pressures 

inherent in the responsibilities just described. 

For many, harassment and threats from their 

partners will be a continuing concern, and 

custody disputes and divorce hearings may 

further complicate their lives. All of these 

factors are potential triggers for relapse to which 

the provider should remain attuned. However, 

as a number of Field Reviewers pointed out, 

revictimization by their abusive partners poses 

the greatest risk of relapse for battered women. 

Whether these women remain in the 

relationship or not, the likelihood of 

revictimization is great—domestic violence is a 

highly recidivistic crime (Zawitz et al., 1993; 

Browne, 1993). Careful attention to recurring 

episodes of violence is essential to working with 

survivor clients to prevent relapse and, if relapse 

does occur, to minimizing its negative effects. 

Issues for Children 

Of Survivors 

Children of domestic violence survivors have 

special problems and needs that may not be 

readily apparent to the substance abuse 

treatment provider. Often this is because the 

more obvious, acute needs of the mother tend to 

eclipse those of her children. Children’s issues 

must be addressed; if ignored, they can become 

antecedents to more severe problems, such as 

conduct disorders or oppositional defiant 

disorders. 

Emotional and Behavioral Effects 

Of Violence on Children 

Children of survivor clients typically display 

strong feelings of grief and loss, abandonment, 

betrayal, rage, and guilt. Older children also 

may have feelings of shame. Some indications 

that such feelings may be developing into 

serious problems for the child include 

 Emotional lability 

 Aggression 

 Hostility 

 Destructive behavior 

♦ Toward others 

♦ Toward objects or animals 

♦ Toward self; self-mutilation 

 Inappropriate sexual behavior 

 Regressive behavior 

♦ Bedwetting 

♦ Thumb-sucking or wanting a bottle (older 

child) 

♦ Rocking 

♦ Needing security objects (i.e., blankets) 

♦ Not speaking 

♦ Dependent behavior (i.e., demanding to 

be carried) (Kalmuss, 1984; Arroyo and 

Eth, 1995; Bell, 1995). 
Chapter 2 

18

The child of a survivor may have his or her 

own, less apparent triggers for emotional 

trauma that may be quite different from the 

mother’s. Children’s triggers generally have to 

do with abandonment and separation issues, 

particularly if the children have been in foster 

care. Possible problem behaviors include the 

child’s becoming overly clinging and needy 

upon reuniting with the mother, being fearful of 

a separation from her again, and acting out with 

hostility and violence to gain attention. 

Children of survivors may also become 

“parentified,” trying to be “perfect.” Often this 

is the result of the child’s feelings that he or she 

is somehow to blame for a parent’s anger and 

subsequent violence. These children may also 

become extremely protective of their mothers. 

Other children may have somatic complaints, 

such as hives, headaches, stomachaches, or other 

unexplained aches or pains. 

Children’s responses to family violence vary 

according to individual temperaments and their 

age at the time the violence occurred. 

Posttraumatic symptoms, including 

sleeplessness and agitation, are common among 

children who experience violence within the 

family home (Pynoos, 1993). Some young 

children exposed to domestic violence may 

demonstrate regression in toileting behaviors 

and emotional distress (Arroyo and Eth, 1995). 

Developmental delays and language disorders 

also have been linked to parental domestic 

violence (Kurtz, 1994; Arroyo and Eth, 1995). 

Some school-aged children become more 

aggressive and anxious and lose ground 

academically (Pynoos et al., 1987). 

Adolescents who have observed their fathers 

abusing their mothers exhibit high levels of 

aggression and acting out, anxiety, learning 

difficulties in school, revenge seeking, and 

truancy. Children who witness or experience 

domestic violence are at increased risk of 

adopting these same strategies in their 

interactions with their partners and children 

(Bell, 1995; Kalmuss, 1984). They may also 

become hypervigilant to the point of immobility 

or, in extreme cases, catatonia. 

Assessment of Children’s Needs 

Some substance abuse programs allow children 

to accompany the mother to the facility where 

she receives services. Depending on the 

program’s resources, children can be assessed at 

that time, treated onsite with counseling groups 

that coincide with adult sessions, or referred to a 

qualified children’s treatment or counseling 

program for concerns such as 

 Foster or kinship care (relative or 

nonrelative) 

 Separation issues 

 Behavioral, mental health, or emotional 

problems 

 Physical health problems 

 Safety. 

Collaboration With 

Children’s Services 

Ideally, substance abuse treatment programs 

will establish collaborative relationships with 

children’s programs available through public 

and private, nonprofit, family service mental 

health and developmental assessment agencies. 

In many areas, these programs provide 

sophisticated case management services that 

access respite care, home aid, and parenting 

skills training that are beyond the scope of most 

substance abuse treatment programs. 

Collaboration with such specialized programs 

would free substance abuse counselors to 

concentrate on providing treatment to their 

survivor clients. The family services case 

manager would assume responsibility for 

making linkages with the myriad institutions 

that affect the mother through the child, 

including 

 The school system 

 The health care system 
Survivors of Domestic Violence 

19

 Social services and employment programs 

 The child welfare system 

 The criminal justice and civil court system 

 Other community-based agencies (including 

family preservation and support). 

Children’s protective 

services agencies 

Some survivor clients may be or will become 

involved with children’s protective services 

(CPS) agencies because their children have been 

or are being abused and neglected. Since many 

battered women fear that CPS will take their 

children from them, they may resist efforts to 

involve CPS, and some will undermine their 

treatment to do so. 

Treatment providers must adhere to the laws 

in their States regarding mandated reporting of 

child abuse and neglect even though clients may 

perceive those actions as a betrayal of trust. One 

way to minimize problems is to discuss 

reporting requirements and the procedures the 

treatment program follows prior to treatment. 

Providers should also establish working 

relationships with CPS to ensure an appropriate 

and best-case response to the family situation 

and the child’s protection. 

The Role of Treatment Providers 

In Supporting the Mother 

The substance abuse counselor is involved with 

the children⎯directly or indirectly⎯through 

the mother. A key responsibility, then, is to 

understand how to interact with and support 

the mother in her parenting role. 

Substance abuse treatment counselors must 

understand that the mother may be involved 

with multiple agencies, all of which make 

demands on her limited time and energy. To 

help her focus on her abstinence, treatment 

providers should 

 Help the mother identify and coordinate the 

various services she needs via external case 

management services or, if unavailable, by 

acting as an advocate on her behalf. 

 Support her efforts to participate in and take 

advantage of these services. 

 Listen empathetically as she voices her 

frustration about the difficulties of meeting 

the demands made by the various agencies 

and service programs with which she is 

involved. 

 Help her clarify the sometimes mixed 

messages she receives from these agencies, 

each of which tends to consider its “problem 

area” a priority (and, as a corollary, ensure 

that the substance abuse program’s messages 

do not contribute to her confusion and 

frustration). 

 Serve as an intermediary and advocate when 

other agency providers ask her to do more 

than is reasonable given her progress in 

treatment (e.g., resume custody before she is 

prepared to take on responsibility for her 

children or begin working while still striving 

to maintain abstinence). 

Treatment providers also can assist survivor 

clients by inviting staff from domestic violence 

agencies such as Homebuilders and from CPS, 

jobs training agencies, and other organizations 

involved with domestic violence survivors to 

the substance abuse program so they can better 

understand the treatment and recovery process. 

Substance abuse treatment counselors also 

should request cross-training in domestic 

violence support as well as in-service training on 

the mission and operation of those agencies that 

come in contact with survivor clients. 

Summary 

As the chapter makes clear, survivors of 

domestic violence present unique substance 

abuse treatment challenges. Because domestic 

violence can be so psychologically damaging, 

particularly if it has been sustained since a 

client’s childhood, a treatment provider should 
Chapter 2 

20

refer to domestic violence experts whenever 

possible. The treatment provider must also be 

careful not to unintentionally place the survivor 

client in danger by making inappropriate 

recommendations. 

Central to the discussion of survivors’ issues 

is the overarching need for informed, ongoing 

collaboration with the agencies that can help the 

survivor rebuild her life. Substance abuse 

treatment providers should try to facilitate this 

collaboration to the greatest extent possible. 

Treatment outcomes are substantially improved 

when interventions encompass all the relevant 

areas of a client’s life, services are coordinated, 

inconsistent messages and expectations are 

reduced, and the effects of both domestic 

violence and substance abuse are well 

understood by all those interacting with the 

survivor client. 

Case Scenario: Profile 

Of a Survivor 

Judy, a white high school graduate in her late 

20s, is a recovering substance abuser and a 

survivor of domestic violence. Her story is 

typical of the many problems and circumstances 

faced by women who enter both the domestic 

violence support and substance abuse treatment 

systems. 

She was molested by her uncle from the age 

of 3 until she was 10; the molestation included 

vaginal penetration. Like many victims of 

sexual abuse, Judy was threatened by her abuser 

and never disclosed the abuse. On one occasion, 

her mother asked whether her uncle had ever 

touched her, and she replied, “No, he does nice 

things for me.” 

At age 15, she became sexually active with 

her 23-year-old boyfriend, Alex. Alex and she 

began using marijuana. When she was 18, she 

started using cocaine with Alex, who was now 

occasionally slapping her and forcing her to 

have sex. 

At that time, she also discovered that she was 

pregnant. She decided to have the baby but 

received only sporadic prenatal care. During 

her pregnancy, both Judy and Alex used cocaine 

and marijuana and drank alcohol. The infant, a 

girl named Candace, was born at full term but 

was small for her gestational age. Alex left Judy 

soon thereafter, and she and Candace moved in 

with a new boyfriend, Billy. He used drugs and 

was both extremely possessive and violent. He 

intimidated Judy and sometimes threatened to 

kill her, Candace, and himself. 

When Candace was 3, Judy, then 21, became 

pregnant again. Billy did not welcome the 

pregnancy and began hitting her in the 

abdomen and breasts when he was angry. Judy 

received no prenatal care during her second 

pregnancy and delivered a preterm, small-forgestational-age baby whom she named Patricia. 

Neither Judy nor her baby was screened for 

drugs or HIV before or immediately after the 

birth. 

By the time Patricia was born, Judy’s drug 

use had escalated to include crack and 

increasing amounts of alcohol. Despite her 

mounting problems, Judy recognized that her 

new baby was a poor feeder. Judy was 

frightened enough to keep a 6-week 

postdelivery pediatric visit during which 

Patricia was diagnosed as “failing to thrive.” At 

the same visit, 3-year-old Candace was weighed 

and found to be only in the 10th percentile of 

weight for her age. 

Two weeks later, Judy and Billy were 

arrested on drug charges—Judy for possession 

and Billy for dealing. She received probation, 

and she and her children moved in with her 

mother, Vivian. Billy was incarcerated, and 

Judy was required by the court to participate in 

substance abuse treatment. 

In a group therapy session in her substance 

abuse treatment program, Judy acknowledged 

her history of family violence, childhood sexual 

abuse, and battering. Her case manager in this 
Survivors of Domestic Violence 

21

program wanted her to join another group of 

childhood incest survivors, but Judy felt 

ashamed and did not want to discuss the incest 

further. She began attending treatment sessions 

sporadically and, after 2 months, dropped out. 

In the meantime, tension developed between 

Judy and Vivian. Judy felt that her mother 

cared more for her granddaughters than she had 

about Judy when she was a child. Now that 

Judy had acknowledged her history of sexual 

abuse, she found herself blaming her mother for 

“allowing” it to happen. She also was jealous 

because she felt that Vivian was a better mother 

to Patricia and Candace than she was. 

After a series of violent fights with her 

mother, Judy moved out and got a minimumwage job, leaving her children with Vivian. 

Around this time, Judy met Cody, a drug 

dealer. Cody moved in with her, but their 

relationship was characterized by frequent 

arguing and mutual battering. Judy’s work 

habits became erratic; she often had bruises and 

sprains that she refused to discuss when her 

concerned coworkers questioned her about 

them. Although she saw her children 

infrequently, she would call late at night when 

she was high and criticize Vivian for keeping 

her children from her. 

Meanwhile, under Vivian’s care, Candace 

gained weight but exhibited a language delay. 

Her preschool teacher called Vivian repeatedly 

about Candace’s problem behavior and acting 

out; she was having trouble paying attention in 

school, was defiant to her teachers, and was 

domineering with her peers. The school also 

reported that Candace had language problems 

and that she frequently cried for her mother. 

Meanwhile, Vivian had quit her job in order 

to care for her grandchildren and was receiving 

Aid to Families with Dependent Children 

(AFDC). At this time, Vivian’s health began to 

deteriorate, and she asked for help with 

Candace and Patricia. When a social worker 

began to talk about sending the children to a 

foster home, Judy was scared into action. 

Developmental evaluations were recommended 

for both children, and Judy took them to those 

appointments. Both children were found to 

have marginal developmental problems, 

possibly due to Judy’s drug use during 

pregnancy. In response to the psychologist’s 

advice, Judy enrolled Candace in a 

developmentally more appropriate preschool 

program that required parental involvement. 

Judy participated in this program with her 

daughter and resumed treatment. 

For a brief time, Judy’s life appeared to 

stabilize. Although she had not finished her 

substance abuse treatment program, she and 

Cody were both working, and she continued to 

receive negative screens for drugs (although she 

was still using occasionally). At the next CPS 

hearing, the children were returned to Judy’s 

custody with the stipulation that she participate 

in parenting classes as well as continue in 

treatment. 

Once her two children moved in with her 

and Cody, the situation began to deteriorate. 

Cody could not tolerate the children, and his 

episodes of violent behavior increased. He put 

his fist through the wall and kicked the door 

down. He became increasingly angry at Judy’s 

frequent absences as a result of “all this kid 

stuff” (parenting classes and Candace’s 

preschool program). He began to “spank” the 

children or grab them roughly by their arms 

when he wanted their attention. They showed 

up at their respective day care and preschool 

programs with bruises, which were attributed to 

“accidents.” No one at the day care or preschool 

programs was aware of Judy’s history or her 

disclosures of childhood abuse and battering in 

the treatment program. 

Cody’s violence continued to escalate and, 

increasingly, was directed at the children. While 

Judy was concerned about his hitting and 

yelling at the children, she didn’t know what to 

do about it. She was feeling overwhelmed by 
Chapter 2 

22

her job, the parenting classes, her meetings with 

social services workers and her probation 

officer, and her child care responsibilities. In 

time, however, she began intervening when 

Cody yelled at or hit the children, deliberately 

provoking him in order to divert his attention 

away from the children and onto herself. The 

neighbors called 911 frequently, but the police 

never found any substantial evidence of 

violence. 

A year passed with no improvement. The 

children continued to attend school, but Judy 

appeared only sporadically at her parenting 

classes and the preschool program. She was 

now beginning to suspect that Cody was 

sexually abusing 5-year-old Candace. She had 

begun to notice the same kinds of behavior in 

her daughter that she remembered in herself 

when she was sexually abused at that age. One 

day she asked Candace whether Cody had ever 

touched her in certain ways. Candace replied, 

“No, he is always nice to me.” Candace 

remembered using almost identical words to her 

own mother years before and was certain that 

her daughter was being victimized in the same 

way. All the rage from her own abuse by her 

uncle erupted. She verbally and physically 

confronted Cody, and a battle ensued, which 

Candace witnessed. (Later this episode became 

a major treatment issue for the child, who 

believed that the violence in her household was 

her fault.) 

Both Judy and Cody sustained injuries in 

their fight. Candace ran next door with her little 

sister, screaming about “all the blood.” The 

neighbors called the police; Judy and Cody were 

both taken to the hospital, and the children were 

taken to a CPS emergency shelter. Judy and 

Cody were arrested for disturbing the peace and 

for possessing drug paraphernalia. Cody was 

charged with first degree (later reduced to third 

degree) assault, for which he eventually 

received a suspended sentence. 

In the hospital, a social worker referred Judy 

and the children to a program for domestic 

violence survivors. After she was treated and 

released from the hospital, Judy stayed 

overnight in jail. The next day she was given a 

court appearance date, and a domestic violence 

advocate arranged transportation to the 

domestic violence program for her and her 

children. Program staff also assisted Judy in 

obtaining a restraining order against Cody and 

accompanied her to court to obtain it. When 

Candace and Patricia were reunited with their 

mother in the domestic violence facility, they 

clung to her, crying. Over the ensuing days, 

they experienced nightmares. 

Despite the minor drug charge, the domestic 

violence program agreed to accept Judy because 

her drug screens were negative; the program 

had no knowledge of Judy’s substance abuse 

treatment history. During intake, staff 

explained the program’s drug use policy: If Judy 

used while in the program, her choices were to 

leave the facility or participate in treatment. The 

domestic violence program advocates did not 

think Judy was using drugs at the time of her 

admission and did not believe that she would 

use during her stay. 

One day, Judy returned to the domestic 

violence program intoxicated, and a joint fell out 

of her purse. The program staff members saw 

and reported it to CPS. CPS then took away her 

children and again sent them to live with their 

grandmother. Judy’s choices were now to either 

get substance abuse treatment or leave the 

facility. She entered a 1-year residential 

treatment program and was assigned to a 

counselor who was not only a recovering addict 

but a survivor of domestic abuse and with 

whom Judy felt an immediate rapport. The 

counselor and Judy together developed a 

treatment plan that took Judy’s concerns and 

goals as well as the needs of her children into 

account. Although they agreed that intensive 

outpatient treatment would have been 
Survivors of Domestic Violence 

23

preferable, she had no place to stay where she 

would have been safe from Cody. She could not 

stay at the domestic violence program for that 

long, and Cody knew where her mother lived. 

Without a safe haven, her recovery and her life 

would have been in jeopardy, so Judy and her 

counselor decided on residential treatment. The 

counselor walked her through the admissions 

process. 

Judy has been in recovery for 2 years, and 

her mother⎯who was encouraged to participate 

in family sessions⎯is supportive. Judy goes to 

work every day and has begun to date an older, 

recovering alcoholic she met at an AA meeting. 

He is more established and sees her children 

regularly. Vivian has again quit her job and is 

receiving AFDC. Cody is receiving substance 

abuse treatment and counseling for domestic 

violence, which were conditions of his 

suspended sentence. Another condition is that 

he remain in treatment and make no attempt to 

contact Judy or the children. The children are 

seen on a daily basis in the domestic violence 

program. But because the program can provide 

only supportive care and play activities, the 

children have been referred to a local agency 

with special supportive and mental health 

services for children. 
25

 3 Batterers: An Overview

and increase the chance that violence will occur 

(Tolman and Bennett, 1990; Bennett, 1995). 

Both battering and substance abuse result in 

harm to the client and others. Responding to a 

client’s penchant for violent behavior is as vital 

as responding to his depression or to the array 

of other conditions that may impede progress in 

treatment and interfere with recovery. 

Perspectives on 

Substance Abuse and 

The Batterer Client 

Although domestic violence occurs in the 

absence of substance abuse, there is a statistical 

association between the two problems. Alcohol 

use has been implicated in more than 50 percent 

of cases involving violent behavior (Roy, 1982). 

Research by Kantor and Straus suggested that 

approximately 40 percent of male batterers were 

heavy or binge drinkers (Kantor and Straus, 

1987). A recent study found that more than half 

of defendants accused of murdering their 

spouses had been drinking alcohol at the time 

(Bureau of Justice, 1994). Another study of 

incarcerated batterers found that 39 percent 

reported a history of alcoholism and 22 percent 

reported a history of other drug addiction. A 

total of 50 percent self-reported current 

addiction; however, this figure rose to 89 

percent when the researchers examined court 

documents. All but one of the subjects admitted 

to having been drunk at the time the battering 

occurred (Bergman and Brismar, 1994). Higher 

T here are myriad reasons why substance 

abuse counselors should address the 

domestic violence of clients who batter 

their partners. Consensus Panel members have 

observed that the violent behavior of a batterer 

client can interfere with his treatment for 

substance abuse, and conversely, his substance 

abuse can interfere with interventions aimed at 

changing his violent behavior (Bennett, 1995). 

Clients who are incarcerated, for example, or 

accused of assault or murder have limited access 

to substance abuse treatment. Practitioners have 

observed that for those clients in treatment, 

battering may precipitate relapse and thwart the 

process of true recovery, which includes 

“adopting a lifestyle that enhances one’s 

emotional and spiritual health, a goal that 

cannot be achieved if battering continues” 

(Zubretsky and Digirolamo, 1996, p. 225). 

Use of psychoactive substances, on the other 

hand, may interfere with a client’s capacity to 

make a safe and sane choice against violence by 

impairing his ability to accurately “perceive, 

integrate, and process information” about 

another’s behavior toward him (Bennett, 1995, p. 

761). Intoxication appears to increase the 

likelihood that a batterer may misinterpret or 

distort a partner’s remarks, demeanor, or actions 

by “blunting whatever cognitive regulators the 

abuser possesses” (Stosny, 1995, p. 36). While 

abstinence from drugs and alcohol does not alter 

battering behavior, substance abuse problems 

negatively affect a batterer’s capacity to change 
Chapter 3 

26

rates of substance abuse consistently correlate 

with higher rates of domestic violence, although 

one important study concluded that “[c]hronic 

alcohol abuse by the male rather than acute 

intoxication is a better predictor of battering” 

(Tolman and Bennett, 1990, p. 91). As one field 

reviewer noted, however, “Assaultive men, in 

general, have high alcohol use scores. Indeed 

the more a man matched the gauge for having 

an abusive personality, the greater his alcohol 

consumption. When a batterer says, ‘the alcohol 

made me do it,’ he’s blaming one 

symptom⎯violence⎯on another⎯alcohol 

abuse.” 

Most Consensus Panelists and field 

reviewers concur that the exact nature of the 

correlation between battering and substance 

abuse remains unclear. 

Anger and hostility are more frequently 

generated by interactions between people, and 

alcohol or other drug use is likely to be linked 

to violent behavior through a complicated set 

of individual, situational, and social factor... 

The prevalence of violence between partners 

cannot be adequately explained merely as the 

consequence of alcohol and other drug abuse, 

nor can it be understood outside the context 

within which it occurs. (Gorney, 1989, p. 231) 

Current research supports the finding that 

substance abuse is only one of many factors that 

influence a batterer’s violent behavior (Collins 

and Messerschmidt, 1993). As with substance 

abuse, other factors are also correlated, such as 

depression, psychopathology, violence in the 

family of origin, social norms approving of 

violence (especially toward women), high levels 

of marital and relationship conflict, and low 

income (Tolman and Bennett, 1990; Bennett, 

1995; Hotaling and Sugarman, 1986; Hotaling 

and Sugarman, 1990; Bograd, 1988). Although 

intoxication may trigger an individual episode 

of violence, addiction does not predispose one 

to be a batterer. This distinction is crucial for a 

provider to understand when treating batterer 

clients, because a batterer’s violence does not 

necessarily end when he stops abusing alcohol or 

other drugs. 

In characterizing substance abuse and 

domestic violence, practitioners have observed 

that the two problems are “separate but similar, 

and they each interact and exacerbate each 

other. For example, both problems are passed 

on from generation to generation; both involve 

denial, with substance abusers and batterers 

blaming victims for their behavior; usually, 

neither problem decreases until a crisis occurs; 

and secrecy is often the rule, with victims of 

abuse (wrongly) blaming themselves for their 

partner’s substance abuse or violent behavior” 

(Engelmann, 1992, p. 6). 

Profiling Batterers

In the past, research has focused more on 

attempts to identify characteristics of victims 

rather than perpetrators of violence (Hotaling 

and Sugarman, 1990). While information about 

batterers is relatively sparse and subject to some 

debate, it can provide the basis for a 

rudimentary understanding of their behavior. 

One caution is in order, however. Exploring 

batterers’ individual characteristics addresses 

only one dimension of the domestic violence 

phenomenon. Some experts believe that 

battering is driven by socially supported sexism 

and inequitable distributions of power that feed 

the batterer’s belief that he has an inherent right 

to control his partner’s behavior. Others 

contend that analysis of batterers’ characteristics 

has limited value if attention is not also directed 

to the larger culture of violence and social 

injustice in which battering occurs (Adams, 

1988; Tolman and Bennett, 1990; Stosny, 1995). 

Research has clearly asserted the importance of 

socioeconomic factors in understanding 

battering: Approval of violence against women, 

low income, and belief in gender-based 

stereotypes emerge repeatedly as correlates of 

domestic violence (Bennett, 1995). As in the case 
Batterers

27

of substance abusers, multiple internal and 

external risk factors appear to influence problem 

development among men who batter. 

Individual Characteristics 

Although batterers are a heterogeneous group, 

research has uncovered a number of 

characteristics that differentiate men who batter 

from men who don’t. Many batterers 

(particularly those who engage in severe 

physical assaults against their partners) 

witnessed parental violence when they were 

children (Hotaling and Sugarman, 1990; 

Pagelow, 1984). While not replicated, findings 

from the large-scale National Family Violence 

Survey that included over 6,000 families suggest 

that experiencing corporal punishment as an 

adolescent may be a risk factor for later partner 

abuse (Straus and Kantor, 1994). As mentioned 

above, chronic alcohol abuse is another 

predictor of violence (Tolman and Bennett, 

1990), and some studies have found that 

batterers are more likely to suffer from 

depression (Hamberger and Hastings, 1986a; 

Saunders and Hanusa, 1986). 

Need for power and control 

Many experts believe that batterers use violence 

or the threat of violence to achieve a sense of 

control, both over their victims and generally 

(Gondolf, 1995). Violence may also reflect a 

personal need for power and domination over 

others. Gondolf, building on McClelland’s 

theory of alcohol and power motivation 

(McClelland, 1975), suggested that the need for 

personal power (reinforced by societal norms of 

male dominance) may be the factor that 

accounts for the high correlation between 

substance abuse and spousal abuse. According 

to this theory, men who have a high need for 

power over others are more likely to abuse 

alcohol and to use violence. Alcohol provides 

an illusion of power; so does beating one’s wife. 

In some cases, a batterer who is drunk can gain 

instant control of his wife—and in a sense his 

entire marital situation—by terrorizing her. 

Furthermore, if the violent incidents are stopped 

through intervention, arrest, or treatment, the 

lack of control perceived by the batterer often 

increases not only the frequency of assault, but 

its severity as well. 

In addition to inflicting physical pain and 

injury, a batterer may also abuse his partner 

psychologically and emotionally. A batterer 

attempts to control the thoughts and feelings of 

the partner by monitoring her behavior, making 

her accountable for his emotional highs and 

lows, denigrating her, criticizing and blaming 

her, and calling her names. Nonphysical abuse 

generally targets the victim’s sense of selfesteem, well-being, and autonomy. Psychological 

abuse can be defined as behavior intended to 

control the victim’s actions and functioning in 

everyday life (often by making her fearful). It 

may take the form of isolating her from her 

friends, family, and other sources of support or 

keeping her from having money to pay bills and 

other expenses. Another form is threatening 

physical harm⎯not only to the victim but to 

family members, friends, or himself. It can also 

be the “silent treatment”: The batterer may 

refuse to speak directly to the victim for 

extended periods, such as days or weeks, 

leaving her guessing about how she has 

displeased or offended him. Emotional abuse is 

denigrating, shaming, ridiculing, or criticizing 

the victim and otherwise attempting to damage 

or destroy her self-esteem. These types of abuse 

often accompany physical violence to some 

degree, although they can also occur in 

relationships that are not physically violent. It is 

unclear how men who batter differ from those 

who don’t in the use of nonphysical forms of 

abuse (see Figure 1-1). 

Any intervention with a batterer that does 

not concomitantly address issues of power and 

control may simply allow the batterer to become 

more sophisticated at other, nonphysical kinds 

of manipulation. To interrupt these types of 
Chapter 3 

28

abuse, couples and/or family therapy may be 

recommended once domestic violence experts 

ascertain that the victim is out of danger. 

Role of anger 

The precise role of anger in battering is unclear. 

When treatment for batterers was first being 

developed, some practitioners viewed anger as a 

primary cause of abuse and believed that 

imparting anger management skills would 

curtail and ultimately eliminate battering 

behavior; others viewed anger as just another 

excuse for violent behavior. Today, many 

researchers and practitioners consider anger as 

only one of a number of antecedents or 

precipitants for violence. Addressing the anger 

is not the same as addressing the larger problem 

of violence, but it may be a useful technique in 

preventing the expression of violence against 

intimate partners (Tolman and Saunders, 1988; 

Tolman and Bennett, 1990).

Consensus Panelists and field reviewers 

concur that although anger is a common 

emotional theme among violent batterers, a 

batterer’s violence is not “caused” by anger. 

They also agree that while anger management 

groups can play an important treatment role, 

they caution that if such groups are not 

judiciously mediated by highly trained 

specialists in domestic violence, they may 

indirectly reinforce violent behavior. 

Inadequately facilitated groups can turn into 

“gripe sessions” that fuel batterers’ anger 

instead of educating them about how to handle 

their feelings without resorting to violence. (For 

an informative debate about anger management 

and batterers’ interventions, see Gondolf and 

Russell [1986] and Tolman and Saunders [1988].) 

Another anger-related issue concerns the 

false belief that “explosive anger” is a hallmark 

of batterers (Stosny, 1995, p. 65), whereas, in 

reality, many batterers are afraid to reveal their 

anger to the outside world and successfully 

present themselves as victims to the clinicians 

charged with treating them (“nothing I do is 

right; she’s always criticizing me”). Some 

clinicians look for overt anger and fail to find it, 

then label batterers as “in denial” about their 

anger. Treatment revolves around “getting 

batterers in touch with their anger and letting it 

out.” Too often, this ill-conceived approach 

(which has been debunked by much 

contemporary literature) has had “disastrous 

consequences for both batterers and their loved 

ones” (Stosny, 1995, p. 66). When responding to 

batterers, it is important to understand the 

complex role that anger plays in both 

precipitating and sustaining violent behavior. 

Responsible treatment incorporates techniques 

for regulating as opposed to revealing anger 

(Stosny, 1995). 

Substance abuse also skews the motivational 

mix of anger and battering in a variety of ways. 

Alcohol and other drugs often serve as mood 

regulators and anger management tools, which 

sometimes exert a calming effect, but also may 

intensify angry feelings. The Consensus Panel 

did not discuss the specific 

psychopharmacological effects of cocaine, 

amphetamine/methamphetamine, or 

phencyclidine or other hallucinogens on 

violence, because there is no evidence to suggest 

that these drugs have any effect on domestic 

violence (although a few studies suggest that 

chronic use may influence aggressive behavior 

in general [Brody, 1990]). Much like efforts to 

understand the links with alcohol, both research 

and experience indicate that personality, 

preexisting brain disorders, and environment 

also play important roles in the relationship 

between substance abuse, anger, and violence 

(Brody, 1990). 

Attachment deficit and 

affect regulation 

As clinicians and researchers have learned more 

about battering, some have begun to consider it 

within the context of an individual’s total 

personality rather than as an isolated behavior. 

In this view, problems with attachment when 
Batterers

29

young, compounded by the experience of 

growing up in a home environment marred by a 

father’s violent behavior and shaming “putdowns,” contribute to the development of a 

“violence-prone borderline personality [who is] 

... addicted to brutality to keep his shaky selfconcept intact. The only time he feels powerful 

and whole is when he is engaged in violence” 

(Dutton, 1995, p. xi). At the same time, the 

painful experience of rejection as a child has also 

bred a deep-seated fear of intimacy or 

“engulfment” (Dutton, 1988; Dutton and 

Browning, 1988). 

Practitioners of psychologically based 

approaches to understanding and treating 

batterers are acutely sensitive to the criticism 

that they are excusing batterers on the basis of 

their underlying psychological problems 

(Dutton, 1995). Supporters of what is often 

termed the psychoeducational approach are 

quick to assert that psychological insights help 

to explain batterers’ behavior; they do not justify 

or excuse it (Dutton, 1995; Stosny, 1995). 

Group Typologies 

While experts agree that the relationship 

between substance abuse and battering is far 

more complicated than cause and effect, some 

attitudes and patterns reappear in men who 

abuse their partners. In an effort to better 

understand and improve treatment for batterers, 

researchers have attempted to group them on 

the basis of common characteristics (Gondolf, 

1988; Hamberger and Hastings, 1986a; Dutton, 

1995; Saunders, 1992). Gondolf organizes 

batterers into three clusters: 

1. “Typical batterers” (the largest group in 

Gondolf’s sample, 52 percent) generally 

confine their violence to their families. For 

the most part, these men are not substance 

abusers, are unlikely to have significant 

mental disorders, have no arrest history, and 

tend to be remorseful after battering 

episodes. In contrast to other batterers, their 

behavior usually results in less severe abuse.

2. Antisocial batterers (41 percent of the sample) 

are extremely abusive and may be violent 

outside the home. This type of batterer is 

emotionally volatile; has some mental health 

problems, such as antisocial personality 

disorder, depression, or anxiety; and may be 

a substance abuser. He may be under the 

care of a physician or in mental health 

therapy. He may have difficulty attending or 

completing a batterers’ program without 

receiving additional mental health services. 

3. Sociopathic batterers (7 percent of the sample) 

comprise the most violent group. Although 

these men are likely to be heavy substance 

abusers, they are the hardest type to engage 

in substance abuse treatment. They have 

little empathy for others, no self-insight, and 

no feelings of guilt or remorse for their 

actions. They are the most likely of the three 

groups to have been arrested (Gondolf, 

1988). 

Hastings and Hamberger characterize 

batterers as having borderline personality 

disorder, antisocial personality disorder, or a 

form of compulsive personality disorder 

(Hamberger and Hastings, 1986a). Saunders 

looked at a range of variables including extent 

and levels of violence inside and outside the 

home, levels of anger and depression, attitudes 

toward women, substance abuse, conflicts in 

relationships, and need for power. According to 

his analysis, those who were violent outside the 

home were the most brutal batterers. They also 

were the most likely to abuse alcohol and to 

have been abused as children (Saunders, 1992). 

In his work, Dutton has observed three types 

of batterers that he classifies as 

1. Psychopathic wife assaulters (40 percent of the 

men in Dutton’s program). These men meet 

the diagnostic criteria for antisocial behavior 

and resemble Gondolf’s sociopaths as well as 
Chapter 3 

30

those men in Saunders’ cluster of men who 

are violent outside the home. Dutton 

believes that the prognosis for treatment is 

poor for this group. In his words, 

“psychopaths don’t look back. As a result, 

they never learn from past mistakes” 

(Dutton, 1995, p. 27). 

2. Overcontrolled assaultive males (about 30 

percent of the men in the program). This 

group consists of men with an overriding 

need for control. In Dutton’s experience, 

they tend to be “perfectionistic” and 

“domineering.” They tend to use emotional 

abuse, including verbal attacks, harassment, 

and withholding of affection to “generate 

submission” (Dutton, 1995, p. 30). 

Overcontrolled assaulters are usually the 

most compliant clients in treatment. 

3. Cyclical/emotionally volatile wife abusers (about 

30 percent of the men in the program). These 

men fear intimacy and suffer from recurrent 

feelings of abandonment and engulfment. 

They are overly dependent on their partners 

and, as a result, are literally “either at their 

wives’ knees or at their throats” (Dutton, 

1995, p. 42). Common traits include “flat 

affect, noncommittal response, and limited 

emotional lexicon” (Dutton, 1995, p. 44). 

They are incapable of describing what they 

feel and tend to repeat the same complaints 

and accusations about their partners over 

and over again. However, it is this group of 

batterers who calculate exactly how severely 

they can injure their partners without leaving 

obvious signs of abuse. It is also this group 

who best fits the “phases of abuse” theory 

first described by Lenore Walker in her 

pioneering work on domestic violence 

(Walker, 1979). These men typically undergo 

a buildup of tension that explodes in an 

episode of acute battering and is followed by 

a remorseful apology and so-called 

“honeymoon period” of concern and 

attention (Dutton, 1995). 

By their very nature, typologies are artificial 

constructs, subject to change as new information 

develops. Despite their limitations, however, 

these groupings suggest that substance abuse 

programs will encounter those batterers who are 

among the most difficult to treat. As an 

example, members of the Consensus Panel 

observed that unlike the cyclical/emotionally 

volatile wife abuser (above), many severe 

batterers, among whom substance abusers are 

overrepresented (Roberts, 1988), do not fit the 

patterns of behavior seen by Dutton and Walker. 

Instead of following up a battering episode with 

a period of remorse (Walker, 1979; Dutton, 

1995), they use the postviolence period as an 

opportunity to blame the victim for starting the 

abuse or to break up with her, or both. 

The following section of this chapter focuses 

on the batterer who is more likely to be seen in a 

substance abuse program. These men have 

multiple problems and function, for the most 

part, in socially and economically impoverished 

environments. Involvement with the criminal 

justice system is almost a certainty, although 

domestic violence may not be the cause. At this 

time, few evaluations exist of batterers’ 

treatment and even the developers of the 

popular “Duluth model” (see Figure 3-1) “have 

no illusion that most men will stop their 

violence and give up their power” (Pence and 

Paymar, 1993, p. xiv). Nevertheless, efforts by 

Consensus Panel members, field reviewers, and 

Statewide Networks Against Domestic Violence 

(such as those in Virginia and Maryland, to 

name just two) indicate that batterers’ treatment 

can be effective if programs place a premium on 

survivor safety (even though the batterer is the 

client), insist that batterers take personal 

responsibility for their behavior, mandate “noviolence contracts,” impart emotional regulation 

techniques, follow up on treatment completers 

and dropouts, and evaluate program outcomes 

regularly (Stosny, 1995). 
Batterers: An Overview 

31

Figure 3-1 

Models for Batterers’ Intervention Programs 

The “Duluth model,” as it is commonly called, was developed at the Domestic Abuse Intervention 

Project in Duluth, Minnesota, (Pence, 1989; Pence and Paymar, 1993) and is probably the most widely 

used model for batterers’ intervention programs in the United States. There are many variations on 

the Duluth model, but all feature victim safety and community coordination as cornerstones and 

require batterers’ programs to be accountable to victims and to victim advocates. The Duluth model is 

based on confronting the denial of violent behavior, exposing the manifestations of power and control, 

offering alternatives to dominance, and promoting behavioral changes. It calls for communitywide 

intervention that employs the resources of law enforcement, courts, domestic violence shelters and 

advocates, health providers, and batterers’ programs. A batterers’ program cannot, in this model, 

exist without the other components in the network. Although some experts feel that the Duluth 

model tends to encourage shame and guilt rather than real change, it sees domestic violence not as a 

form of personal pathology, anger and hostility, or substance-induced behavior, but as an outcropping 

of men’s socially sanctioned domination of women. Batterers’ programs developed under this model 

are designed to educate men about power and control, not merely to assist them in managing anger or 

personal problems. Communitywide coordination ensures that batterers are arrested and prosecuted 

and that victims are protected. 

The psychoeducational model promotes responsibility for violent behavior and the development of 

mechanisms for self-regulation, empathy or compassion for others, and appropriate emotional 

vocabulary to express intimacy. Safety precautions for significant others, no-violence contracts, 

provision of information, changing attitudes toward women, reinforcement or development of values 

via modeling, anger and stress management, and assertiveness skills are key features of this cognitivebehavioral approach (Palmer et al., 1992; Stosny, 1995). Group and individual treatment can be 

utilized within this model, although single-sex groups tend to be the norm. Results of one study 

suggest that highly structured groups (with defined curricula, homework assignments, and skilled 

facilitation) work more effectively than less structured groups (Edleson and Syers, 1990, 1991). 

Couples therapy treats men who batter together with their partners, often in a group setting. This is a 

controversial approach to batterers’ intervention that has fallen into disrepute because of concerns 

about partner safety, its “implicit message that both partners are equally responsible for the violence,” 

and its failure to acknowledge the role of gender and historical power inequities (McKay, 1994, p. 36). 

Substance abuse treatment providers should not treat batterer-and-victim couples together without 

consulting a domestic violence expert. 
Chapter 3 

3

Treatment Issues for the 

Substance-Abusing 

Batterer 

Crisis Intervention and 

The Victim’s Safety 

Like any client entering substance abuse 

treatment, the batterer is typically in a crisis 

state when he first presents for services. He may 

have been referred to treatment by the courts 

after being arrested for drug- or violence-related 

charges, or he may have been left alone by a 

battered partner seeking safety for herself and 

the children. Even when his outward demeanor 

is calm and accepting, violence may be 

imminent. 

Substance abuse counselors typically regard 

a crisis situation as a prime opportunity to 

intervene with a client and engage him in the 

treatment process. In this context, a crisis is 

frequently transformed into a positive event for 

both the substance abuser and those who care 

about him. With substance-abusing batterers, 

the situation is different. Because batterers tend 

to defer responsibility and to project their anger 

onto others, a crisis situation may spur a violent 

incident at home. Examples of crises that may 

precipitate violence include loss of employment, 

the impending loss of family relationships 

through separation or divorce, emotional and 

psychological breakthroughs during 

psychotherapy, a citation for driving while 

intoxicated, court-mandated treatment for 

substance abuse, being served with a restraining 

order, a partner’s pregnancy, or the birth of a 

child. For this reason, when a substanceabusing batterer experiences a crisis, treatment 

providers should have a plan in place for 

addressing the fallout. Although it requires a 

shift in focus from the client to the family, the 

most immediate concern when a crisis occurs is 

the safety of those who have been or may 

become the batterer’s victims, in particular his 

2

partner and children, whether they remain with 

the batterer or not (see Chapter 5 and Appendix 

B for specifics on notification procedures and 

conformance with Federal and State 

confidentiality regulations). 

Family members, and in particular the 

client’s partner, should be consulted regarding 

what is best for their safety (although the 

provider should bear in mind that their version 

of the situation may be somewhat skewed). 

Extreme caution and tact should be used to 

avoid further endangering the victim(s). If 

available, substance abuse counselors should 

refer and defer to trained violence support 

professionals or the partner’s advocate to 

develop a safety plan that includes logistics for 

leaving the home quickly or, if she does not 

want to leave him, other strategies for increasing 

her safety. 

Fostering Accountability 

Because batterers tend to shift responsibility and 

blame onto others, the degree to which a client 

begins to assume responsibility for his actions 

can serve as a barometer for his substance abuse

treatment progress. To that end, assessment and 

monitoring can be incorporated into the 

treatment plan to evaluate the degree to which 

the batterer is taking responsibility for his 

violent actions. The batterer’s accountability can 

be highlighted by linking his actions with 

tangible consequences. One way to achieve this 

is through the use of a “no-violence contract” 

with clearly delineated sanctions for violation 

(see Chapter 4). The substance abuse counselor 

must also be familiar with and understand the 

legal status of the batterer and how it affects his 

access to ongoing treatment services. 

In addition, the use of multiple screening 

measures such as the Revised Conflict Tactics 

Scale (CTS2) for couples (Straus et al., 1996) and 

the Psychological Maltreatment of Women 

Inventory (Tolman, 1989, 1995), both 

reproduced in Appendix C, can aid the 
Batterers

33

treatment provider in determining the extent of 

abuse while focusing the batterer’s attention on 

his behavior. 

Batterers’ Intervention 

Program Models 

If available, collaboration with and referral to 

batterers’ intervention programs can facilitate 

the treatment of substance abusing batterers. 

Some of the models being used today are 

summarized in Figure 3-1. 

Abstinence 

During screening and throughout the treatment 

process, substance abuse counselors should 

explore the context in which the batterer client 

uses alcohol and other drugs in order to identify 

the chain of events and emotions that preceded 

or accompanied particular instances of 

substance abuse and violent episodes. Based on 

their experience, the Consensus Panelists 

recommend eliciting the following information 

about the relationship between the substance 

abuse and the violent behavior: 

 Exactly when in relation to an instance of 

substance abuse the violence occurs 

 How much of the violent behavior occurs 

while the batterer is drinking or on other 

drugs 

 What substances are used before the violent 

act 

 What feelings precede and accompany the 

use of alcohol or other drugs 

 Whether alcohol or other drugs are used to 

“recover” from the violent incident. 

By understanding the dynamics of 

intoxication and abstinence as a precursor to 

violence, the treatment provider can formulate a 

treatment plan that incorporates strategies for 

ensuring the partner’s and other family 

members’ safety and for helping the batterer 

focus on modifying the behaviors and events 

that precipitate substance abuse and violence. 

The focus in treatment must be on encouraging 

the batterer client to develop enough selfawareness to recognize the beliefs and attitudes 

as well as to control the emotions that contribute 

to his violent behavior. 

Bonding With Peers 

Friendships with members of the same sex are 

generally seen as a positive expression of selfdevelopment in both male and female clients 

being treated for substance abuse. Treatment 

staff must be on the alert, however, for signs of 

collusion among male batterer clients who have 

formed close friendships during treatment. 

Although such bonds often help clients learn 

about forming close and trusting relationships 

with others and examine their behavior in 

relation to that of their peers, in some cases, 

violent behavior can be instigated or condoned 

among batterer clients who reinforce each 

other’s excuse-making mechanisms (see Figure 

3-2). 

One field reviewer who works with batterers 

writes that 

In our anger management class, we pursue a 

new definition of manhood through the 

proper exercise of personal power. Personal 

power does not include violence of any kind, 

except for self defense. Personal power 

involves the negotiation of a system that is 

often seen as indifferent and hostile in a 

productive way⎯giving the batterer an 

opportunity to feel powerful in a rational 

manner. We redefine manhood in terms of 

emotional cost-benefit analysis and problem 

solving. Clinically, it appears to be working. 

Parenting 

Many substance abusers, male and female, have 

poor parenting skills, whether or not they are in 

a battering relationship. An examination of the 

client’s parental role is essential to 

understanding his violent behavior, since a 

batterer may use alcohol, other drugs, or 

violence to respond to conflict within the family 

structure. Young boys often learn violent 
Chapter 3 

34

behavior from male role models. Among the 

challenges in substance abuse treatment for 

batterer clients are to 

 Raise the batterers’ awareness of the impact 

of their violence on their children’s future 

behavior 

 Help batterers adopt other, nonviolent 

modes of behavior through anger 

management and coping skills training 

 Reinforce the importance of modeling 

nonviolent behavior in their interactions with 

their partners as well as their children. 

The effects of a batterer’s violence on his 

children has important implications for his 

treatment plan. Although family therapy is 

often an effective component of substance abuse 

treatment, this approach is inadvisable for the 

violent batterer until he has learned to take 

responsibility for his behavior and has learned 

how to respond to crises without using violence. 

Given the potential for harm to both partner and 

children, the Consensus Panel recommends 

postponing family and couples counseling until 

the batterer has demonstrated a pattern of 

nonviolent and noncoercive behavior for a given 

period of time (usually a year). The decision to 

provide or refer for family or couples therapy 

also should be conditional upon whether or not 

the victim freely chooses to participate in 

counseling (the request should be made 

privately; a victim should never be asked to make 

that decision in a batterer’s presence). Until these 

conditions are met, the batterer should be 

treated independently of other family members. 

Ongoing Support 

Over the past 50 years, the substance abuse 

treatment field has grown and developed into a 

national network of 12-Step groups, church 

affiliations, and social systems. In contrast, 

there are no ongoing organizations that support 

change for men who batter or for their victims. 

Figure 3-2 

Positive and Negative Aspects of 

Bonding Among Batterers 

Positive 

 Support for change 

 Amelioration of feelings of isolation; 

support for communicating experiences 

with others 

 Help in dealing with crisis 

 Friendships 

Negative 

 Support for control and dominant 

behavior over partners 

 Support of counterproductive activities 

(e.g., having multiple sexual partners) 

 Support of negative parenting activities 

(e.g., having children by different women) 

 Support for a negative definition of 

manhood

 Support for believing he is correct and 

does not have to negotiate or compromise 

 Access to information on how to violate 

laws such as orders of protection 

 Use of alcohol and other drugs 

 Opportunity to participate in “gripe 

sessions”—tirades against women under 

their control 

 Reinforcement of perceived victim status 

Although some batterers may enter an aftercare 

program following substance abuse treatment, 

most do not. Widely scattered groups called 

Batterers Anonymous (BA) (Goffman, 1984) 

have not been totally embraced by domestic 

violence workers because their emphasis on 

participant anonymity appears to be 

incompatible with the violence field’s focus on 

accountability. Some Consensus Panel members 

fear that, unless a batterer has already 

successfully completed a batterers’ program, 

groups like BA may unwittingly encourage 
Batterers

35

misogyny (see Figure 3-2). On the other hand, 

some field reviewers who work with violent 

substance-abusing clients have found that the 

antiviolence messages of BA and similar groups 

appear to help batterers contain their violence 

by emphasizing the consequences of violent 

behavior. Accredited or certified domestic 

violence programs are sound resources for 

information and referrals to appropriate batterer 

self-help support groups. 

A number of batterers’ intervention 

programs are beginning to offer aftercare 

services. Some are experimenting with 

mentors, who fulfill roles similar to sponsors in 

12-Step programs. In this approach, a 

recovering batterer, under the supervision of a 

batterers’ program or shelter that ensures his 

accountability, mentors a batterer who has 

completed a batterers’ program. Continuing 

contact is essential because program completion 

is not necessarily an indication of whether a 

participant has stopped or even reduced his use 

of violence and coercion. 
37

4 Screening and Referral of 

Survivors and Batterers in 

Substance Abuse Treatment 

Programs

for substance abuse treatment services be 

questioned about domestic violence. Questions 

should cover childhood physical and sexual 

abuse as well as current abuse. (See Appendix 

C.) 

Screening for domestic violence in substance 

abuse treatment settings is undertaken to 

identify both survivors and batterers. The 

domestic violence assessment, like the other 

elements of a substance abuse assessment, 

gathers the specific and detailed information 

needed to design appropriate treatment or 

service plans (Sackett et al., 1991). While the 

Consensus Panel believes that addictions 

counselors can be trained relatively easily to 

screen clients for domestic violence, assessment 

services are more complex and require in-depth 

knowledge and skill. Assessment should be 

conducted by a domestic violence expert if 

possible. 

Once it is determined that a client is a victim 

of domestic violence, a provider must determine

the client’s needs for violence-related services 

such as medical care and legal advocacy. In 

addition to identifying violence as an issue 

affecting substance abuse treatment planning, 

another important purpose of screening for 

domestic violence is to ensure the safety—both 

I t is crucial for substance abuse treatment 

providers to learn if their clients are either 

perpetrators or victims of domestic violence 

as early as possible in the treatment process. 

This chapter details signs to look for and 

techniques for eliciting information about 

domestic violence, which many affected clients 

are understandably reluctant to discuss. The 

suggestions and recommendations in this 

chapter are presented primarily for substance 

abuse treatment providers who work with 

clients involved in domestic violence as either 

batterers or survivors. They may also prove 

helpful to those providing domestic violence 

support services to their clients who have 

concomitant substance abuse problems. 

Screening 

Because of the well-documented relationship 

between domestic violence and substance abuse 

(Leonard and Jacob, 1987; Kantor and Straus, 

1989; Amaro et al., 1990; Pernanen, 1991; Windle 

et al., 1995), and because domestic violence 

affects survivors’ and batterers’ recovery from 

substance abuse (Cronkite and Moos, 1984; 

Smith and Cloninger, 1985), the Consensus 

Panel recommends that all clients who present 
Chapter 4 

38

physical and psychological—of a survivor client. 

(A word of caution: There is a tendency to think 

of residential treatment as a safety zone for both 

batterers and survivors with substance abuse 

problems. Domestic violence experts, however, 

note that batterers in treatment frequently 

continue to harass their partners by 

circumventing program rules and threatening 

them by phone, by mail, and through contacts 

with other approved visitors. Telephone and 

other communication and visitation privileges 

should be carefully monitored for identified 

batterers and survivors in residential programs.) 

Methods of Screening 

For Domestic Violence: 

Survivors 

Substance abuse treatment providers and 

domestic violence support staff use different 

terms to describe the screening process. 

Domestic violence programs refer to the initial 

contact with a client as intake, which is roughly 

analogous to what substance abuse treatment 

providers refer to as screening. Once a woman 

has been accepted to the program, domestic 

violence staff will conduct a psychosocial intake, 

which is similar to assessment in the substance 

abuse treatment field. 

Clues for the Substance Abuse 

Treatment Provider 

The most obvious indicator of domestic violence 

is the presence of physical injuries, especially 

patterns of untreated injuries to the face, neck, 

throat, and breasts. Many survivors of domestic 

violence may be reluctant to seek medical 

treatment because they are afraid that 

documentation of violence in the household will 

result in their children being removed or 

because they are afraid of further violence as a 

result of the disclosure. These women may get 

their injuries treated at a number of different 

clinics or emergency rooms in order to avoid 

documentation of recurrent injuries. 

Other indicators may include a history of 

relapse or noncompliance with substance abuse 

treatment plans; inconsistent explanations for 

injuries and evasive answers when questioned 

about them; complications in pregnancy 

(including miscarriage, premature birth, and 

infant illness or birth defects); stress-related 

illnesses and conditions (such as headache, 

backache, chronic pain, gastrointestinal distress, 

sleep disorders, eating disorders, and fatigue); 

anxiety-related conditions (such as heart 

palpitations, hyperventilation, and panic 

attacks); sad, depressed affect; or talk of suicide 

(McKay, 1994). According to Consensus 

Panelists and field reviewers, many batterers 

intensify their physical attacks when they learn 

their partner is pregnant. 

Another clue is documented or reported 

child abuse perpetrated by the partner of a 

client. Evidence suggests that a father who 

abuses his children often abuses his wife as well 

(Bowker et al., 1988). Providers should be alert 

to the possibility that the mother of a child who 

has been or is being abused by her partner is 

also being abused herself. 

The provider can also glean information 

from a woman’s description of her partner’s 

treatment of her. Behaviors that suggest he may 

be abusing her include 

 Isolating her (keeping her away from family, 

friends, and others who are supportive of her 

recovery from substance abuse) 

 Forcing her to sell drugs or prostitute herself 

for drugs 

 Preventing her from attending treatment or 

12-Step meetings 

 Threatening to harm her, himself, or others 

 Engaging in reckless behavior that endangers 

himself or others 

 Damaging property or belongings 

 Harming other family members or pets 
Screening and Referral 

39

 Threatening to abandon her or to take 

children away. 

During an initial interview, many survivors 

will deny that they have been battered. 

Therefore, treatment staff must be alert to 

indicators of possible domestic violence and 

must continue to pursue them, with sensitivity 

and tact, over the course of treatment. 

Conducting the Interview 

Screening for domestic violence should take into 

account the client’s cultural background and 

environment. Interviewers should be 

knowledgeable about the social mores of clients’ 

groups and trained to avoid culturally bound 

stereotypes and jargon. Anecdotal evidence 

suggests that female interviewers may be more 

effective at working with survivors. 

A substance abuse treatment provider who 

suspects that a client is being abused by her 

partner must use caution and tact in 

approaching this subject. Timing is important, 

too; in most cases, more information about a 

survivor’s experience of violence will begin to 

emerge as she gains confidence and as treatment 

staff continue to foster an atmosphere of trust 

and respect. It is important not to ask 

potentially painful questions too soon; 

otherwise, a client may feel overwhelmed and 

reluctant to return. 

Screening for domestic violence is more 

likely to be effective when the interviewer offers 

concrete examples and describes hypothetical 

situations than when the client is asked vague, 

conceptual questions. If using a yes/no 

questionnaire, interviewers should be prepared 

to follow up on “no” answers. 

Another helpful screening technique is to 

focus questions on the behavior of the client’s 

partner in order to ameliorate any discomfort 

she may feel in talking directly about herself. 

An important caveat to this recommendation, 

however, is that the interviewer should beware 

of “bad-mouthing” or otherwise attacking the 

batterer, as doing so may cause the abused client 

to defend the batterer and assume the role of his 

ally. 

Setting is also important in asking clients 

sensitive questions about their home lives. 

Privacy and an atmosphere of trust and respect 

are necessary if the interviewer expects to obtain 

candid answers to screening questions, 

especially since survivors may for many reasons 

be unable to tell the whole truth about being 

abused. It is of utmost important for treatment 

staff to be aware that a client who may be a 

survivor of domestic violence should never be 

asked about battering when she is in the 

presence of someone who might be her batterer. 

In fact, providers should always interview 

clients about domestic violence in private, even 

if the woman requests the presence of another 

person who is unlikely to be her batterer. It is 

not uncommon for batterers to manipulate 

friends and family members into relaying 

information they heard in the interview that 

would put the client at risk. Her potential 

abuser may be a boyfriend or spouse, a 

stepfather or father, a mother’s boyfriend, or a 

male sibling. Querying her in the presence of 

the abuser can seriously endanger her and may 

place her at risk of reprisal. In addition, 

obtaining accurate information from a survivor 

is highly unlikely in this situation. 

Uncovering past sexual abuse 

The Consensus Panel recommends that 

treatment providers ask about the substanceabusing client’s family of origin in a way that 

gives the client “permission” to talk about it 

openly. For example, providers might preface 

their questions with, “In most homes where 

there is substance abuse, families have other 

problems, too. I’m going to ask some questions 

to see whether any of these things have 

happened to you or your family.” Again, the 

interviewer should keep reassuring the client of 

confidentiality and safety while asking the 

following questions: 
Chapter 4 

40

 “Were you ever told by an adult to keep a 

secret and threatened if you did not?” 

 “Were you ever forced to watch sex between 

other people?” 

 “Were you ever touched in a way you didn’t 

like?” 

 “How old were you when you first had sex 

(including anal, vaginal, and oral 

penetration)?” Then, “How old was the 

person you had sex with?” 

Uncovering current abuse 

Discussion of childhood abuse may open the 

door to discussion of current violence. In 

moving the interview from past to current 

violence, the possibility that they are survivors 

should be explored first, before questions about 

perpetrating violence themselves. This initial 

screening can be done by asking questions such 

as 

 “Do you feel safe at home?” 

 “Has anyone in your family ever physically 

hurt you?” 

 “Has anyone in your family made you do 

sexual things you didn’t want to do?” 

 “Have you ever hurt anyone in your family 

physically or sexually?” 

At this point, the interviewer can ask more 

specific questions regarding the nature and 

circumstances of specific incidents. Three 

questions have been cited as key to identifying 

victims of domestic violence: 

 “Have you been hit, kicked, punched, or 

otherwise hurt by someone within the past 

year? If so, by whom?” 

 “Do you feel safe in your current 

relationship?” 

 “Is there a partner from a previous 

relationship who is making you feel unsafe 

now?” (Feldhaus et al., 1997). 

The interviewer might go on to say, “We will 

be talking about these situations at different 

times throughout your treatment, and I want to 

know about any upsetting experiences that you 

may have had. Even if you don’t feel like 

talking about this with me today, it is important 

that we eventually address all aspects of your 

life.” The client should also be asked about her 

thoughts, feelings, and actions in particular 

situations. Questions (such as the following) 

about marital rape and nonconsensual sex 

should be included: 

 “Do you feel comfortable with the ways you 

have sex?” 

 “Has your partner ever forced you to do 

anything sexually that made you feel 

uncomfortable or embarrassed?” 

 “Do you feel you can say no if you don’t 

want to have sex?” 

 “Are you ever hurt during sex?” 

 “How do you feel about talking about safe 

sex and HIV with your partner?” 

The interviewer needs to keep in mind that 

the client who has been sexually assaulted by 

her partner may normalize her experience, 

particularly if it has been a repeated one. If sex 

has always, or nearly always, been accompanied 

by violence or substance abuse, she may believe 

this is typical of all sexual relations. 

If it becomes evident during a screening 

interview that a client has been or is being 

abused by her partner, the following four key 

questions can help delineate the frequency and 

severity of the abuse: 

 “When was the first time you were 

[punished, hurt, or whatever word reflects 

the survivor’s interpretation of abuse]?” 

 “When was the last time you were abused?” 

 “What is the most severe form of abuse you 

have experienced?” 

 “What is the most typical way in which you 

are abused?” 

Sometimes pointing to a body map is easier 

for a survivor client than naming where she has 

sustained injuries from battering (see Appendix 

C). It is also important to include questions 
Screening and Referral 

41

about the extent of her injuries and the batterer’s 

involvement in the criminal justice system. 

Framing the questions

The interviewer should be aware that many 

survivors of domestic violence see the batterer’s 

substance abuse as the central problem or cause 

of the abuse, believing that “if he would just 

stop drinking (or taking drugs),” the violence 

would end. In framing screening questions, it is 

extremely important to convey to the survivor 

that there is no justification for the battering and 

that substance abuse is no excuse. Questions 

such as, “Does he blame his violence on his 

alcohol or other drug use?” or, “Does he use 

alcohol (or other drugs) as an excuse for his 

violence?” serve the dual purpose of 

determining whether the client’s partner may be 

a substance abuser while reinforcing to her that 

substance abuse is not the real reason for his 

violence. 

Nor should questions feed into the batterer’s 

excuse-making mechanism. The interviewer can 

shift the focus and the blame for the abuse away 

from the survivor by asking her questions about 

the batterer such as “Has he always handled 

problems by getting violent?” 

Cultural considerations 

In keeping a client-centered perspective, 

treatment providers must be aware of cultural 

factors that bear on the survivor’s view of her 

experience and her willingness to talk about it. 

For many survivors, being battered is often a 

source of great shame that must be kept secret at 

almost any cost. Others may be unaccustomed 

to talking about family matters openly and 

directly with nonfamily members. To put the 

client at ease as much as possible, it may be 

helpful and appropriate for the interviewer 

initially to seek her permission to ask the 

screening questions, using language such as: “In 

order to help you, I need to know about what 

has been happening in your home. May I ask 

you some questions about you and your 

[partner, boyfriend, husband]? Or would you 

rather be asked these questions at another 

time?” 

Respecting the survivor’s sense of privacy in 

this way can boost her sense of control over her 

present situation. This can be especially 

important in light of the fact that most survivors 

present for services in a crisis. For example, a 

battered woman who seeks help with a 

substance abuse problem may have been 

abandoned by her abusive partner or may be in 

drug withdrawal. Her general feelings of 

powerlessness may be eased somewhat by this 

approach. 

Although most women who are victims of 

abuse appear to respond better to a female 

interviewer, a client should be asked, and 

granted, her preference (Bland, 1995; Minnesota 

Coalition for Battered Women, 1992). If 

translators or hand signers are needed, a neutral 

party (not a family member) should be enlisted 

to perform this function. 

Barriers to an accurate screen 

As mentioned previously, it is common for a 

survivor of domestic violence to evade the issue 

or lie when asked about her abusive 

experiences. Survivors’ reasons for lying about 

being abused are numerous and varied. Many 

blame themselves for the violence and make 

excuses for the batterer’s erratic or destructive 

behavior. For example, a client who has been 

battered by her partner may attempt to justify 

his behavior with comments such as, “I 

deserved it,” “I nagged him,” or, “It was my 

fault.” It is common for a survivor to believe 

that if only she would stop upsetting the 

batterer, or “pushing his buttons,” the abuse 

would stop (American Medical Association, 

1994). As one field reviewer noted, this selfblame may be more a mechanism to explain the 

violence that dominates survivors’ lives than to 

justify it. 

Some survivors go further than downplaying 

and self-blame and deny that there is abuse. 
Chapter 4 

42

Such denial may be a functional mechanism for 

her that helps her avoid dealing with problems 

that seem overwhelming and insurmountable. 

Denial is also, in some cases, an adaptive 

survival technique developed as a direct 

response to unsuccessful attempts to obtain 

help. Additionally, the survivor of domestic 

violence may not be entirely truthful because 

she may be accustomed to using manipulation 

as a survival mechanism. Because survivor 

clients do not know how interviewers will use 

information about battering, they do not always 

divulge it. 

Finally, as discussed in Chapter 2, many 

survivors have concrete reasons for hiding 

domestic violence. A survivor could lose 

custody of her children if it is discovered that 

they live in a violent household. And the 

batterer may well have told her that he will beat 

or kill her or her children if she reports the 

abuse. 

Screening for Domestic 

Violence: Batterers 

Screening Techniques 

And Questions 

A discussion of family relationships is an 

element of all substance abuse screening 

interviews. Based on their experience, the 

Consensus Panel recommends using this 

component of the interview to address the issue 

of domestic violence with male clients. To 

initially gauge the possibility that the client is 

being abusive toward his family members, the 

interviewer can ask whether he thinks violence 

against a partner is justified in some situations 

(Kantor and Straus, 1987). This is the concept of 

“circumstantial violence.” It is best to explore 

this possibility using a third person example so 

as not to personalize the question or make the 

client feel defensive; for example: “Some people 

think that, under certain circumstances, it’s OK 

to hit your wife (girlfriend, etc.). Under what 

circumstances do you think violence might be 

justified?” 

The answer reveals clues about whether and 

when a client might use violence against his 

partner. The interviewer can now shift the 

questions to the client himself. The interviewer 

can ask questions to assess the client’s sense of 

self-efficacy and self-control: 

 “If you were faced with overwhelming stress 

(use a hypothetical situation), do you think 

you could keep your cool?” 

 “What do you think you’d do?” 

Specific questions about events in the client’s 

family, particularly his own current worries, 

may provide a sense of the environment in 

which violence may be occurring. 

Part of an interviewer’s aim here is to give 

the client a good reason to discuss the violence 

in a manner similar to that described for 

interviewing survivors⎯to help the client see 

that there are benefits to acknowledging the 

abuse. The interviewer may tell the client that 

violence toward a partner is not uncommon 

among the other people enrolled in a treatment 

program, opening the door for the client to 

respond truthfully. 

By taking an open-ended social and family 

history, the interviewer can gradually move to 

specific, direct questions regarding violence and 

abuse in the current relationship. For example: 

 “Have you ever been physically hurt by 

someone in your family?” If the client’s 

partner has hurt him or her, the reverse may 

also be true. 

 “Have you ever hurt someone in your 

family?” 

 “Have you ever physically controlled, hit, 

slapped, or pushed your partner?” (If yes) 

“When was the last time this happened?” 

Some batterers are so focused on their 

substance abuse problems that the violence is 

relatively unimportant to them. Others have 
Screening and Referral 

43

lived with violence for so long that they have 

little understanding of the nature of their own 

behavior. Such individuals may provide 

information about their abusive behavior only 

incidentally or may dismiss it as unimportant. 

In their Guidelines for Talking to Abusive Husbands 

(EMERGE, 1995), experts from the EMERGE 

domestic violence support program recommend 

that providers: 

 Ask specific, concrete questions (e.g., “What 

happens when you lose your temper?”). 

 Define violence (e.g., “When you hit her, was 

it a slap or a punch?” “Do you take her car 

keys away? Damage her property? Threaten 

to hurt or kill her?”). 

 Find out when the violence occurs and who 

the target is. 

 Be direct and candid. (Resist the urge to use 

a euphemism such as, “Is your relationship 

with your partner troubled?” because you 

are uncomfortable asking the question. 

Instead, talk about “his violence” and keep 

the focus on “his behavior.”) 

 Become familiar with batterers’ excuses for 

their behavior: 

♦ Minimizing: “I only pushed her.” “She 

bruises easily.” “She exaggerates.” 

♦ Citing good intentions: “She gets hysterical 

so I have to slap her to calm her down.” 

♦ Use of alcohol and drugs: “I’m not myself 

when I drink.” 

♦ Claiming loss of control: “Something 

snapped.” “I can only take so much.” “I 

was so angry, I didn’t know what I was 

doing.” 

♦ Blaming the partner: “She drove me to it.” 

“She really knows how to get to me.” 

♦ Blaming someone or something else: “I was 

raised that way.” “My probation officer is 

putting a lot of pressure on me.” “I’ve 

been out of work.” 

 Don’t be manipulated or misled by excuses. 

(Identify violence as a problem and hold the 

client responsible for his actions.) 

Avoiding Collusion 

Avoiding the implication that substance abuse is 

the “cause” of violence is as important in 

screening batterers as it is in screening 

survivors. Batterers often blame the victim, the 

victim’s substance abuse, or their own substance 

abuse for the battering. In asking screening 

questions such as those just described, substance 

abuse treatment providers must be careful not to 

enable a batterer to place the blame for the 

battering on the victim or the drug. 

Interviewers must neither directly nor indirectly 

support the batterer’s assertion that some other 

force has caused the violence or substance abuse 

(Cayouette, 1990). 

An example of collusion would be the 

interviewer’s assent that the client drinks 

because of some external source of stress, such 

as his job or his wife’s “nagging.” It is common 

for the survivor herself to think, feel, and act in 

accordance with this view, so often a tacit 

agreement exists between a batterer and a 

survivor to blame the latter for the violence. The 

client’s failure to take responsibility for his 

behavior is further reinforced when a treatment 

provider or other team member speculates that 

circumstances, rather than the individual, are 

the cause. 

Interviewing the Partner 

Since clients who disclose their violence toward 

their partners often minimize its frequency and 

severity, experienced domestic violence staff 

may interview the batterer’s partner in order to 

obtain salient information about his 

dangerousness to himself, his partner, and 

others. In fact, many batterers’ programs 

require batterers to give permission for staff to 

interview the female partner as a prerequisite 

for acceptance into the program. This type of 

collateral interviewing, however, is quite 

different from that practiced in the substance 

abuse treatment setting and requires specialized 

skills and expertise. Prior to conducting the 
Chapter 4 

44

interview, violence support staff and the 

involved partner carefully weigh the risks 

associated with participating in such an 

interview (e.g., the possibility that it may 

precipitate another battering incident). If the 

partner agrees to the interview, she will be 

interviewed alone. Her perspective will be 

compared with the batterer’s and used carefully 

and sensitively by the violence specialist in 

working with the batterer. (Appendix C 

presents an example of a survivor questionnaire 

that is used as a tool in assessing a batterer’s 

dangerousness.) 

Many substance abuse treatment providers 

routinely facilitate therapy sessions with 

substance abusers and their families. However, 

this approach should not be used with substanceabusing batterers and their partners. While 

substance abuse programs can cooperate with 

batterers’ programs by reinforcing “no violence” 

messages and behaviors, providers should refer 

the client to a domestic violence specialist for 

further assessment and intervention. Some 

batterers’ programs will not accept active 

substance abusers. In that case, participation in 

a batterers’ program can become a specified part 

of the aftercare plan (Engelmann, 1992). 

Screening for Presence 

Of Child Abuse 

When family violence comes to the attention of 

the treatment provider, it is essential to 

determine whether children have been present 

or have been involved in any way. During the 

initial screening of the client, the Consensus 

Panel recommends that the interviewer should 

attempt to determine whether the children have 

been physically harmed and whether their 

behavior has changed (e.g., they have become 

mute or they scream or cry). 

The confidentiality regulations spelled out in 

Title 42, Part 2, of the Code of Federal Regulations

require that a client be given notice regarding 

the limitations of confidentiality⎯orally and in 

writing⎯upon admittance to a substance abuse 

treatment program (see Appendix B). Inquiries 

into possible child abuse should not occur until this 

notice has been given and the client has 

acknowledged receipt of it in writing. Great care 

must be taken when approaching either a 

batterer or a survivor of domestic violence about 

whether any children in the household have 

been abused. 

There may be a number of barriers to 

obtaining a complete and accurate picture of the 

children’s situation from these clients. First, 

adults who abuse children are generally aware 

of the laws that require substance abuse 

treatment providers, among others, to report 

suspected child abuse to agencies such as 

children’s protective services (CPS), and they 

tend not to volunteer such information for fear 

of recrimination. Second, a survivor may be 

aware that her perceived “failure” to protect her 

children from violence may have implications 

for her retaining custody of them. Such fears are 

likely to be reinforced by her feelings of shame 

and guilt over “letting it happen.” Or she may 

be abusing the children herself. 

It is not advisable for the substance abuse 

treatment provider to perform an assessment of 

children for abuse or incest; this function should 

be performed by personnel with special 

expertise. The substance abuse treatment 

provider should, however, note any indications 

of whether abuse of children is occurring in a 

client’s household and pass on what they find to 

the appropriate agency. 

Indications of Child Abuse 

In the Consensus Panel’s experience, clues to 

possible child abuse may be obtained by 

questioning the client regarding 





Whether CPS has been involved with anyone 

who lives in the home 

Children’s behaviors such as bedwetting and 

sexual acting out 
Screening and Referral 

45

 “Special” closeness between a child and 

other adults in the household 

 The occurrence of “blackouts”: Batterers 

often claim blackouts for the period of time 

during which violence occurs. 

This area of questioning need not be repeated 

for each child in the household, but rather can 

be done in a general way in order to get a sense 

of the overall family environment. 

If a treatment provider suspects that the 

child of a client has been a victim of violence, he 

or she must refer the child to a health care 

provider immediately. If it appears that the 

parent will not take the child to a doctor (who is 

required by law to report the suspected abuse), 

the provider must contact home health services 

or CPS. This should be done even if a child 

appears to be unharmed, because some injuries 

may not be immediately apparent. 

Immediate attention to the child’s emotional 

state is also important. Emergency room 

physicians or nurses who conduct physical 

examinations may not be in a position to 

thoroughly assess the impact of abuse on the 

child’s emotional status. Initially, it may be that 

the most that can be done is to reassure the child 

that he is safe and will be taken care of. Ideally, 

however, he should be referred to a therapist 

who specializes in counseling traumatized 

children. 

Reporting Suspected 

Neglect or Abuse 

Clients must be informed that mandated 

reporters, a category that includes substance 

abuse treatment providers, are required to 

notify CPS if they suspect child abuse or neglect 

(see Chapter 5, Legal Issues). In addition, a 

client can be informed of the right to report his 

or her partner’s abuse of children. Whatever 

decision is made concerning who will actually 

notify CPS, ultimately it is the mandated 

reporter’s responsibility to ensure that this is 

done. 

The treatment provider must assess the 

impact on a survivor client of reporting 

suspected or confirmed child abuse or neglect. 

If she cannot be protected from her abuser on a 

24-hour basis, she may become the object of his 

violence if he blames her for the report, so a 

safety plan should be developed. It is equally 

important to prepare for the impact of reporting 

child abuse on the children and on the family as 

a whole. The possible results of such a report 

must be considered and explained to the client 

in advance. For instance, if CPS is unable to 

confirm that abuse or neglect has occurred, the 

children could be endangered if the abuser 

learns of the report. In other instances, CPS may 

remove the children from the home until further 

investigation can be undertaken. If the 

investigation confirms abuse or neglect, a series 

of court appearances will be required, and 

children may be placed in foster care either in 

the short or long term. In any case, it is 

imperative for professionals working with 

family members to provide information about 

what to expect and, if at all possible, talk with 

the CPS caseworker and accompany the family 

to court hearings. Child abuse and neglect is a 

complicated issue and will be discussed in detail 

in a pending Treatment Improvement Protocol. 

Referral 

When answers to screening questions suggest 

that clients may be either batterers or survivors 

of domestic violence, the Consensus Panel 

recommends an immediate referral to a 

domestic violence support program. When 

referrals are not possible, ongoing consultation 

with a domestic violence expert is strongly 

encouraged. In some instances, clients have 

been mandated into substance abuse treatment 

by the courts. Participation in a battering 

program may be another court-mandated 

requirement. Substance abuse treatment 

providers should not hesitate to use the leverage 
Chapter 4 

provided by the criminal justice system to 

ensure that clients who batter participate in 

batterers’ treatment as well. 

Referring Survivors 

If, during the screening, the client reveals that 

she is in immediate danger, the counselor needs 

to attend to this danger before addressing other 

issues and, if necessary, should suspend the 

interview for this purpose (Sullivan and Evans, 

1994). The treatment provider should be 

familiar with methods for de-escalating the 

situation or obtaining help (see Appendix D for 

a safety plan) and may advise the client to take 

some simple legal precautions and to safeguard 

important documents (see Figures 4-1 and 4-2). 

If the client and counselor decide to involve the 

police, they should first discuss possible reprisal 

by the batterer and plan a response. 

A substance abuse treatment provider may 

be the first person to whom the survivor has 

revealed her victimization. Whether she has 

previously disclosed the abuse to other agencies 

or programs will have a bearing not only on the 

level of danger she is in or perceives herself to 

be in, but will also have an impact on the 

process of establishing linkages with other 

agencies and sources of support. 

If screening reveals domestic violence, then 

further assessment is required. Though the 

substance abuse treatment provider should help 

the client build a safety plan, assessment is best 

performed by a domestic violence support 

program. Questions that will aid referral 

include 

 “To whom have you talked about this in the 

past?” 

 “Are you, or is anyone in your family, 

currently in danger from someone in your 

household? Do you think that being here 

now, talking to me, could put you in danger? 

If so, how?” 

46

Figure 4-1 

Safeguarding Important Documents 

As part of the survivor’s safety plan, it may 

be helpful to advise the survivor client to 

keep important documents in a safe deposit 

box or in a place where her partner cannot 

gain access to them. These materials may 

include some or all of the following: 

 Social security documents 

 Marriage license 

 Passport(s) 

 Copies of any protective orders or divorce 

or custody papers 

 Green card 

 Children’s birth certificates 

 Information about medical history, 

including vaccination schedules for 

children and records on health care visits 

 Extra sets of home and car keys 

 Photographic documentation of abuse 

 Deeds or leases that document residence, 

titles to cars 

 Other financial documents such as 

savings deposit books and payment 

books 

If a survivor client expresses concern about 

the safety of her children, especially if they are 

left in the care of the batterer while she is in 

treatment, this is the time to refer the client for 

shelter and legal advocacy. Resources can be 

identified by contacting a local domestic 

violence program, or, if one is not available, a 

State program. The National 24-Hour Domestic 

Violence Hotline (1-800-799-SAFE) is another 

resource for domestic violence programs. 

Substance abuse treatment facilities should 

ensure that these resources are readily available 

to their staff. 
Screening and Referral 

47

Figure 4-2 

Gathering Documentation 

All States have mandatory reporting laws for child abuse, but only some have or are developing such 

laws for reporting domestic violence. Some battered women’s advocates support such laws because 

they “take the pressure off” the victims to report their batterers. Some domestic violence service 

providers also believe that it is the community’s responsibility⎯not the victim’s⎯to stop the 

batterer’s behavior. Some States mandate the arrest of batterers whether or not their victims press 

charges, and some are proposing mandatory physician reporting of battering. Concerns have been 

raised, however, about preserving victims’ ability to decide whether they want to become involved in 

the criminal justice system or in domestic violence programs. For this reason, such laws are opposed 

by some battered-women’s groups, who believe they put women at greater risk. 

Regardless of whether a survivor elects to pursue legal remedies, she is well-advised to document 

the nature and extent of the domestic violence she and her family have experienced by compiling 

copies of 

 Criminal justice reports, including prior legal actions (e.g., restraining orders) against batterers 

 Any previous CPS reports that can be obtained 

 Hospital records and health history of the client 

Complete criminal justice and medical records may be difficult to obtain. In the case of medical 

records, for example, survivors may have made visits to numerous institutions (e.g., clinics and 

emergency rooms) in order to avoid raising the suspicion of domestic violence. Issues of 

confidentiality also may be an impediment to obtaining these records. (See Appendix B for more 

information on confidentiality.) When clients are unsuccessful in compiling information from 

standard sources, their self-reports to substance abuse treatment providers, documented in their 

program records, can be used to fill in the gaps and to help support their claims. When entering notes 

into the client’s record, however, it is important to include the facts as presented or observed. Records 

can be subpoenaed and “gratuitous comments or opinions” may be used against survivors in custody 

cases (Minnesota Coalition for Battered Women, 1992, p. 41). 

Referring Batterers 

When suspected batterers are identified during 

the screening process, substance abuse 

treatment providers should refer them to 

batterers’ intervention programs as a key part of 

the treatment plan. With the client’s signed 

consent to release information, substance abuse 

counselors can share pertinent information with 

domestic violence staff in an effort to ensure that 

both problems are addressed. 

Well-run batterers’ treatment programs may 

not be available in every community. Before 

initiating referrals, the Consensus Panel 

recommends that substance abuse treatment 

staff compile a list of potential programs and 

providers, check their credentials with domestic 

violence support programs for survivors or local 

battered women’s shelters, and contact 

appropriate programs or specialists to establish 

agreed-upon referral procedures. 
Chapter 4 

48

The confidentiality regulations do not inhibit 

such referrals as long as consent to release 

information has been obtained and the 

procedures detailed in Appendix B have been 

followed. 

Treatment Concerns for 

Survivors and Batterers 

Even though a provider has referred a client 

involved in domestic violence to a survivors’ or 

batterers’ program or incorporated participation 

in such programs as part of the aftercare plan, 

domestic violence remains an issue. The 

treatment provider should see that the following 

actions are taken, either by the substance abuse 

or violence program or by a case manager 

assigned responsibility for the client’s holistic 

care. 

The “No-Contact Contract” 

Some survivors’ programs require participants 

to sign a contract agreeing to have no contact 

with their batterers for the duration of the 

program. In addition to helping to ensure her 

safety, such contracts can provide opportunities 

for staff to evaluate a survivor’s current 

attitudes toward and thinking about the 

batterer. Such “reality checks” can be helpful if, 

as is often the case, a survivor begins to believe 

the batterer’s assurances that he has changed 

and is no longer violent. The staff can point out 

the reality of the situation if the batterer is still 

abusing alcohol or other drugs and has not 

changed his life in any significant way. 

The “No-Violence Contract” 

Batterers entering treatment for substance abuse 

can be required to sign a contract agreeing to 

refrain from using violence. While such “noviolence contracts” are most effective when 

linkages with batterers’ intervention programs 

are also in place, they can help structure 

treatment by specifying an achievable 

behavioral goal. It is more difficult for clients to 

play one agency against another when all those 

involved in a particular case prescribe common 

goals. When the court has a role in mandating 

treatment services and specifying sanctions for 

failure to comply, clients have an added 

incentive to adhere to such stipulations as “noviolence” contracts. Consensus Panel members 

believe that the prospects for positive outcome 

(e.g., reductions in substance abuse and 

domestic violence) will be improved when 

substance abuse and batterers’ treatment 

programs and the courts collaborate to ensure 

that needed services are provided, consistent 

behavioral messages are communicated, and 

consequences for violating contracts and other 

programmatic stipulations are upheld. 

Recovery Pitfalls for Batterers 

And Survivors 

A number of violence support experts, including 

members of the Consensus Panel, have observed 

a tendency among some substance-abusing 

batterers to twist the messages of 12-Step 

programs in order to evade responsibility for 

their violent behavior: 

Men in recovery often gain more tools of 

abuse from their distorted interpretation of 12-

Step and treatment programs. One of the most 

frequently used tools by batterers in groups 

has been the label of codependent. Men use it 

to put down their partners, saying this means 

battered women are as sick or sicker than 

them, to define victims as at least partly 

responsible for their violence, and to 

manipulate women into feeling guilty and 

ashamed of their expectations that men stop 

abusing. (Cayouette, 1990, p. 3) 

Providers should be alert to signs that clients 

are misinterpreting the 12-Step philosophy to 

justify or excuse continued violence, especially 

since 12-Step programs can play a valuable role 

in supporting batterers’ treatment as well as 

recovery from substance abuse when its 

principles are followed rather than distorted 

(Wright and Popham, 1995). Men who have 
Screening and Referral 

49

embraced the 12-Step model will often challenge 

the excuse-making of batterers, encouraging 

them to take responsibility for all their actions, 

including the domestic violence. (Cayouette, 

1990). 

Group therapy is an essential feature of most 

substance abuse treatment programs. However, 

members of the Consensus Panel who have 

worked extensively with substance-abusing 

survivors observe that survivors “may have an 

especially difficult time talking about past 

experiences if men are included in the group. 

Often, the safest and most comfortable time for 

her to discuss violence is during one-on-one 

sessions with her counselor. These sessions are 

also an opportune time to ask about her needs 

regarding the abuse” (Minnesota Coalition for 

Battered Women, 1992, p. 39). Survivors also 

appear to benefit by participating in same-sex 

groups that do not use confrontational 

techniques (Minnesota Coalition for Battered 

Women, 1992; Wright and Popham, 1995). 

Ongoing Attention to Issues 

Of Domestic Violence 

As discussed previously in this chapter, many 

survivors and batterers presenting at substance 

abuse treatment facilities do not disclose 

domestic violence on intake, and treatment 

providers must rely on signs of violence that 

become apparent as the client spends time in 

treatment. Ongoing attention to issues of 

domestic violence is particularly important in 

these clients not only because it may take time 

for them to begin talking about it, but also 

because as they become abstinent, additional 

issues arise that are integrally related to the 

violence (Prochaska et al., 1992, 1994a, 1994b; 

Snow et al., 1994; Velicier et al., 1990). As with 

substance abuse, the full dimensions of a 

domestic violence problem are seldom 

immediately clear and may emerge 

unexpectedly at a later stage in treatment. If this 

happens, questions posed during screening can 

be asked again, and a referral to a violence 

support or batterers’ intervention program can 

be initiated. 
51

5 Legal Issues 

strengthening prevention and prosecution of 

violent crimes against women and children, the 

law made domestic violence a civil rights 

violation. What this means is that a victim of 

“crimes of violence motivated by gender” can 

bring a suit for damages in civil court in 

addition to any charges made in criminal court. 

Some of the more important provisions of the 

law include 

 Greater penalties for sex crimes 

 Funding for States to improve law 

enforcement, prosecution, and services for 

female victims of violent crimes 

 Increased security in public transportation 

systems and national and urban parks 

 Funding for rape prevention and education 

programs, targeted to, among others, middle 

and senior high school students 

 Enhanced treatment for released sex 

offenders 

 The development of model confidentiality 

legislation 

 Funding for programs for victims of child 

abuse as well as for individuals who are 

homeless, for runaways, and for street youth 

at risk of abuse 

 The creation of a national domestic violence 

hotline 

 Funding to improve mandatory arrest or 

proarrest (a policy stating that police will 

make arrests in domestic violence incidents) 

programs, to improve tracking of domestic 

violence cases, to increase coordination of 

A ll jurisdictions in the United States 

have implemented regulations and 

laws designed to protect victims of 

domestic violence. The Violence Against 

Women Act (VAWA), which was signed into 

law by President Clinton in September 1994, 

strengthens many of these protections and 

outlines Federal as well as State enforcement 

provisions and penalties. The Federal penalties 

mandated by VAWA are more stringent than 

existing State penalties: The bill, for example, 

makes it a Federal offense to cross State lines in 

violation of a civil protection order. In order to 

provide useful advice and support, substance 

abuse treatment providers should be familiar 

with VAWA and with relevant State and local 

regulations as well as with the legal resources 

available to victims of domestic violence. 

Substance abuse treatment providers should 

also have working relationships with the 

criminal justice system and local providers of 

legal and domestic violence services to whom 

they can refer a client with such problems. (See 

Appendix E for a listing of national programs 

and hotlines that can help providers identify 

local services.) 

Federal Law 

The Violence Against Women Act 

VAWA is a civil rights statute that was passed 

as part of the Violent Crime Control and Law 

Enforcement Act (Public Law 103-322). Besides 
Chapter 5 

52

services, to strengthen legal advocacy, and to 

educate judges 

 The prohibition of the purchase of firearms 

by individuals subject to a final civil 

protection order 

 The implementation of more protections for 

battered immigrant women and children, 

including liberalization of the “battered 

spouse waiver” enforced by the Immigration 

and Naturalization Service (INS). 

Some provisions of VAWA may be 

particularly important to women in substance 

abuse treatment who are also survivors of 

domestic violence. Under VAWA, 

 Past sexual behavior or alleged sexual 

predisposition of the victim is no longer 

admissible evidence in civil or criminal 

proceedings involving sexual misconduct. 

 New Federal criminal penalties apply to 

anyone who crosses a State line in order to 

commit domestic violence or to violate a civil 

protection order. 

 Anyone who forces a spouse or domestic 

partner to cross a State line for these 

purposes also is subject to penalties. 

 States are required to enforce civil protection 

orders issued by the courts of other States. 

 Victims must have the opportunity to testify 

regarding the potential danger of the pretrial 

release of a defendant. 

 Defendants are required to make financial 

restitution to victims. 

 The U.S. Postal Service is required to 

maintain the confidentiality of shelters and 

individual abuse victims by not disclosing 

addresses or other locating information. 

One of the most important aspects of VAWA 

is the civil rights remedy for gender-motivated 

violence mentioned above. Relief in civil court 

may include monetary damages, injunctions, or 

declaratory judgment to redress the civil rights 

violation. 

As of this writing, at least one district court 

decision has been issued that upholds the 

provisions of VAWA. In Doe v. Doe (929 

F.Supp.608 D.Conn. 1996), a woman sought 

damages for 17 years of “physical and mental 

abuse and cruelty” by her husband. He moved 

to dismiss the case on the grounds that VAWA 

was unconstitutional. The Federal district court 

denied the motion to dismiss and upheld 

VAWA’s constitutionality. If VAWA withstands 

other pending challenges, it may become an 

important weapon for women seeking to break 

free from battering partners.

Welfare Reform 

The issue of preventing domestic violence has 

important implications for welfare reform; when 

considered in conjunction with issues involving 

substance abuse treatment, the overall picture 

becomes extremely complicated. In fact, some 

States (such as Kansas) have established laws 

that require people receiving welfare to be 

screened, assessed, and treated for substance 

abuse. It is important for treatment providers to 

be aware of the issues involved; careful 

coordination of services with domestic violence 

workers can help to avoid serious problems 

(Raphael, 1996). 

The Personal Responsibility and Work 

Opportunity Reconciliation Act of 1996 (Public 

Law 104-193), signed into law on August 22, 

1996, calls for greater use of paternity 

determinations to enforce child support 

regulations. This can be problematic for welfare 

recipients who are victims of domestic violence. 

Abuse is often exacerbated or reactivated when 

legal action is taken against the batterer for child 

support. Many abused women are afraid to 

seek child support because they fear that doing 

so will result in the batterer being given 

visitation rights, which would force disclosure 

of their new location. Although current Federal 

law does provide “good cause” exemptions in a 

number of situations, including domestic 
Legal Issues 

53

violence, this option is used by fewer than 1 

percent of welfare applicants nationally 

(Raphael, 1996; Zorza, 1995b). Providers should 

tell survivor clients concerned about 

confidentiality that these exemptions exist. 

Local Laws: Civil 

Protection and 

Restraining Orders 

The most common and easily obtainable 

mechanism of relief for victims of domestic 

violence is the civil protection order. This 

general term includes any injunction or other 

order (such as a restraining order) that is issued 

for the purpose of preventing violent or 

threatening acts against another person. 

Generally, these orders prohibit harassment, 

contact, communication, or physical proximity. 

Protection orders may be temporary or final and 

may be issued by a civil or a criminal court. 

Protection orders can be issued independently 

or as part of another proceeding, such as a 

divorce or criminal complaint, but are separate 

from support or child custody orders. 

Statutes and case law in all States and the 

District of Columbia allow an abused adult to 

petition the court for an order of protection, and 

in most State courts, a parent or another adult 

can file for a civil protection order on behalf of a 

minor child (Klein and Orloff, 1993). Depending 

on the relevant statutes and case law on the 

books of any given jurisdiction, conduct 

sufficient to support issuance of a civil 

protection order can include 

 Criminal acts (most commonly battery, but 

also criminal trespass, robbery, burglary, 

kidnapping, malicious mischief, and reckless 

endangerment) 

 Sexual assault and marital rape 

 Interference with personal liberty 

 Interference with child custody 

 Assaults involving motor vehicles 

 Harassing behaviors 

 Stalking 

 Emotional abuse 

 Damage to property 

 Transferred intent (in which someone other 

than the petitioner is injured by violence 

directed toward the petitioner) (Klein and 

Orloff, 1993). 

State courts have consistently upheld the 

constitutionality of domestic violence statutes. 

Civil protection order statutes have been held to 

rationally and reasonably uphold the State’s 

interest in preventing domestic abuse, because 

these statutes do not 

 Deprive abusers of liberty and interest in 

their homes 

 Deprive abusers of their families or 

reputations 

 Inflict cruel and unusual punishment 

 Violate equal protection, due process, 

freedom of association, or free space. 

In addition, courts have found that 

procedural aspects of civil protection orders do 

not violate the defendant’s right to a jury trial. 

Most jurisdictions allow an individual to 

petition for civil protection with or without the 

aid of a lawyer. In fact, some courts have 

upheld laws that permit court clerks to assist 

petitioners in filing for protection orders. 

Although the assistance of legal counsel is 

preferable, pro se representation—or selfrepresentation—is an option for victims who 

cannot afford the services of an attorney. Pro se 

actions allow domestic violence survivors to 

seek the immediate protection of the courts, and 

it can also empower them as they seek to gain 

control of their lives. Furthermore, many areas 

lack attorneys who are able and willing to act as 

advocates for battered women, although in 

some jurisdictions lay advocates are available to 

counsel victims of domestic violence, help 

prepare court papers, and handle 

uncomplicated cases in court.
Chapter 5 

54

Other Legal Issues 

For many clients, treatment for substance abuse 

includes an effort to acknowledge—to 

themselves and perhaps to others—the harm 

they have visited on family and friends. A 

victim of domestic violence will explore the role 

substance abuse played in the abusive 

relationship. A perpetrator of domestic violence 

may have agreed to enter treatment in lieu of 

trial or incarceration; he will need to examine 

that aspect of his behavior as well as his 

substance abuse. Finally, a client who enters 

treatment presenting an entirely different 

constellation of issues may disclose during the 

course of counseling that he or she has either 

assaulted or been assaulted by a spouse. During 

the course of counseling victims—or 

perpetrators—of domestic violence, substance 

abuse program staff will hear about violent 

behavior. What is the program’s legal obligation 

in such circumstances? How should programs 

deal with inquiries from lawyers or criminal 

justice officials? What should a program do 

when a counselor or client records are 

subpoenaed or the police come armed with a 

search warrant? This section discusses these 

issues and the tension between the need to 

protect people from harm and the need to 

respect the client’s confidentiality. 

Confidentiality is protected under 42 Code of 

Federal Regulations (C.F.R.), Part 2, implementing 

42 U.S.C. §290dd-2. (All references to §2 . . . 

below refer to these regulations.) 

Although the Federal confidentiality 

regulations may prohibit reporting domestic 

violence to law enforcement authorities, 

substance abuse treatment providers should still 

ask about it. Whether the information is passed 

along or not, it still bears on treatment. 

Providers should acknowledge the abuse; help 

the client separate her responsibility from that of 

the batterer; counsel her that the violence may 

escalate; help assess her safety and offer 

available options; clearly document the abuse 

(enlisting the aid of a forensic examiner, if 

necessary); provide referrals to shelter, legal 

services, and counseling; and facilitate such 

referrals with her consent. Treatment providers 

must not let confidentiality restrictions prevent them 

from routinely inquiring about domestic violence in 

the course of providing appropriate care to clients. 

Reporting Child Abuse 

And Domestic Violence 

What should a program do when a client admits 

he has battered his spouse at some time in the 

past—or during his participation in treatment? 

Does the program have a duty to call law 

enforcement officials if a woman threatens to 

assault her husband or child—an act the 

counselor knows she has committed in the past? 

What can a program do if a client attacks his 

wife at the program? These are three very 

different questions that require separate 

analysis. 

Is there a legal duty to 

report past crimes? 

The general question about the duty to report 

past criminal activity is one that arises 

frequently for substance abuse treatment 

programs. Many substance abusers engage in 

criminal behavior while they are abusing drugs 

and even during the course of treatment. In a 

situation in which a client has told a substance 

abuse counselor that he or she has battered a 

spouse or child in the past, there are generally 

three questions the program needs to ask as it 

considers whether to make a report: (1) Does 

State law require the program to make a report? 

(2) Does State law permit the program to make a 

report? (3) How can a report be made without 

violating the Federal law and regulations 

governing confidentiality of patients’ records (42 

U.S.C. §§290dd-2 and 42 C.F.R. Part 2)? 

First, under State law, is there a legal duty to 

report child abuse or other domestic violence? 

For substance abuse counselors the answer to 
Legal Issues 

55

this question is “yes” if child abuse is involved 

and generally “no” if battering of a spouse is 

involved. 

Reporting child abuse 

All States (and the District of Columbia) require 

a broad range of care providers—including 

substance abuse treatment programs—to report 

when there is reasonable cause to believe or 

suspect child abuse or neglect. While many 

State statutes are similar, each has different rules 

about what kinds of conditions must be 

reported, who must report, and when and how 

reports must be made. In most States, failure to 

report may result in civil or criminal charges. 

All States extend immunity from prosecution to 

persons reporting child abuse and neglect; in 

other words, a person who reports abuse cannot 

be sued. 

While all States require agencies to report 

child abuse, most alcohol and drug programs 

are limited by Federal law in the kind and 

amount of information they may disclose to 

anyone without a patient’s written consent. 

(The regulations require that a particular form of 

written consent be used. Appendix B contains a 

full discussion of these regulations as well as a 

sample consent form.) However, the Federal 

confidentiality regulations do permit substance 

abuse treatment programs to comply with State 

mandatory child abuse reporting laws. 

Note, however, that this is a narrow 

exception to the regulation’s general rule 

prohibiting disclosure of any information about 

a client. It permits only initial reports of child 

abuse or neglect. Programs may not respond to 

followup requests for information or subpoenas 

for additional information, even if the records 

are sought for use in civil or criminal 

proceedings resulting from the program’s initial 

report, unless the client consents or the 

appropriate court issues an order under §2.64 or 

§2.65 of the regulations. 

Reporting domestic violence 

against adults 

Assault of another person, including a spouse, is 

a crime. Few States impose a duty to report a 

crime committed in the past, although some 

States do require physicians treating certain 

types of injuries incurred as the result of a 

violent criminal act (e.g., a shotgun wound) to 

make a report to the police. Even those States 

that still have laws that require reports of past 

criminal acts rarely prosecute violations of the 

law. Therefore, unless a particular State should 

mandate reporting of spousal abuse by health 

care providers and mental health counselors, it 

is unlikely that a substance abuse treatment 

counselor will have a legal obligation to report. 

When is reporting permitted? 

Does State law permit counselors to report a 

crime involving domestic violence to law 

enforcement authorities? Whether or not there 

is a legal obligation imposed on citizens to 

report past crimes to the police, occasions may 

arise when counselors feel a personal obligation 

to report an admission of domestic violence to 

law enforcement authorities. However, State 

law may protect conversations between 

counselors of substance abuse programs and 

their clients (by making them privileged) or 

exempt counselors from any requirement to 

report past criminal activity by clients. Such 

laws are important to clients in substance abuse 

treatment, many of whom have committed 

offenses during their years of alcohol or drug 

abuse. If part of the therapeutic process for 

clients includes acknowledging the harm they 

have done others, substance abuse programs 

that routinely reported clients’ admissions of 

past criminal activity would have limited ability 

to work with clients in the recovery process. 

Laws protecting conversations between 

counselors of substance abuse programs and 

their clients are designed to protect that 

relationship, an important part of the treatment 

process. Survivor clients as well as batterers 
Chapter 5 

56

need to know that their disclosures are 

protected. 

State laws vary widely in the protection they 

accord communications between patients and 

counselors. In some States, admissions of past 

crimes may be considered privileged and 

counselors may be prohibited from reporting 

them; in others, admissions may not be 

privileged. Moreover, each State defines the 

kinds of relationships protected differently. 

Whether a communication about past criminal 

activity is privileged (and therefore cannot be 

reported without the patient’s consent) may 

depend on the type of professional the counselor 

is and whether he or she is licensed or certified 

by the State. 

Any program that is especially concerned 

about this issue should ask a local attorney for 

an opinion letter about whether there is a duty 

to report and whether any counselor-patient 

privilege exempts counselors from that duty. 

Complying with Federal and State law 

Any program that decides to report a client’s 

admission of past spousal abuse must do so 

without violating either the Federal 

confidentiality regulations or State laws. A 

program that decides to report a client’s 

admission of battering or any other criminal 

activity can comply with the Federal regulations 

by following one of these three methods: 

1. If a criminal justice agency has required the 

batterer to enter treatment in lieu of 

prosecution or incarceration, and the batterer 

has signed a criminal justice system consent 

form that is worded broadly enough to allow 

this sort of information to be disclosed, the 

program can report the client’s admission of 

a crime to the referring criminal justice 

agency. Generally, programs that treat such 

mandated patients agree to report progress 

in treatment, failure to attend treatment, and 

certain categories of criminal acts to the 

referring criminal justice agency. Mandated 

patients sign a special consent form 

permitting programs to do so. (A full 

explanation of criminal justice system 

referrals and consent form appears in 

Appendix B.) Note, however, that the 

Federal regulations limit what the criminal 

justice agency can do with the information. 

Anyone receiving information pursuant to a 

criminal justice system consent “may 

redisclose and use it only to carry out that 

person’s official duties with regard to the 

patient’s conditional release or other action 

in connection with which the consent was 

given” (§2.35(d)). Thus the disclosure can be 

used by the criminal justice agency that 

ordered the offender to enter treatment to 

revoke his or her participation in treatment 

in lieu of criminal justice processing, but 

most likely not to prosecute the batterer for a 

separate crime (in other words, for making 

the assault the program is reporting). Only if 

a special court order is obtained pursuant to 

§2.65 of the regulations (also explained in 

Appendix B) can information obtained from 

a program be used to investigate or 

prosecute a patient (42 U.S.C. §290dd-2(2)(C) 

and 42 C.F.R. §2.12(d)(1)). 

2. The program can make a report in a way that 

does not identify the individual as a client in 

a substance abuse program. (Disclosures 

that do not identify the offender as someone 

with a substance abuse problem are 

permitted. See the explanation of §2.12(a)(1) 

in Appendix B.) This can be accomplished 

either by making an anonymous report or—

for a substance abuse program that is part of 

a larger entity, say, a managed care 

organization—by making the report in the 

larger entity’s name. For example, a 

counselor employed by a program that is 

part of a mental health facility could phone 

the police, identify herself as “a counselor 

at the Palm County Health Center,” and 

report the assault. This would convey the 
Legal Issues 

57

vital information without identifying the 

client as an alcohol or drug abuser. 

Counselors at free-standing substance abuse 

programs cannot give the name of the 

program. 

3. The program can obtain a court order under 

§2.65 of the regulations, permitting it to make 

a report if the crime is “extremely serious.” 

The program must take care that the court 

issuing the order abides by the requirements 

of the regulations. (Court orders are 

discussed in Appendix B.) 

By using any one of these methods, the 

program will have discharged its reporting 

responsibility without violating the Federal 

regulations. Before reporting, however, the 

program should also be sure that a report would 

not violate any State laws making 

communications between clients and counselors 

privileged. Because of the complicated nature of 

this issue, any program considering reporting a 

batterer’s admission should seek the advice of a 

lawyer familiar with local law as well as the 

Federal regulations.

Is there a duty to report threats? 

In working with batterers, substance abuse 

treatment programs may face questions about 

their “duty to warn” someone of a client’s threat 

to harm his spouse or child. Even when a 

counselor has no legal obligation to report a 

client’s threat, a treatment professional may feel 

an ethical, professional, or moral obligation to 

try to prevent a crime. 

Over the past 20 years, States across the 

nation have adopted a principle—through 

legislation or court decision—requiring 

psychiatrists and other therapists to take 

“reasonable steps” to protect an intended victim 

when they learn that a patient presents a 

“serious danger of violence to another.” This 

trend started with the case of Tarasoff v. Regents 

of the University of California, 17 Cal.3d 425 

(1976), in which the California Supreme Court 

held a psychologist liable for money damages 

because he failed to warn a potential victim his 

patient threatened to, and then did, kill. The 

court ruled that if a psychologist knows that a 

patient poses a serious risk of violence to a 

particular person, the psychologist has a duty 

“to warn the intended victim or others likely to 

apprise the victim of the danger, to notify the 

police, or to take whatever other steps are 

reasonably necessary under the circumstances.” 

In most States, therapists and other care 

providers must warn a victim or the police 

when a patient makes a credible threat of 

violence to another identified person. (Of 

course, not every threat uttered by a patient 

should be taken seriously. It is only when a 

patient poses a serious threat of violence toward 

a particular person that the duty to warn arises.) 

Counselors who fail to warn either the intended 

victim or the police may be liable for money 

damages or license revocation. 

In a situation where a client threatens to 

assault a spouse, and the counselor believes he 

is serious, the counselor must ask him- or herself 

at least two—and sometimes three—questions: 

1. Is there a legal duty to warn in this particular 

situation under State law? 

2. Even if there is no State requirement that the 

program warn an intended victim or the 

police, do I feel a moral obligation to do so? 

The first question can only be answered by 

an attorney familiar with the law in the State in 

which the substance abuse program operates. If 

the answer to the first question is “no,” it is 

advisable to discuss the second question with a 

knowledgeable lawyer too. 

3. If the answer to the two questions above is 

“yes,” can the counselor warn the victim or 

someone likely to be able to take action 

without violating the Federal confidentiality 

regulations? 

The problem is that there is an apparent 

conflict between the “duty to warn” imposed by 
Chapter 5 

58

the many States that have adopted the principles 

of the Tarasoff case and the Federal 

confidentiality requirements. Simply put, the 

Federal confidentiality law and regulations 

prohibit the type of disclosure that Tarasoff and 

similar cases require unless a substance abuse 

program can use one of the Federal regulations’ 

narrow exceptions. These aside, the Federal 

regulations make it clear that Federal law 

overrides any State law that conflicts with the 

regulations (§2.20). In the only case, as of this 

writing, that addresses this conflict between 

Federal and State law (Hasenie v. United States, 

541 F. Supp. 999 (D. Md. 1982)), the court ruled 

that the Federal confidentiality law prohibited 

any report. 

There are five ways a substance abuse 

treatment program can report a client who 

makes a serious threat to harm someone (or 

himself). The first three of those methods have 

already been outlined above in the discussion 

about reporting admissions of past crimes: 

1. The program can make a report to the 

criminal justice agency that mandated the 

batterer into treatment so long as there is a 

criminal justice system consent form signed 

by the batterer that is worded broadly 

enough to allow this sort of information to be 

disclosed. (As noted above, the Federal 

regulations limit what the criminal justice 

agency partner can do with the information.) 

2. The program can make a disclosure to the 

potential victim or law enforcement officials 

that does not identify the individual who has 

made the threat as a patient in substance 

abuse treatment. This can be accomplished 

either by making an anonymous report or—

for a substance abuse treatment program that 

is part of a larger entity, such as a managed 

care organization—by making the report in 

the larger entity’s name. 

3. The program can go to court and request a 

court order in accordance with §2.64 of the 

Federal regulations, authorizing the 

disclosure to the intended victim, or in 

accordance with §2.65, authorizing disclosure 

to a law enforcement agency. The 

regulations limit disclosures to law 

enforcement agencies for the purpose of 

investigating or prosecuting a patient to 

“extremely serious” crimes, “such as one 

which causes or directly threatens loss of life 

or serious bodily injury, including homicide, 

rape, kidnapping, armed robbery, assault 

with a deadly weapon, and child abuse and 

neglect” (§2.65). See Appendix B for a 

discussion of both court order exceptions. 

4. The program can make a report to medical 

personnel if the threat poses an immediate 

danger to the health of any individual and 

requires immediate medical intervention 

(§2.51). Thus, for example, a program could 

notify a private physician about a suicidal 

patient so that medical intervention can be 

arranged. 

5. The program can obtain the client’s consent. 

This is extremely unlikely if the client is the 

batterer, and even survivor clients often do 

not want their batterer’s threats reported to 

the law. 

If none of these options is practical, what 

should a program do? If a program believes 

there is clear and imminent danger to a client or 

another person, it is probably prudent to report 

the danger to the authorities or the threatened 

individual, particularly in States that follow the 

Tarasoff rule. While each case presents different 

questions, it is doubtful that any prosecution (or 

successful civil lawsuit) under the 

confidentiality regulations would be brought 

against a program or counselor who believed in 

good faith that there was real danger to a 

particular individual. On the other hand, a civil 

lawsuit for failure to warn might well result if a 

threat were actually carried out. In any event, 

the program should try to make the warning in 

a manner that does not identify the individual as 

a substance abuser. 
Legal Issues 

59

As in other areas where there are no clear-cut 

answers and the law is in flux, programs should 

find a lawyer familiar with State law who can 

provide advice on a case-by-case basis. 

Programs would also be well advised to 

establish a protocol ensuring that the clinical or 

program director has a chance to review the 

situation before a report is made. “Duty to 

warn” issues are an area in which staff training 

may be helpful. 

What should a program do if an 

assault occurs on the premises? 

The answer is more straightforward when a 

client has committed or threatens to commit a 

crime on program premises or against program 

personnel. In this situation, the Federal 

regulations permit the program to report the 

crime to a law enforcement agency or to seek its 

assistance. Moreover, in these circumstances, 

the program can disclose details about the 

incident, including the suspect’s name, address, 

last known whereabouts, and status as a client at 

the program (§2.12(c)(5)). 

Communicating With 

The Legal System 

Counselors working with victims—or 

perpetrators—of domestic violence may find 

that lawyers, law enforcement officials, and 

others view them as a good source of 

information. A call from a lawyer asking about 

a client, a visit from a law enforcement officer 

asking to see records, or the arrival of a 

subpoena to testify or produce treatment 

records—what should a program do in each of 

these circumstances? 

The answer is (1) consult the client, (2) use 

common sense, and (3) as a last resort, consult 

State law (or a lawyer familiar with State law). 

Responding to Lawyers’ Inquiries 

Starting with the first scenario—a lawyer calls 

and asks about Jane White’s treatment history or 

treatment. As a first approach to the question, 

Jane’s counselor must tell the lawyer, “I don’t 

know that I have a client with that name. I’d 

have to check my records.” This is because the 

Federal confidentiality regulations prohibit any 

other response without the client’s written 

consent. The regulations view any response 

indicating that Jane White is the counselor’s 

client as an unauthorized disclosure that Jane 

White is in substance abuse treatment. 

Even if the counselor has the client’s written 

consent to speak with the lawyer, she may find 

it helpful to consult with the client before having 

a conversation about her: “I’m sure you 

understand that I am professionally obligated to 

speak with Jane White before I speak with you.” 

It will be hard for any lawyer to disagree with 

this statement. 

The counselor should then speak with the 

client to ask whether the client knows what 

information the caller is seeking and whether 

the client wants her to disclose that or any other 

information. She should leave the conversation 

with a clear understanding of the client’s 

instructions—whether she should disclose the 

information, and if so, how much and what 

kind. It may be that the lawyer is representing 

the client and the client wants the counselor to 

share all the information she has. On the other 

hand, the lawyer may represent the client’s 

spouse or some other party with whom the 

client is not anxious to share information. There 

is nothing wrong with refusing to answer a 

lawyer’s questions, but a polite tone is best. If 

confronted by what could be characterized as 

“stonewalling,” a lawyer may be tempted to 

subpoena the requested information and more. 

The counselor will not want to provoke the 

lawyer into taking action that will harm the 

client.

If the lawyer represents the client and the 

client asks the counselor to share all 

information, the counselor can speak freely with 

the lawyer once the client signs a proper consent 
Chapter 5 

60

form. However, if the counselor is answering 

the questions of a lawyer who does not 

represent the client (but the client has consented 

in writing to the disclosure of some 

information), the counselor should listen 

carefully to each question, choose her words 

with care, limit each answer to the question 

asked, and take care not to volunteer 

information not called for. 

Visits by Law Enforcement 

A police officer, detective, or probation officer 

who asks a counselor to disclose information 

about a client or a client’s treatment records 

must be handled in a similar manner. The 

counselor should give a noncommittal response, 

such as “I’ll have to check my records to see 

whether I have such a patient.” Of course, if the 

patient was mandated into treatment in lieu of 

prosecution or incarceration, program staff may 

be obligated to speak with someone from the 

referring criminal justice agency, and the client 

will have signed a criminal justice system 

consent form authorizing the program to do so. 

If the officer’s inquiry has come “out of the 

blue,” the counselor should speak with the client 

to find out whether the client knows the subject 

of the officer’s inquiry, whether he wants the 

counselor to disclose information and if so, how 

much and what kind and whether there are any 

particular areas the client would prefer she not 

discuss with the officer. Again, the counselor 

must get written consent from the client before 

speaking with the officer. 

If the counselor knows that a client is a 

fugitive from justice, a refusal to assist or give 

officers information is a criminal offense in some 

States. 

Responding to Subpoenas 

Subpoenas come in two varieties. One is an 

order requiring a person to testify either at a 

deposition out of court or at a trial. The other—

known as a subpoena duces tecum—requires a 

person to appear with the records listed in the 

subpoena. Depending upon the State, a 

subpoena can be signed by a lawyer or a judge. 

Unfortunately, it can neither be ignored nor 

automatically obeyed. 

In this instance, the counselor’s first step 

should be to call Jane White—the client about 

whom she is asked to testify or whose records 

are sought—and ask what the subpoena is 

about. It may be that the subpoena has been 

issued by or on behalf of Jane’s lawyer with 

Jane’s consent. However, it is equally possible 

that the subpoena has been issued by or on 

behalf of the spouse’s lawyer (or the lawyer for 

another adverse party). If that is the case, the 

counselor’s best option is to consult with Jane’s 

lawyer (after getting Jane’s written consent) to 

find out whether the lawyer will object—ask the 

court to “quash” the subpoena—or whether the 

counselor should simply get the client’s written 

consent to testify or turn over her records. An 

objection can be based on a number of grounds 

and can be raised by any party, including the 

person whose medical information is sought. 

Often, the counselor may assert the client’s 

privilege for the client. 

Dealing With the Police 

A program may unknowingly admit a client 

who is sought by the police. If the police 

discover that someone they are seeking is at the 

program and come armed with an arrest 

warrant, what should the program do? How 

should programs handle search warrants? The 

answers to these questions are quite different. 

Arrest Warrants 

An arrest warrant gives police the authority to 

search the program facilities; however, the 

program is not authorized to help the police by 

pointing out the client they are seeking unless 

the client is being sought because he or she 

committed a crime on program premises or 

against program personnel. The unfortunate 
Legal Issues 

61

result is that the confidentiality of all clients in 

the program may be compromised when the 

police enter and search for a fugitive. There is 

no solution to this problem unless the police 

secure a court order under §2.66, which would 

authorize the program to disclose the identity of 

the client, or the program convinces the client to 

surrender. (Voluntary surrender by a client is a 

disclosure by the client, not the program.) It is 

usually in the client’s best interest to surrender 

voluntarily, since arrest is probably inevitable 

and his cooperation may weigh in his favor with 

the prosecutor and judge when the question of 

bail arises. The risk is that the client will 

attempt to escape, which might expose the 

program to a charge of assisting unlawful 

escape. To reduce this possibility, the program 

should work with the police so that law 

enforcement personnel have secured the area 

around the program. 

Search Warrants 

A search warrant does not authorize the 

program to permit the police to enter the 

premises. Even if signed by a judge, a search 

warrant is not the kind of “court order” that the 

Federal regulations require before the program 

can allow anyone to enter and see clients or 

client records when clients have not consented. 

Law enforcement officials are unlikely to know 

about the restrictions of the Federal regulations, 

however, and they will probably believe that a 

search warrant permits them to enter and search 

the program. What should a program do? 

Presented with a search warrant, program 

staff should show the officer a copy of the 

Federal regulations and explain their 

restrictions. Staff can suggest that the officer 

obtain a court order that will authorize the 

program to make the disclosure called for in the 

search warrant. No harm will ordinarily be 

caused by resultant delay (although the police 

may not agree with this view). The program 

should call its lawyer and let him or her talk 

with the police. Failing that, a program could 

try to call the prosecutor who has sent the 

police, explain the regulations, and point out 

that any evidence seized without the proper 

court order may be excluded at trial, since it will 

have been seized illegally. 

If none of these steps works, the program 

must permit the police to enter. Refusal to obey 

a direct order of the police may be a crime, even 

if the police are wrong, and forcible resistance 

would be unwise. If the program has made a 

good faith effort to convince the law 

enforcement authorities to pursue the proper 

route, it is unlikely that it would be held liable 

for allowing entry when argument fails. 

Conclusion 

Programs should develop protocols for dealing 

with the constellation of legal issues that may 

arise during the treatment of victims—or 

perpetrators—of domestic abuse. Programs 

should have a copy of the Federal regulations 

available at all times to show law enforcement 

officials and establish a relationship with an 

attorney who can be called upon to help in these 

situations. Finally, programs should reach out 

to law enforcement agencies before a crisis arises 

and work with them to develop ways of dealing 

with these kinds of issues. If the regulations are 

explained when there is no emergency and there 

can be no suspicion that the program is hiding 

anyone or anything, and a protocol is 

established, unpleasant confrontations may be 

avoided. 
63

6 Linkages: A Coordinated 

Community Response 

overwhelming number of problems faced by 

substance abuse treatment clients who are 

affected by domestic violence. Increasingly, 

programs are looking to strong collaboration 

and linkages with other service agencies to meet 

their clients’ needs. Such collaboration is 

particularly important in isolated rural 

communities where lack of resources and 

distance from services are significant problems. 

In all communities—urban, rural, and 

suburban—individuals who provide substance 

abuse and domestic violence services in the 

public sector generally have experienced the 

negative consequences of fragmented and 

unintegrated service systems. Historically, their 

resourcefulness in obtaining necessary care for 

their clients has created an informal system of 

referrals and unofficial case management. Such 

linkages are becoming more formalized as 

system administrators realize the costeffectiveness of collaboration and coordination 

of services and as public sector purchasers of 

Medicaid managed care become more 

sophisticated in contracting with managed 

behavioral health care organizations to ensure a 

continuum of services for clients served in the 

public sector. 

Thus the current behavioral health care 

environment may be one especially open to 

change in the direction of linkages, 

collaboration, coordination, and service 

integration. This chapter calls on providers to 

I solation is a salient characteristic of domestic 

violence: It occurs in isolation and it isolates 

its victims from community life. Countering 

this pervasive isolation with a coordinated 

community response is perhaps the strongest 

way to eliminate domestic violence from our 

society (Clark et al., 1996). “If we are ever to 

eradicate domestic violence, the whole 

community must become alerted to the problem 

and how best to support the victims and convey 

to the abusers that abuse is a crime that is never 

justified” (Zorza, 1995a, p. 54). 

Although the primary focus of this 

Treatment Improvement Protocol is on linking 

substance abuse treatment and domestic 

violence support services, the linkages cannot 

stop there: Other efforts to link and integrate 

community resources are essential—not only to 

ensure that the needs of individual survivors 

and batterers are met but also to raise public 

awareness and to begin to create the 

coordinated community response that is 

necessary for change. Coordinated intervention 

is crucial. These efforts must address needs for 

housing, child care, emotional and physical 

safety, health and mental health care, economic 

stability, legal protection, vocational and 

educational services, parenting training, and 

support and peer counseling, among others. 

Linkages will also help each agency fulfill its 

own mission. Few programs have the resources 

available to address the sometimes 
Chapter 6 

64

be especially positive and creative in thinking 

about these issues and designing action plans. 

Those who have seen past efforts at service 

integration fail, who are skeptical about 

structural change within State service delivery 

systems, and who may be ambivalent about 

giving up turf are encouraged to support 

coordination and collaboration—that is, separate 

agencies planning together and working 

together to create new delivery approaches with 

support at the State level. This chapter focuses 

on two approaches to building linkages; the first 

based on systemic reform and the second rooted 

in the community. Two crucial linkages are 

highlighted—that between substance abuse 

treatment and domestic violence support 

services and that between these services and the 

criminal justice system. 

Systemic Reform 

Linkages are frequently conceived of as local 

program-to-program relationships, and much of 

the remainder of this chapter is devoted to such 

linkages. While not disputing the importance of 

community-based interagency networking, the 

Consensus Panel believes that a new way of 

thinking about linkages on the systems level can 

help address the multiple social service needs of 

substance-abusing victims and perpetrators of 

violence. In calling for substantive, top-down 

reform, the Panel allies itself with those 

domestic violence experts (Hart, 1995b; Hart et 

al., 1995) and mental health experts (Stroul, 

1993) advocating a new approach to organizing 

and institutionalizing coordinated social service 

delivery systems. 

Under this new paradigm, the familiar 

concept of a “continuum of services” is elevated 

to the State level and substantially expanded to 

include a formal structure and process to 

oversee system-level coordination among 

agencies. While specific goals would vary from 

State to State, the Panel believes that such 

systemic reform would enable States to create a 

collaborative infrastructure that, in turn, would 

allow programs to deliver care that is 

 Client-centered—focused on meeting clients 

“where they are” and matching their needs 

with appropriate services as opposed to 

fitting clients into a predefined program; 

wraparound services follow the client 

 Holistic—offering comprehensive services 

from a variety of agencies that are designed 

to respond to a client’s multiple needs: 

substance abuse treatment, mental health 

counseling, domestic violence support, 

parenting skills training, housing 

 Flexible—the service mix changes as the 

client’s needs change 

 Collaborative—multiple agencies can work 

together freely on behalf of a client without 

having to consider agency funding or other 

administrative issues that may interfere with 

the assistance process 

 Coordinated—individualized service plans 

are developed for each client and monitored 

via case management 

 Accountable—encourages the client’s input 

to the comprehensive treatment plan, 

adheres to standards or accepted best 

practices for treatment, establishes and tracks 

qualitative and quantitative outcome 

measures, and evaluates services on the basis 

of client and community satisfaction. 

Currently, most social services—including 

substance abuse treatment and domestic 

violence support—function as a series of parallel 

programs with their own sources of funding, 

leadership, and constituencies (Hart, 1995b; Hart 

et al., 1995; Stroul, 1993). Clients needing 

services from more than one program not only 

face a number of hurdles (e.g., differing 

eligibility requirements, hours of operation, and 

locations), but may also receive services that are 

counterproductive because they are not part of a 

coordinated treatment plan (Hart, 1995b). 
Linkages 

65

In the environment that would emerge after 

converting from parallel services to an 

integrated delivery system, cooperation on the 

client’s behalf would replace competition for the 

client and for the attendant funding that follows 

admission to a specific program or to a 

treatment slot or bed. Collaboration would 

eliminate duplication of services and receipt of 

inappropriate services. With a client-centered 

philosophy prevailing, the provision of 

adjunctive support services like child care, 

transportation, and housing would assume 

greater importance and would more likely be 

funded (Stroul, 1993). 

Systemic reform on this scale requires 

structural, administrative changes at the State 

level. As a first step toward revamping service 

delivery to multiple-needs clients, the Panel 

envisions a mechanism that would 

 Coordinate planning among disparate 

agencies based on client and community 

needs assessments 

 Devise financing strategies that would allow 

for blended funding and strive for equitable 

allocation of resources among agencies 

 Establish a vehicle for resolving any 

problems that emerge in the course of 

providing integrated services (e.g., 

development of compatible management 

information systems, cross-training, and 

support and authority for case management). 

In its assessment of systems of care for 

children (Stroul, 1993), Georgetown University’s 

Child Development Center discovered that, as 

expected, integrated systems of care expanded 

access to services, including adjunctive support, 

and increased the use of case management to 

monitor service delivery and advocate for 

individual clients and their families. The study 

also found that this approach, in some instances, 

reduced costs. For example, three counties in 

California saved more than $35 million over 4 

years for residential care by using a systems 

model of service delivery. Similarly, Fort Bragg, 

North Carolina, reduced the costs of caring for 

children with serious emotional disturbances by 

51 percent through the systems of care 

approach. The State of Kentucky likewise 

reduced the cost of services from $13.5 million to 

$9.5 million (Stroul, 1993). 

Although these models have yet to be 

applied to the substance abuse and domestic 

violence fields, the Consensus Panel believes 

they hold promise for redefining the existing 

service delivery system to ensure more 

appropriate and effective care for substanceabusing domestic violence victims and 

perpetrators. The Panel strongly recommends 

that Federal and State policymakers consider a 

series of demonstrations designed to test the 

feasibility of changing the current system to 

institutionalize a formal administrative structure 

for promoting and supporting collaboration and 

linkages among social service programs. 

Community-Based 

Linkages 

The health care environment is increasingly 

forced to respond to the demand for cost 

containment; therefore, undertaking 

collaborative endeavors is critical to the future 

of many programs, especially at the community 

level. As noted, few have the resources to offer 

under one roof all the specialty services that 

clients need. Creative linkages can supplement 

and complement programs, building on their 

strengths and compensating for their 

weaknesses. Linkages can open avenues to 

diverse sources of funding to offset the 

inevitable ebb and flow of resources. And in a 

practical vein, a growing number of funding 

sources are granting funds only when presented 

with evidence of coordinated activities among grant 

applicants. 
Chapter 6 

66

Community Assessment 

Before linkages can be developed, it is necessary 

to know what resources exist within the 

community. Each entity has its own 

organization and its own culture that must be 

understood for collaboration to be successful. 

Every State has a unique infrastructure for 

housing the health care, legal, social, and other 

services related to substance abuse treatment 

and domestic violence services. Communities 

themselves also vary in government structure, 

available resources, and funding streams. Some 

combine alcohol treatment with treatment for 

other substance abuse, whereas others separate 

the two. Some locate services for victims of 

domestic violence in the criminal justice system, 

which affects the tone and procedures used to 

deliver services, while others locate such 

services in a hospital system linked to the 

emergency department. A program within a 

nonprofit entity in the private sector has far 

different restraints than one housed in a 

government agency. 

Disciplines also differ dramatically in 

structure and orientation. Some substance 

abuse treatment programs, for example, are 

staffed by nurses, and others are staffed by 

certified addiction counselors. Many existing 

programs, such as Minnesota’s Turning Point 

and African American Services, have 

incorporated family violence issues into 

substance abuse treatment, and communities 

throughout the United States are increasingly 

integrating the two areas (Clark et al., 1996). A 

single treatment approach would be enhanced 

by making programs accountable to the local 

community, strengthening the linkages between 

the two fields and the court system, and 

improving evaluation procedures. 

The Argument for 

Case Management

In the current early state of development of 

linkages between the fields of substance abuse 

treatment and domestic violence services, it has 

been suggested that “the linkage mechanism 

that seems most appropriate is case 

management” (Collins et al., 1997, p. 400). 

Increasingly, the substance abuse treatment field 

has recognized that case management may be a 

key contributor to successful treatment (Ridgely 

and Willenbring, 1992). In the case management 

approach, a specially trained single practitioner 

or case management team is responsible for 

coordinating linkages to the wide variety of 

services—including domestic violence 

support—needed by many if not most clients in 

substance abuse treatment (Sullivan, 1994). 

Although locating and gaining initial access 

to these services can be challenging, many 

programs have found that use of case 

management is well worth the effort, since it 

helps clients work through problems that may 

trigger use of alcohol and other drugs or that 

interfere with progress in treatment. Such 

problems may include homelessness, mental 

illness, HIV infection, lack of vocational skills, 

and unemployment (Willenbring, 1994). An 

additional advantage is that the case manager 

serves as a client advocate, representing the 

client’s interests in both accessing other agencies 

and ensuring that their services are used 

effectively (Rapp et al., 1994). 

Linking Substance Abuse 

Treatment and Domestic 

Violence Services 

Several locales have attempted to develop 

model programs integrating substance abuse 

and domestic violence services. These include 

the Amend Program in several Colorado 

communities (Rogan, 1985–1986), the Intercede 

Program of Longford Health Sources in Ohio 

(Burkins, 1995), and the Pittsburgh Veterans 

Affairs Medical Center (Gondolf, 1995). A study 

of linkage efforts in Illinois found that staff 

cross-training is inadequate to meet the goals of 

these efforts (Bennett and Lawson, 1994). 
Linkages 

67

This TIP takes some of the first steps in 

formalizing linkages between the two fields. 

Chapters 2 and 3 present substance abuse 

treatment providers, who may lack knowledge 

about this population, with psychosocial profiles 

of survivors and batterers and their needs for 

specialized care. Such training is a key 

ingredient in bringing the two fields closer. 

Chapter 4 stresses the need for screening for 

domestic violence early in the substance abuse 

treatment process and the importance of timely 

referral of clients affected by domestic violence 

to the appropriate agencies. Routine screening 

for cross-problems by both types of programs is 

a major step toward linkage. 

Linkages With the Criminal 

Justice System 

One of the first linkages that must be identified 

by a substance abuse treatment program that is 

working with domestic violence survivors is 

with the legal system (see Chapter 5). A legal 

professional or legal service is the best resource 

for resolving problems that pertain to individual 

clients’ involvement in the justice system and 

may be the best resource for information and 

guidance regarding the Violence Against 

Women Act (VAWA). Many of the Act’s 

provisions—such as those relevant to 

immigrants—are complex and detailed. In 

addition, other Federal and State statutes may 

include provisions that appear to contradict 

those of the VAWA. 

To treat substance abuse clients who are 

either survivors or batterers, treatment 

providers must be knowledgeable about policies 

and laws related to domestic violence; they must 

understand the roles of police, judges, probation 

staff, and other representatives of the justice 

system and be able to interact effectively with 

these individuals when necessary. As one field 

reviewer noted, “Integrating the criminal justice 

system’s efforts should be the first step in 

forming linkages. If a provider wants assistance 

protecting a woman or getting a batterer to 

attend treatment, it is the criminal justice system 

that can get this done.” 

Specialized courts to process domestic 

violence cases, which combine intensive 

survivor services, treatment for batterers, and an 

active judicial role in the social contexts of the 

community, have been established. The Dade 

County, Florida, Domestic Violence Court, 

which commenced in late 1992, is a noteworthy 

example, and outcomes are still being evaluated 

(Fagan, 1996). However, some early data 

indicate that recidivism rates among treated 

batterers processed through these courts are 

high and comparable to rates found in studies of 

the deterrent effects of protective orders and 

arrests. Failure rates are strongly correlated 

with lengthy prior records and a history of 

abuse in the batterer’s family of origin (Fagan, 

1996). 

In pursuing victim protection goals, criminal 

justice agencies have been required to expand 

their traditional focus on the detection and 

punishment of crimes. Placing these 

expectations on police and prosecutors may 

require tasks and roles for which they are not 

well trained. Such role and policy ambiguities 

can affect the performance of agencies with 

respect to their missions. As Fagan notes: 

There is no doubt that linkages between legal 

institutions and services for domestic violence 

victims are critical to stopping violence. 

However, these linkages may best be 

accomplished through a strategic division of 

roles among institutions that tap the strengths 

of each organization. . . . Although legal 

systems should be open and accessible to 

battered women, these institutions should not 

take on the role of managing the coordination 

of services that involve social service, shelter, 

and other interventions. (Fagan, 1996, pp. 39–

40)
Chapter 6 

68

Collaborative Treatment Planning 

For Survivors and Batterers

Treatment plans for substance abuse clients who 

are survivors or batterers must incorporate all 

the issues surrounding both sets of problems 

and ideally will be coordinated by a case 

manager. Treatment planning for matters such 

as time sequencing (e.g., when to start support 

for a domestic violence survivor in substance 

abuse treatment) and goals of treatment is not 

effective without consideration of all the factors 

that have a bearing on the client’s best interests. 

Substance abuse treatment providers, domestic 

violence experts, and legal or other relevant 

professionals should plan treatment 

collaboratively. 

Because treatment plans for domestic 

violence survivors are built around the premise 

that safety must always be the first priority, 

substance abuse treatment may initially take a 

back seat. For example, a client who lives with a 

violent partner may report being pressured or 

coerced by him to use alcohol or other drugs. In 

these instances, some degree of relapse may 

need to be tolerated in light of the threat to the 

client’s safety. A survivor’s frequent reporting 

of such a situation, however, signals the need for 

substance abuse treatment and domestic 

violence staff to jointly reconsider treatment 

priorities. 

A batterer entering treatment for substance 

abuse can be required to sign a contract 

agreeing, among other stipulations, to refrain 

from using violence (see Chapter 4). Such “noviolence contracts” are most effective when 

linkages are made with other agencies involved 

with his case, and violations should be reported 

to all involved agencies, especially the criminal 

justice system. 

Treatment providers can help persuade the 

courts to consider alternative sanctions that take 

the victim’s circumstances into account. 

Incarcerating batterers can actually harm their 

victims by taking away the family income. On 

the other hand, not incarcerating the batterer 

may give him the false message that his 

behavior is not that bad and thus tacitly give 

him “permission” to continue his violence. 

Courts may order the batterer to receive 

counseling, perform public service, or a variety 

of other sanctions. 

Identifying Critical 

Linkages, Barriers, 

And Opportunities 

Figure 6-1 highlights some of the key linkages 

substance abuse programs should consider in 

developing collaborative strategies to assist 

clients with domestic violence problems. Some 

duplication across the lists is intentional. 

Figure 6-2 lists some of the potential 

obstacles to forming collaborative relationships 

between substance abuse treatment and 

domestic violence programs, as well as 

opportunities for collaboration and ideas for 

taking action to form such relationships. 

Establishing a Linkage 

Relationship 

All relationships begin with a “getting-to-knowyou” phase; initial, face-to-face interactions 

often establish the tone for future interaction. 

These initial meetings should include a 

discussion of the origins of both communities in 

order to help each understand the other’s beliefs 

and attitudes. Other topics for discussion 

include each program’s goals for its clients, the 

barriers routinely faced with clients, typical 

interactions with clients, and expected 

outcomes. Key individuals in each system can 

coach the staff of the other in working with and 

understanding that system and the needs of its 

clients. During the initial phase, it also may be 

helpful to acknowledge some of the stereotypes 

held by each field about the other and to discuss 

them frankly. 
Linkages 

69

Figure 6-1 

Key Linkages 

Health Care 

 Screening for Child Abuse and Neglect 

(SCAN) teams in hospital emergency 

rooms 

 Health administrators 

 Veterans health care systems 

 Primary care physicians 

 Obstetricians/gynecologists 

 Pediatricians 

 Nurses and nurses assistants 

 Midwives 

 Nurse practitioners in adult, 

obstetrician/gynecologist, and pediatric 

settings 

 Physician assistants 

 Public health workers 

 Dentists 

 Emergency medical technicians 

 Medical social workers 

 Home health services 

 Forensic examiners 

 Plastic and maxillofacial surgeons 

 Physical, speech, and occupational 

therapists 

 Health educators 

 Wellness groups 

 Women, Infants, and Children (WIC) 

Supplemental Food Program specialists 

 Alternative medicine practitioners 

 Health care programs (e.g., infant 

mortality reduction programs, HIV/AIDS 

programs, and tuberculosis programs) 

Justice System 

It is important to understand the operations 

of the court system in your jurisdiction and 

to identify the judges who oversee 

 Drug cases 

 Driving Under the Influence (DUI) and 

Driving While Intoxicated (DWI) 

infractions 

 Child abuse and child neglect cases 

 Domestic violence violations 

 Custody cases 

 It is also useful to identify experts in the 

following offices and programs: 

 Probation and parole 

 Legal Aid 

 District Attorney’s office 

 Family courts 

 Specialty units of attorneys (e.g., for child 

abuse and neglect and family violence) 

 Jails and prisons 

 Bail bondsmen 

 Law enforcement (all levels, e.g., sheriffs 

and police) 

 Pretrial release agencies 

 Public defenders 

 Divorce attorneys 

 Pro bono attorneys 

 Juvenile detention facilities 

 Victim assistance programs 

 Appropriate section of the local Bar 

Association 

Education/Schools 

 School boards 

 School administrators 

 Teachers 

 Teaching assistants 

 School counselors 

 School social workers 

 School nurses 

 General equivalency diploma (GED) 

specialists 

 Head Start and child care specialists 
Chapter 6 

70

Figure 6-1 (continued) 

Education/Schools (continued) 

 Vocational education and training 

counselors 

 Guidance counselors 

 Special education specialists (emotional 

and physical problems) 

 Early intervention specialists 

 School psychologists 

 Physical education teachers and coaches 

 Prevention specialists 

 Parent–teacher organizations (PTOs) 

 English as a Second Language (ESL) 

classes 

 Literacy volunteers

Adult Education 

 Night schools 

 Community colleges 

 Senior day care centers 

 Native-American centers 

 Hispanic-American centers 

 Asian-American centers 

Employers 

 Employee Assistance Programs (EAPs) 

 Human resource administrators 

 Foundation administrators 

 On-the-job counselors and social workers 

Social Welfare 

 Foster care (family foster care, relative 

foster care, and residential foster care, 

including group homes) 

 Social welfare administrators 

 Social workers 

 Temporary Assistance to Needy Families 

 Welfare-to-work programs 

 Food stamp programs 

 WIC 

 Child protective services 

 Adult protective services (especially for 

elderly persons) 

 Head Start 

 Income maintenance 

 Child care programs 

 Transportation subsidy programs 

 Community-based child abuse and 

neglect prevention services and programs 

 Hotlines 

 Family support programs 

 Community-based family agencies 

(provide parent education and specialized 

counseling for children at low or no cost) 

 Family preservation programs 

 Homeless shelters 

 Maternal and child health programs 

 Women’s programs 

Domestic Violence 

 Hotlines 

 Shelters 

 Child care workers and child advocates 

 Programs for children in violent families 

 Transitional living (homeless) experts 

 Clinicians, public and private (e.g., 

therapists) 

 Programs for batterers 

 Legal advocacy systems 

 Visitation centers for children 

 Support groups 

 Surveillance systems 

 Abuse and assault hotlines 

 Rape crisis programs 
Linkages 

71

Figure 6-1 (continued) 

Domestic Violence (continued) 

 Victim services 

 Model programs offering specialized 

services for sexually abused children 

 College-based date rape programs 

 Survivor support groups 

 Forensic nurse examiners 

Mental Health 

 Clinicians (e.g., psychiatrists, social 

workers, psychologists, and psychiatric 

nurses) 

 Child guidance centers 

 Mental hospitals and institutions 

 Community-based activity centers for 

deinstitutionalized persons 

 Group homes and halfway houses 

 Hotlines and crisis centers 

 Hospital inpatient units 

 Hospital outpatient services 

 Community mental health centers 

 Outpatient day services (community 

mental health day hospitals)

Substance Abuse 

 Residential or inpatient detoxification 

programs, intensive residential programs, 

and therapeutic community programs 

and services (private, public, and 

combined) 

 Outpatient drug-free, methadone 

maintenance, and partial-day programs 

and services (private, public, and 

combined) 

 Self-help groups (e.g., Alcoholics 

Anonymous, Narcotics Anonymous, 

Cocaine Anonymous, and Rational 

Recovery) 

 Al-Anon (support groups for families of 

substance abusers) 

 Prison- or jail-based substance abuse 

programs 

 DUI and DWI programs 

 Veterans Affairs substance abuse 

treatment programs 

 Special programs for adolescents, 

children, and families 

 Special treatment programs for pregnant 

women or women with dependent 

children 

 Halfway houses, recovery homes 

 Alcohol and drug prevention programs 

 Community-based coalitions for the 

prevention of substance abuse 

 EAPs (government and private) 

Other Community Resources 

 Governmental and regulatory agencies 

 Funding sources 

 Religious institutions (e.g., churches and 

synagogues) 

 Community housing programs 

 Recreation programs 

 Neighborhood watch associations 

 Immigrant services 

 Child care programs 

 Transportation programs for persons with 

developmental and physical disabilities 

 Support groups (e.g., Grandparents as 

Parents) 

 Fathers’ responsibility projects 

 Nutritional centers, food banks 

 Senior citizens’ agencies 

 Travelers Aid
Chapter 6 

72

Figure 6-2 

Facets of Collaboration Between Substance Abuse Treatment 

and Domestic Violence Programs 

Perceptions and Attitudes of Those Working in the Field 

 Barriers Stereotypes, generalizations, and myths about the other field 

 Opportunities Special joint conferences to explore common ground and bridge gaps 

 Action Ideas Develop cross-training courses for providers in network through community 

college or other sources 

Exchange agency newsletters 

Serve on one another’s board of directors 

Arrange continuing education unit credits for participants 

Funding and Reimbursement 

 Barriers Limitations on reimbursable services, particularly under managed care 

Limitations imposed by the terms of funded research, which may constrain the 

program’s ability to provide needed services 

 Opportunities Work with State Director to incorporate language in managed care contracts to 

support needed services 

Identify other funding sources more amenable to services being offered and seek 

funding for specific program components 

 Action Ideas Learn about blended funding strategies 

Adjust program accounting system to receive and account for blended funds 

Track outcomes of clients receiving services from linkage partners and document 

their outcomes for research and funding entities; use results to secure 

additional funding 

Welfare Reform 

 Barriers Increased limits on shelter stays 

 Opportunities Increased funding of collaborative and innovative programming 

 Action Ideas For example, in Wisconsin, the Milwaukee Women’s Center has developed a 

collaboration between employment maintenance organizations, health 

maintenance organizations, and community-based organizations to establish 

specialized services for survivors who are substance abusers 

Fundraising 

 Barriers Limited availability of funds from any source 

 Opportunities Identify appropriate partners for funding opportunities and lay groundwork for 

response to funding opportunities 

Identifying funding sources is in and of itself an incentive to establish linkages 
Linkages 

73

Figure 6-2 (continued) 

 Action Ideas Partner with a proven “fundraiser” to supply a needed specialized service (e.g., 

via subcontract) 

Send interested staff to grant-writing workshops 

Through board/community contacts, identify an advocate who will introduce 

the program to potential funders 

Identify a volunteer who will review the CBD and other resources for Requests 

for Proposals (RFPs) and Requests for Applications (RFAs) 

Publicize positive program results continually 

Convene a meeting with local funders and discuss the feasibility of encouraging 

joint applications between domestic violence and substance abuse providers 

Sociopolitical Issues 

 Barriers Prevailing political climate, which does not readily offer support for treatment 

programs 

Relative newness of both fields and their lack of history, which does not easily 

allow documentation of success 

Lack of social acceptance for both programs 

Perception of domestic violence as a “woman’s field,” in contrast to the 

perception of politics as a “man’s world” 

 Opportunities Grassroots-level recognition of the overlap of the problems of substance abuse 

and domestic violence 

Research and evaluation to document the effectiveness of both efforts in ways 

that are understood by policymakers 

 Action Ideas Form political action coalitions 

Programmatic, Staffing, and Logistical Concerns 

 Barriers Wide variety of different agencies and agendas with which programs must work 

Growing push for higher credentials 

 Opportunities Expanded roles of counselors and other professionals in each field; increased 

respectability and acceptance of these fields 

 Action Ideas Work with the National Association of Alcohol and Drug Abuse Counselors to 

explore this issue fully and investigate credentialing implications 

Seek legitimacy for staff skills through courses developed and offered by 

recognized bodies (e.g., colleges and associations) 

Recordkeeping and Data Management 

 Barriers Increasing need for employees to have computer skills and for organizations to 

have access to on-line and other technological resources 

 Opportunities Increased information available for staff to use 

Increased ability to provide documentation of successes 

 Action Ideas Joint training, leadership programs, staff and materials exchange, information 

and evaluation exchange 
Chapter 6 

74

Figure 6-2 (continued) 

Relationship With the Criminal Justice System 

 Barriers Competing need for information 

Therapeutic alliance versus prosecution’s adversarial need for information 

 Opportunities Develop boundaries and administrative/therapeutic splits to protect information 

being used for treatment from information related to behaviors and actions 

Relationship Between Workplace and Treatment 

 Barriers Identification of domestic violence problems can have adverse impact on career 

no matter what the resolution of the case 

 Opportunities Develop a problem-based definition of abuse that is linked to behavioral goals 

At these initial meetings, using a staff 

member with strong facilitation skills can be 

invaluable. An alternative is to use a facilitator 

from an outside agency not affiliated with either 

program (e.g., from a university or community 

college). The facilitator can recognize 

burgeoning problems and defuse them before 

group members become defensive and 

uncooperative, and he or she can help 

participants bridge gaps in understanding by 

clarifying terminology and asking for feedback 

to ensure that all parties are interpreting 

information the same way. A followup memo 

documenting the understandings that emerged 

from the meeting and listing areas of agreedupon responsibility can also assist the 

collaborative process. 

Airing and Addressing Grievances 

In collaborative relationships, difficulties can 

arise if one entity feels taken advantage of, 

perceives that the other is deriving more 

benefits from the association, receives more 

credit, or believes that power is unequal 

between the two groups. Balance is central to an 

effective collaboration that satisfies the 

expectations and needs of all involved. When a 

collaborative domestic violence effort, for 

example, used the letterhead of one 

participating organization, the other partners 

were displeased because their participation was 

not acknowledged. To give equal recognition to 

all partners, a new project-specific letterhead 

reflecting all the collaborators was designed. 

Not all solutions will be so simple, but this 

example demonstrates the importance of frank 

communication, responding to the concerns of 

all the partners in the network, and moving 

quickly to resolve problems. 

Readiness for Collaboration: 

Program Evaluation 

Many programs have in place a system for 

periodic internal evaluation of their success in 

meeting their goals. Decisionmakers may find it 

useful to reexamine a program or organization 

specifically in terms of its readiness to take 

advantage of and maintain a collaborative 

association. 

Staff roles 

For successful linkages, program staff—

beginning with boards of directors—must be 

sensitive to the other program’s requirements 

and culture. A board that consists of members 

who are committed to supporting program 

goals and overcoming challenges is essential to 

effective operation. Motivated and wellconnected directors can, for example, help 

identify community funding sources that will 

support the development of collaborations. 
Linkages 

75

Administrators can promote linkages by 

identifying conflicts or economies of scale in the 

areas of fiscal management, accounting, contract 

management, funding development, program 

evaluation and organizational audits, human 

resources and payroll management, 

management information systems, and other 

technology. They can also enhance linkages and 

develop funding sources by working with other 

agencies and programs to compete for block 

grant funds and to split funding for substance 

abuse and domestic violence. Program 

managers should appoint a staff member as a 

contact and liaison for each linkage. 

Administrators and managers should seek to 

create an organizational environment that 

encourages and supports staff members’ 

collaboration activities, which are often timeconsuming. Staff members’ new collaborative 

relationships, as well as their existing 

relationships with other agencies, are critical to 

success. 

Cultural competence 

Substance abuse treatment and domestic 

violence professionals also must educate 

themselves on issues particular to each cultural 

or ethnic subgroup their clients represent. 

Failure to do so diminishes outcomes and 

completion rates for minority populations. 

Cultural competence is more important than 

ever now, as the country moves toward a 

“majority-less” ethnic composition and major 

cities become pluralities of cultures rather than 

majority-minority paradigms. Responding to the 

needs of clients will require an awareness of 

practice and attitude and an organizational 

structure that continually monitors: 

 How are services provided to diverse 

groups? 

 What is the environment in which services 

are offered? 

 What is the composition of the group? 

 How included do diverse clients feel during 

the treatment process, and what cultural 

activities are directed to a specific 

population? 

 How can treatment be tailored to a particular 

group? 

 Are there staff members who know the 

language of non-English-speaking clients? 

 What networks have been created with other 

experts and members of the community to 

provide services to this population? 

Lastly, cultural competence implies that 

agencies are equipped to respond to 

“insensitivity” and that they make inclusiveness 

an institutionalized value, in part by employing 

highly skilled multicultural staff (Cross et al., 

1989). 

The critical role of evaluation 

Evaluation helps programs measure how 

effective they are in achieving their goals and 

gives them information to redesign and improve 

program components. Increasingly, funding 

sources require documentation of the program’s 

success and of individual outcomes. However, 

in the fields of substance abuse treatment and 

domestic violence, outcomes may not always be 

as clear-cut or as measurable as funders would 

like. Administrators must be aware that a 

funding source or other outsider to the field may 

not agree with or approve of a program’s 

criteria for success. For example, relapse is an 

expected part of recovery from substance abuse, 

and abstinence may not be the sole indicator of 

treatment success. Treatment effectiveness 

should also be measured by larger social 

indicators, such as higher employment rates, 

better personal relationships, and fewer legal 

entanglements (Wolk et al., 1994). After 

treatment, some people will not be drug-free for 

the rest of their lives, but they will experience 

more stability and more productive lives, 

resulting in significant benefits to society. 
Chapter 6 

76

Understanding the True 

Costs of Collaboration 

Even if an organization takes all the steps above, 

the path to collaboration is still paved with 

unforeseen difficulties. The importance of 

differences in perspectives between the two 

fields, as discussed in Chapter 1, should not be 

underestimated. One survey of staff in both 

types of program found that more than half of 

all staff cited “conflicting beliefs about personal 

responsibility” as a reason for noncooperation 

between programs (Bennett and Lawson, 1994). 

Service delivery structure and funding also can 

block collaboration. 

Furthermore, confidentiality and informedconsent practices vary among fields (see 

Appendix B). Large programs may have trouble 

linking with small programs, especially if 

documentation and tracking procedures are 

incompatible. Conversely, small grassroots 

programs may have problems following the 

formal procedures required by larger 

organizations or may lack staff to ensure that 

paperwork is completed in a timely fashion. 

Professionally led and staffed organizations may 

doubt the competence of paraprofessional staff 

members who are in recovery and may discount 

their suggestions in the course of treatment 

planning. Similarly, untrained staff may fail to 

recognize the validity of the insights and 

suggestions proffered by professional social 

work and mental health care givers. 

Other issues affecting the costs of 

collaboration include the number of approvals 

and layers of bureaucracy that must be 

negotiated to obtain services from a linked 

agency, requirements for research and 

evaluation that may be attached to participation 

in a network, and the amount of staff time 

required to maintain linkages and resolve 

problems. 

Other Linkage Strategies 

Funding Sources and 

Reimbursement 

Funding sources for domestic violence support 

include the criminal justice system through 

Federal block grants, State money, or fines 

levied against perpetrators. Private and 

community organizations also represent 

funding sources. Employee assistance programs 

(EAPs) can serve as both allies and access points 

to solicit and obtain corporate funding. Third 

party reimbursement for domestic violence 

services is slowly gaining some acceptance. At 

one time, insurers might have refused to pay for 

these services for a woman who was covered 

under the batterer’s policy, reasoning that the 

woman’s injury was self-inflicted because she 

chose to stay with the batterer. In some cases, 

the batterer must authorize payment for 

treatment for the survivor if medical, health, or 

disability coverage is in his name. 

One reason domestic violence has not been 

incorporated into concepts of managed care is 

that, as discussed in Chapter 1, some advocates 

for domestic violence survivors have rejected 

the use of a medical model to define the 

problem. In addition, most managed care 

companies have specific requirements about 

who can deliver services; if no program staff 

meet those requirements, it is not likely that the 

program will be reimbursed. Domestic violence 

support encompasses services such as housing 

and job training that are outside the realm of 

health care and that have outcomes difficult to 

measure in terms of health improvement, which 

are the outcomes of interest to health 

maintenance organizations (HMOs). However, 

many managed care organizations are investing 

funds to help their enrollees deal with issues 

that are not traditionally medical; many HMOs 
Linkages 

77

offer strss management and exercise programs. 

All health systems are increasingly recognizing 

the cost-effectiveness of early detection and 

prevention in general in their covered 

populations, and some have set up routine 

screening for substance abuse. Furthermore, 

increased interest in outcomes measurement 

and consumer satisfaction has broadened the 

spectrum of behaviors monitored and outcomes 

measured by health care providers. 

Reimbursement from managed care 

organizations and other third parties relies on 

diagnostic classifications and treatment 

categories. Advocates for reforms in health care 

and social welfare must find ways to classify 

joint substance abuse–domestic violence 

problems to ensure reimbursement. Although 

some domestic violence programs use the 

classification “trauma” and receive 

reimbursement for treatment, services are 

frequently provided as nonreimbursable 

advocacy or coaching. Victims who are thought 

to have underlying problems are typically 

referred to other programs (e.g., for 

psychological or substance abuse treatment). 

Research indicates that there are no 

psychological risk markers for becoming a 

victim of adult domestic violence (Hotaling and 

Sugarman, 1990). However, certain 

characteristic symptoms are seen in many 

people following highly traumatic life events. 

Some battered women experience these 

symptoms as a result of violence-associated 

trauma, and they are normal psychological 

responses to stressful life events. Often, these 

symptoms dissipate as women achieve greater 

safety from the abuse. Other women may 

require more intensive therapeutic interventions 

to heal from the effects of violence. The 

American Psychiatric Association’s Diagnostic 

and Statistical Manual of Mental Disorders, Fourth 

Edition (DSM-IV) (American Psychiatric 

Association, 1994), offers some diagnoses that 

may be helpful in classifying survivors’ 

symptoms and helping programs receive 

reimbursement for treatment. Some survivors 

may meet criteria for posttraumatic stress 

disorder (see Chapter 2) or for depressive and 

anxiety disorders. 

Licensing, Credentialing, 

And Certification 

Credentialing processes for substance abuse 

treatment providers must assess their ability to 

screen for violence and create a safety plan, as 

well as their knowledge of legal issues related to 

domestic violence. They should demonstrate a 

knowledge of child abuse and neglect, child 

sexual abuse, partner violence, elder abuse, 

extended family violence, and violence as an 

issue in relationships other than marital or 

partner relationships. 

Examples of Effective 

Community-Based 

Linkages 

In Bismarck, North Dakota, the Federation of 

Family Funding promoted and supported the 

development of a multiagency partnership plan 

to help families experiencing domestic violence. 

All providers involved with the family meet 

face-to-face every month to share information, 

make plans, and discuss strategies for ensuring 

progress. In a Los Angeles program for 

pregnant or substance-abusing battered 

mothers, a team of providers involved in all 

aspects of a client’s treatment meets as a group 

with the client. Children’s grandmothers, if they 

are the formal court-appointed caretakers of the 

children, are included in the case conferences; 

perpetrator fathers are not. Interagency 

agreements are made in advance to protect 

confidentiality. 

Examples in Health Care Settings 

Many of the linkages between domestic violence 

support services and other service organizations 
Chapter 6 

78

that have been most effective have occurred in 

health care settings, especially in hospitals. 

Linkages of the type described here might 

benefit from involvement of staff from substance 

abuse treatment programs. At the Dekalb 

Medical Center in Atlanta, emergency room 

nurses who suspect that a woman has been 

battered call a patient representative with 

specialized knowledge to interview the patient 

after medical treatment is provided (Dekalb 

Medical Center, 1993). The representative, who 

is able to spend more time with the patient than 

the nurses, refers the patient to a community 

shelter or makes other referrals and also 

provides feedback to the emergency room staff. 

Other examples of hospital-based service 

linkages come from Boston, Minneapolis, and 

Seattle (Loring and Smith, 1994). At Children’s 

Hospital in Boston, staff from AWAKE, an 

advocacy program for battered women and their 

children, are called in to provide safety planning 

and support for patients who are violence 

survivors. In Minneapolis at the Hennepin 

County Medical Center, an advocate from a 

battered women’s shelter makes rounds in all 

services—not just the emergency room—to 

speak directly with medical staff and interview 

violence survivors. In this way the hospital 

administration and medical staff are assured 

that in addition to receiving appropriate medical 

care, survivors are assisted in other areas, such 

as locating the batterer, obtaining legal 

protection, and proceeding with assault charges 

when appropriate. Harborview Hospital in 

Seattle employs an “adult abuse protocol” with 

components of various systems to ensure 

comprehensive services to the battered woman 

patient. Finally, health maintenance 

organizations, many of which maintain detailed 

databases to track service utilization and 

outcomes, may find it easier than general 

hospital systems to identify and reach out to 

survivors of domestic violence. 

Promising Activities and 

Future Directions

In 1994 the Board on Children and Families, the 

National Research Council, and the Institute of 

Medicine sponsored a 3-day workshop, Violence 

and the American Family (Chalk, 1994). 

Although the focus was a broad one and 

included child and elder abuse as well as other 

forms of family violence, many of the 

participants suggested action ideas for linkages 

among agencies involved in the treatment of 

domestic violence survivors and batterers. As 

can be readily seen, no single agency or system 

can successfully undertake the broad tasks and 

initiatives outlined below that were suggested 

by workshop participants. Rather these projects 

invite broad collaboration and cooperation. 

In the area of social services, tasks to be 

undertaken included (Chalk, 1994) 

 Developing a set of principles for designing 

violence interventions that would ensure 

client empowerment, build on family 

strengths, and be based on effectiveness 

evaluations 

 Creating violence intervention and 

prevention systems at the community level 

that build on formal and informal social 

networks in diverse neighborhoods 

 Requiring schools to make violence 

prevention education mandatory 

 Exploring new methods of cash payments to 

families to deter violence resulting from 

economic stress. 

In the area of health, the workshop 

participants identified three specific initiatives 

(Chalk, 1994): 

 A national campaign against violence to 

focus on health aspects and costs of family 

violence to society 

 Improvement of screening and diagnosis 

among health and mental health 

professionals of risks and injuries associated 

with family violence 
Linkages 

79

 Consensus-building about what is known 

about family violence, leading to the 

formation of a constituency to serve as an 

advocacy group to educate public officials. 

In the area of criminal justice, three issues 

were raised as fruitful areas for activities (Chalk, 

1994): 

 Effectiveness research on the use and 

enforcement of restraining orders to deal 

with domestic violence; new methods of 

offender control, such as electronic 

monitoring may be effective 

 Research on the availability and effectiveness 

of court-ordered treatment and on returning 

abusers to their families 

 Consideration of new proposals that 

experiment with the development of a onefamily, one-judge court system. 

In addition to these recommendations, the 

workshop participants outlined three broad 

steps necessary to establish a much-needed basis 

for future research and program plans (Chalk, 

1994): 

 Develop a broad-based public education 

campaign to foster understanding of family 

violence 

 Bridge the gap between research resources 

and policy needs, especially by developing 

rigorous evaluations of public sector 

programs to reduce domestic violence 

 Integrate preventive measures for domestic 

violence into a comprehensive, communitybased program of family support services 

across a spectrum of developmental 

milestones. The goal goes beyond 

information sharing and seeks to simplify 

access to services. 

A Public Health Approach 

A public health approach has been effective in 

reducing morbidity and mortality by modifying 

behavior in many areas (e.g., campaigns to 

reduce smoking, to reduce alcohol abuse among 

pregnant women, and to prevent head injuries 

by wearing helmets). A public health approach 

to violence has been suggested (Koop and 

Lundberg, 1992) in response to the surge in 

morbidity and mortality due to violence 

(Prothrow-Stith, 1991). As the epidemiological 

evidence mounts that society’s rising mortality 

figures are due in large part to violence, public 

health professionals acknowledge the 

destruction of “quality years of life” as well as 

the expensive healing process and now study 

the problem in terms of understanding and 

changing unhealthy outcomes (Koop and 

Lundberg, 1992). 

Public health officials, generally solutiondriven rather than theory-driven, view domestic 

violence as the result of a complex array of 

causal factors. By focusing on “risk factors,” 

they can identify structural, cultural, and 

situational conditions that accompany, precede, 

and follow events of interpersonal violence 

(Moore, 1995). They also monitor public health, 

identify at-risk groups, and implement 

programs with evaluation components. 

Education is a critical component of a public 

health campaign. In Houston, for example, the 

March of Dimes targeted both health care 

professionals and the public with educational 

interventions and brochures about battering 

during pregnancy; public service 

announcements were developed for the media. 

Coordination of Care 

Though the examples above do not include 

substance abuse treatment as one of their 

linkages, they provide a blueprint for the 

coordination of care that the Consensus Panel 

recommends. While the Panel believes the 

current system of parallel services should be 

integrated at the State level, meaningful change 

can occur at the community level. For either 

substance abuse treatment or domestic violence 
Chapter 6 

80

support services to be successful, the two fields 

must pool their energies to address gaps in 

client services outside the immediate networks of 

substance abuse treatment and violence support. 

Enduring linkages with other agencies and 

programs must be established to supply those 

ancillary services essential for positive client 

outcomes. 
81

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Appendix B 

Federal Confidentiality 

Regulations 

95

by Margaret K. Brooks, Esq.1

1

Margaret K. Brooks is an independent consultant in Montclair, New Jersey. 

F ederal law (United States Code, Title 42, 

§§290dd-2 [1992]) and the Federal 

regulations that implement it—Title 42, 

Part 2, of the Code of Federal Regulations (42 

C.F.R. Part 2)—guarantee the strict 

confidentiality of information about all persons 

receiving substance abuse prevention and 

treatment services.2

 They are designed to 

protect privacy rights and thereby attract 

individuals into treatment. The regulations are 

more restrictive of communications than are 

those governing the doctor-client relationship or 

the attorney-client privilege. Violating the 

regulations is punishable by a fine of up to $500 

for a first offense or up to $5,000 for each 

subsequent offense (§2.4). 

While some persons may view the 

restrictions that Federal regulations place on 

communications as a hindrance, if not a barrier, 

to program goals, due foresight can eliminate 

most of the problems that arise from the 

regulations. Familiarity with the regulations 

will facilitate communication and minimize the 

incidence of confidentiality-related conflicts 

among program, client, and outside agencies. 

Types of Programs 

Covered by the 

Regulations 

Any program that specializes, in whole or in 

part, in providing treatment, counseling and 

assessment, and referral services, or a 

combination thereof, for clients with alcohol or 

other drug problems must comply with the 

Federal confidentiality regulations (§2.12(e)). It 

is the kind of services provided, not the label, 

that determines whether a program must 

comply with the Federal law. Calling itself a 

“prevention program” does not insulate a 

program that also offers treatment services from 

the need to comply with confidentiality 

regulations. Although the Federal regulations 

apply only to programs that receive Federal 

assistance, the word assistance is broadly 

interpreted and includes indirect forms of 
Appendix B 

96

Federal aid such as tax-exempt status or State or 

local funding that is derived, in whole or in part, 

from the Federal government. 

Federal Confidentiality 

Laws 

The Federal confidentiality law and regulations 

protect any information about a client if the 

client has applied for or received any alcohol- or 

drug abuse-related services—including 

assessment, diagnosis, detoxification, 

counseling, group counseling, treatment, and 

referral for treatment—from a covered 

program.3

 The restrictions on disclosure apply 

to any information that would identify the client 

as a substance abuser, either directly or by 

implication. The rule applies from the moment 

the client makes an appointment. It applies to 

clients who are civilly or involuntarily 

committed, minors, clients who are mandated 

into treatment by the criminal justice system, 

and former clients. Finally, the rule applies 

whether or not the person making the inquiry 

already has the information, has other ways of 

getting it, enjoys official status, is authorized by 

State law, or comes armed with a subpoena or 

search warrant.4 

Conditions Under Which 

Confidential Information 

May Be Shared 

Information that is protected by the Federal 

confidentiality regulations may always be 

disclosed after the client has signed a proper 

consent form. If the client is a minor, parental 

consent must also be obtained in some States. 

The regulations also permit disclosure without 

the client’s consent in several situations, 

including communicating information to 

medical personnel during a medical emergency 

or reporting child abuse to the authorities. 

The most commonly used exception to the 

general rule prohibiting disclosures is for a 

program to obtain the client’s consent. The 

regulations’ requirements regarding consent are 

somewhat unusual and strict and must be 

carefully followed. 

Items required for disclosure 

of information 

Disclosures are permissible if a client has signed 

a valid consent form that has not expired or 

been revoked (§2.31). A proper consent form 

must be in writing and must contain each of the 

items that appear in Figure B-1. 

A general medical release form, or any 

consent form that does not contain all of the 

elements listed in Figure B-1, is not acceptable. 

A sample consent form may be found in Figure 

B-2. Two of the required items in Figure B-1 

merit further explanation: the purpose of the 

disclosure and how much and what kind of 

information will be disclosed. These two items 

are closely related. All disclosures, especially 

those made pursuant to a consent form, must be 

limited to information that is necessary to 

accomplish the need for or purpose of the 

disclosure (§2.13(a)). It would be improper to 

disclose everything in a client’s file if the person 

making the request needed only one specific 

piece of information. 

In completing a consent form, one must 

determine the purpose of or need for the 

communication of information. Once this has 

been identified, it is easier to determine how 

much and what kind of information will be 

disclosed and to restrict the disclosure to what is 

essential to accomplish the identified need or 

purpose. As an illustration, if a client needs to 

have the fact that he or she has entered a 

treatment program verified in order to be 

eligible for a benefit program, the purpose of the 

disclosure would be “to verify treatment status,” 

and the amount and kind of information to be 

disclosed would be “enrollment in treatment.” 

The disclosure would then be limited to a 

statement that “Jane Doe (the client) is receiving 

counseling at XYZ Program.” 
Federal Confidentiality Regulations 

97



















Figure B-1 

Client Consent Form: 

Required Items* 

Name or general description of the 

program(s) making the disclosure 

Name or title of the individual or 

organization that will receive the 

disclosure 

Name of the client who is the subject of 

the disclosure 

Purpose of or need for the disclosure 

How much and what kind of information 

will be disclosed 

A statement that the client may revoke 

the consent at any time, except to the 

extent that the program has already acted 

in reliance on it 

Date, event or condition upon which the 

consent expires, if not previously revoked 

Signature of the client (and, for minors in 

some States, his or her parent) 

Date on which the consent is signed 

*As set forth in 2.31(a). 

The client’s right to revoke consent 

The client may revoke consent at any time, and 

the consent form must include a statement to 

this effect. Revocation need not be in writing. If 

a program has made a disclosure prior to the 

revocation, the program has “acted in reliance” 

on the consent and is not required to try to 

retrieve the information it has already disclosed. 

The regulations state that acting in reliance 

includes providing services in reliance on a 

consent form permitting disclosures to a third 

party payer. Thus, a program may bill the third 

party payer for past services to the client even 

after consent has been revoked. A program may 

not, however, make any disclosure to the third 

party payer in order to receive reimbursement 

for services provided after the client has revoked 

consent (§2.31(a)(8)). 

Expiration of the consent form 

The form must also contain a date, an event, or a 

condition on which it will expire, if not 

previously revoked. A consent must last “no 

longer than reasonably necessary to serve the 

purpose for which it is given” (§2.31(a)(9)). If 

the purpose of the disclosure is expected to be 

accomplished in 5 or 10 days, it is better to 

stipulate that amount of time rather than to 

request a longer period or have a uniform 60- or 

90-day expiration date for all forms. 

The consent form may specify an event or a 

condition for expiration, rather than a date. For 

example, if a client has been placed on probation 

on the condition that he or she attend the 

treatment program, the consent form should not 

expire until the expected time of completion of 

the probationary period. Alternatively, if a 

client is being referred by the program to a 

specialist for a single appointment, the consent 

form should say that consent will expire after he 

or she has seen “Dr. X,” unless the client is 

expected to need ongoing consultation with the 

specialist. 

Signatures of minors and 

parental consent 

In order for a program to release information 

about a minor, even to his or her parent or 

guardian, the minor must have signed a consent 

form. The program must obtain the parent’s 

signature to make a disclosure to anyone else 

only if it was required by State law to obtain 

parental permission before providing treatment 

to the minor (§2.14). (Parent includes parent, 

guardian, or other person legally responsible for 

the minor.) In other words, if State law does not 

require the program to get parental consent in 

order to provide services to a minor, parental 

consent is not required to make disclosures 

(§2.14(b)). If, by contrast, State law requires 

parental consent to provide services to minors, 

parental consent also is required to make any 

disclosures. 
Appendix B 

98

Figure B-2 

Consent for the Release of Confidential Information 

I, ____________________________________________________________________, authorize 

(Name of client) 

_______________________________________________________________________________ 

(Name or general designation of program making disclosure) 

to disclose to ___________________________________________________________________ 

(Name of person or organization to which disclosure is to be made) 

the following information: _______________________________________________________ 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

(Nature of the information, as limited as possible) 

The purpose of the disclosure authorized herein is to: ________________________________ 

_______________________________________________________________________________ 

_______________________________________________________________________________ 

(Purpose of disclosure, as specific as possible) 

I understand that my records are protected under the Federal regulations governing 

Confidentiality of Alcohol and Drug Abuse Client Records, 42 C.F.R. Part 2, and cannot be disclosed 

without my written consent unless otherwise provided for in the regulations. I also understand that I 

may revoke this consent at any time except to the extent that action has been taken in reliance on it, 

and that in any event this consent expires automatically as follows: 

______________________________________________________________________________ 

(Specification of the date, event, or condition upon which this consent expires) 

Dated: _________________________________________________________________ 

(Signature of participant) 

 _________________________________________________________________ 

(Signature of parent, guardian, or 

authorized representative when required) 
Federal Confidentiality Regulations 

99

Required notice against 

redisclosing information 

Once the consent form has been properly 

completed, one formal requirement remains. 

Any disclosure made with written client consent 

must be accompanied by a written statement 

that the information disclosed is protected by 

Federal law and that the recipient may not make 

any further disclosure unless permitted by the 

regulations (§2.32). This statement, not the 

consent form itself, should be delivered and 

explained to the recipient at the time of 

disclosure or earlier. 

The prohibition on redisclosure is clear and 

strict. Those who receive the notice are 

prohibited from rereleasing information except 

as permitted by the regulations. A client may, of 

course, sign a consent form authorizing such a 

redisclosure. A sample Notice of Prohibition 

appears in Figure B-3. 

Decisions Concerning Disclosure 

The fact that a client has signed a proper consent 

form authorizing the release of information does 

not force a program to make the proposed 

disclosure, unless the program has also received 

a subpoena or court order (§§2.3(b); 2.61(a)(b)). 

The only obligation the program has is to refuse 

to honor a consent that is expired, deficient, or 

otherwise known to be revoked, false, or invalid 

(§2.31(c)). 

In most cases, the decision whether or not to 

make a disclosure pursuant to a consent form is 

within the discretion of the program, unless 

State law requires or prohibits disclosure once 

consent is given. In general, it is best to follow 

this rule: Disclose only what is necessary, for 

only as long as is necessary, in light of the 

purpose of the communication. 

Rules Governing 

Communication of 

Information 

Seeking Information From 

Collateral and Referral Sources 

Making inquiries of parents, other relatives, 

health care providers, employers, schools, or 

criminal justice agencies might seem at first 

glance to pose no risk to a client’s right to 

confidentiality, particularly if the person or 

entity approached for information referred the 

client to treatment. Nonetheless, it does. 

Figure B-3 

Prohibition on Redisclosing Information Concerning 

Substance Abuse Treatment Clients 

This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse 

treatment, made to you with the consent of such client. This information has been disclosed to you 

from records protected by Federal confidentiality rules (42 C.F.R. Part 2). The Federal rules prohibit 

you from making any further disclosure of this information unless further disclosure is expressly 

permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 

C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient 

for this purpose. The Federal rules restrict any use of the information to criminally investigate or 

prosecute any alcohol or drug abuse client. 

 
Appendix B 

100

When a program that screens, assesses, or 

treats a client asks a relative or parent, a doctor, 

an employer, or a school to verify information it 

has obtained from the client, it is making a 

“client-identifying disclosure.” Client-identifying 

information is information that identifies 

someone as a substance abuser. In other words, 

when program staff seek information from other 

sources, they are letting these sources know that 

the client has asked for treatment services. The 

Federal regulations generally prohibit this kind 

of disclosure, unless the client consents. 

How should a program go about making 

such requests? The easiest way is to get the 

client’s consent to contact the relative, doctor, 

employer, school, or health care facility. When 

filling out the consent form, staff should give 

thought to the “purpose of the disclosure” and 

“how much and what kind of information is to 

be disclosed.” For example, if a program is 

assessing a client for treatment and seeks 

records from a mental health provider, the 

purpose of the disclosure would be “to obtain 

mental health treatment records to complete the 

assessment.” The “kind of information 

disclosed” would be limited to a statement that 

“Robert Roe (the client) is being assessed by the 

XYZ Program.” No other information about 

Robert Roe would be released. If the program 

not only seeks records but also wishes to discuss 

with the mental health provider the treatment 

he or she provided the client, the purpose of the 

disclosure would be “to discuss mental health 

treatment provided to Robert Roe by the mental 

health program.” If the program merely seeks 

information, the kind of information disclosed 

would, as in the example above, be limited to a 

statement that “Robert Roe is being assessed by 

the XYZ Program”; however, if the program 

needs to disclose information it has gained in its 

assessment of Robert Roe to the mental health 

provider in order to further the discussion or 

coordinate care, the kind of information 

disclosed would be “assessment information 

about Robert Roe.” 

A program that routinely seeks collateral 

information from many sources could consider 

asking the client to sign a consent form that 

permits it to make a disclosure for purposes of 

seeking information from collateral sources to 

any one of a number of entities or persons listed 

on the consent form. Such a form must still 

include “the name or title of the individual or 

the name of the organization” for each collateral 

source the program may contact. 

Even when information is disclosed over the 

telephone, program staff are required to notify 

the recipient of the information of the 

prohibition on redisclosure. Mention should be 

made of this restriction during the conversation; 

for example, the staff member could say, “I’ll be 

sending you a written statement that the 

information I gave you about Mr. Roe may not 

be redisclosed.” 

Communications with employers may 

warrant special consideration. When a client

enters treatment voluntarily, program staff 

should maintain an open mind about whether 

communications with an employer would be 

beneficial to the client. A client who tells 

program staff that his or her employer will not 

be sympathetic about the decision to enter 

treatment may well have an accurate picture of 

the employer’s attitude. Should staff insist on 

communicating with the employer, the client 

may lose his or her job. If such communication 

takes place without the client’s consent, the 

program may be faced with a lawsuit.5

Communications With 

Insurance Carriers 

Programs must obtain a client’s written consent 

on the form required by the Federal regulations 

in order to communicate with any third party 

payer who may be responsible for funding the 

client’s treatment. Some clients do not want 

their treatment reported to the insurer. Clients 
Federal Confidentiality Regulations 

101

whose employers are self-insured may fear they 

will be fired, demoted, or disciplined, should 

their employer learn they have a substance 

abuse problem. Clients whose treatment is 

covered by health insurance may fear they will 

lose their benefits and be unable to obtain other 

coverage once their current insurer discovers 

they have been treated for a substance abuse 

problem. What should programs do in these 

circumstances? 

The program clearly cannot make a 

disclosure to a third party payer without the 

client’s consent. If the third party payer is the 

client’s employer, the program would not only 

be violating the Federal regulations but also 

would be risking a lawsuit, should the client be 

fired or disciplined. If the third party payer is 

an insurance company, the program is taking 

similar risks: If the client’s insurance is canceled 

or he or she cannot obtain coverage elsewhere, 

the program may face a lawsuit.6 

If a client does not want the insurance carrier 

to be notified and is unable to pay for treatment, 

the program may refer the client to a publicly 

funded program, if one is available.7

 Programs 

should consult State law to learn whether they 

may refuse to admit a client who is unable to 

pay and who will not consent to the necessary 

disclosures to his or her insurance carrier. 

Insurance carriers, particularly managed care 

entities, are demanding more and more 

information about the clients covered by their 

policies and the treatment provided to those 

clients. Programs need to be sensitive about the 

amount and kind of information they disclose, 

because the insurer may use this information to 

deny benefits to the client. For example, if, in 

response to a request from the insurer, the 

program releases the client’s entire chart, the 

insurer may learn from the intake notes that the 

client’s substance abuse problem included both 

alcohol and illegal drugs. The insurer may then 

deny benefits, arguing that since its policy does 

not cover treatment for abuse of drugs other 

than alcohol, it will not reimburse for treatment 

when abuse of both alcohol and drugs is 

involved. As a second example, the insurer may 

learn that the client began drinking at age 11 

and deny benefits for a “preexisting condition.” 

Treatment notes may contain personal 

information about the client’s family life that is 

extraneous for insurance company review, the 

sole purpose of which is to determine whether 

treatment should be covered and, if so, what 

kind. 

Communication Among Agencies 

Communication with other 

care providers

Treatment programs sometimes need to 

maintain ongoing communication with the 

referral source or with other professionals 

providing services to clients. The best way to 

proceed is to get the client’s consent. 

In wording the consent form, one should 

take care to permit the kinds of communications 

necessary. For example, if the program will 

need ongoing communication with a mental 

health provider, the “purpose of the disclosure” 

would be “coordination of care for Mildred 

Moe”; “how much and what kind of information 

to be disclosed” might be “treatment status, 

treatment issues, progress in treatment.” If the 

program is treating a client who is on probation 

at work and whose continued employment is 

contingent on treatment, the “purpose of 

disclosure” might be “to assist the client to 

comply with employer’s mandates” or “supply 

periodic reports about treatment”; “how much 

and what kind of information will be disclosed” 

might be “progress in treatment.” The kinds of 

information that would be disclosed in the two 

examples are quite different. The program 

might well share detailed clinical information 

about a client with a mental health provider, if it 

would assist in coordinating care. Disclosure to 

an employer, by contrast, would generally be 

limited to a brief statement about the client’s 
Appendix B 

102

progress in treatment. Disclosure of clinical 

information to an employer generally would be 

inappropriate. 

The program should also be careful in setting 

the expiration date or event on which expiration 

of the consent form is based. A consent form 

with a mental health provider might expire 

when treatment ends, while a form permitting 

disclosures to an employer might expire when 

the client’s probationary period at work ends. 

Referral for additional services 

When a staff member of a treatment program 

refers a client to another program for services 

(e.g., domestic violence support or vocational 

rehabilitation) and makes an appointment for 

the client, he or she is making a disclosure 

covered by the Federal regulations—a disclosure 

that the client has sought or received substance 

abuse treatment services. A consent form is, 

therefore, required. If the substance abuse 

treatment program is part of a larger program to 

which the client is being referred, a consent form 

may not be necessary under the Federal rules, 

since there is an exception for information 

disclosed to staff within the same program. 

Transferring clients to the hospital

Substance abuse treatment programs, 

particularly those with limited medical 

resources, may transfer clients to a hospital for 

intensive medical management and care. How 

should programs handle such transfers, since 

they involve a disclosure of client-identifying 

information? 

Programs may deal with this issue in two 

ways. First, they may ask all clients admitted to 

treatment to sign a consent form permitting 

disclosure to the cooperating hospital, should 

hospitalization be required. Second, they may 

take advantage of a provision in the Federal 

regulations that permits a program to make 

disclosures in a “medical emergency” to medical 

personnel “who have a need for information 

about a client for the purpose of treating a 

condition which poses an immediate threat to 

the health of any individual.” The regulations 

define “medical emergency” as “a condition 

which poses an immediate threat to the health of 

any individual and which requires immediate 

medical intervention” (§2.51). If a client’s 

condition requires emergency treatment, the 

program may use this exception to communicate 

with medical personnel at a hospital. Whenever 

a disclosure is made to cope with a medical 

emergency, the program must document in the 

client’s records the name and affiliation of the 

recipient of the information, the name of the 

individual making the disclosure, the date and 

time of the disclosure, and the nature of the 

emergency. 

Mandatory reporting to public 

health authorities 

All States require that new cases of acquired 

immunodeficiency syndrome (AIDS) be 

reported to public health authorities, which 

submit this information to the Federal Centers 

for Disease Control and Prevention. In some 

cases, they also use it for other purposes. Some 

States also require the reporting of new cases of 

human immunodeficiency virus (HIV) infection. 

States also require reporting of certain infectious 

diseases, such as tuberculosis and sexually 

transmitted diseases. The public health 

authority often uses reports of infectious 

diseases to engage in “contact tracing,” that is, 

finding others to whom an infected person may 

have spread the disease. 

The types of information that must be 

reported and for which diseases, who must 

report, and the purposes to which the 

information is put vary from State to State. 

Therefore, program directors must examine 

their State laws to discover (1) whether they or 

any member of their staff is a mandated 

reporter, (2) when reporting is required, (3) 

what information must be reported and whether 

it includes client-identifying information, and 
Federal Confidentiality Regulations 

103

(4) what will be done with the information 

reported.8

If State law permits the use of a code rather 

than a client’s name, the program may make the 

report without the client’s consent since no 

client-identifying information is being revealed. 

If client-identifying information must be 

reported, there are a number of ways programs 

can comply with State mandatory reporting 

laws without violating the Federal 

confidentiality regulations. They include the 

following: 







Obtaining consent. The easiest way to 

comply with a State law that mandates 

reporting of client-identifying information to 

a public health authority is to obtain the 

client’s consent. The information reported by 

the program may not be redisclosed by the 

public health authority unless the consent 

form is drafted to permit redisclosure. 

Reporting without making a clientidentifying disclosure. If the program is 

part of another health care facility (for 

example, a general hospital or mental health 

program), it can include the client’s name in 

reports if it does so under the name of the 

parent agency, as long as no information is 

released that would link the client with 

substance abuse treatment. 

Using a Qualified Service Organization 

Agreement (QSOA). A treatment program 

that is required to report clients’ names to a 

public health department also may enter into 

a QSOA with a general medical care facility 

or a laboratory that conducts testing or other 

services for the program. The QSOA, which 

is explained in detail later in this appendix, 

permits the program to report the names of 

clients to the medical care facility or 

laboratory, which may then report the 

information, including client names, to the 

public heath department. However, no 

information is provided that would link 

those names with substance abuse treatment. 

 Reporting under the audit and evaluation 

exception. One of the exceptions to the 

general rule prohibiting disclosure without 

client consent is found in §2.53, which 

permits programs, under certain conditions, 

to disclose information to auditors and 

evaluators. The U.S. Department of Health 

and Human Services (HHS) has written 

two opinion letters that approve the use of 

the audit and evaluation exception to report 

HIV-related information to public health 

authorities.9

 Read together, these two letters 

suggest that substance abuse programs may 

report client-identifying information even if 

that information will be used by the public 

health department to conduct contact tracing, 

as long as the health department does not 

disclose the name of the client to the 

“contacts” it approaches. The letters also 

suggest that the public health authorities 

could use the information to contact the 

infected client directly. Section 2.53 is 

intended to permit an outside entity, such as 

a peer review organization or an accounting 

firm, to examine or copy a program’s records 

in order to determine whether it is operating 

in accordance with regulations. It was not 

intended to permit an outside entity to gain 

information to perform other tasks or 

accomplish other social ends. The legal 

validity of these two letters may, therefore, 

be considered debatable. 

Telephone Calls to Clients 

If someone telephones a client at a program, the 

staff may not reveal that the client is at the 

program unless the program has a written 

consent form signed by the client to make a 

disclosure to that particular caller. Given this 

restriction, how should a program handle 

telephone calls to clients? There are at least four 

options: 
Appendix B 

104

 The program can obtain the client’s written 

consent to accept telephone calls from 

particular people and consult a list of these 

individuals’ names when the client receives a 

phone call. 







If the client has not consented to receive calls 

from a particular person, the staff member 

can put the caller on hold and ask the client if 

he or she wants to speak to the caller. If the 

client wants to accept the call, the client, not 

the staff member, is making the disclosure 

that he or she is at the treatment program. If 

the client does not want to speak to the caller, 

the staff member must tell the caller, “I’m 

sorry, but I can’t tell you whether Tommy 

Toe is here.” At no time may the program 

reveal, even indirectly, that the person being 

inquired after is a client at the program. 

The program can uniformly take messages 

for clients, telling all callers, “I’m sorry, but I 

cannot tell you if Tommy is here, but if he is I 

will give him this message.” Again, this 

leaves it up to the client whether to make a 

disclosure about being in treatment. 

The program can set up a “client phone” that 

is answered only by clients. Since only 

clients would answer the telephone and give 

the phone number to others if the number 

were unlisted, the program would be making 

no disclosures. The program should caution 

clients to act discreetly and thoughtfully 

when handling calls for others. 

Clients Mandated Into Treatment 

By the Criminal Justice System 

Programs treating clients who are required to 

enter and participate in treatment as part of a 

criminal justice sanction must follow the Federal 

confidentiality rules. In addition, some special 

rules apply when a client is in treatment as an 

official condition of probation, sentence, 

dismissal of charges, release from detention, or 

other disposition of any criminal proceeding, 

and information is being disclosed to the 

mandating agency. 

A consent form or court order is still required 

before any disclosure may be made about an 

offender who is mandated into assessment or 

treatment. However, the rules concerning the 

length of time that a consent remains valid are 

different, and a “criminal justice system 

consent” may not be revoked before its 

expiration event or date. 

The regulations require that the following 

factors be considered in determining how long a 

criminal justice system consent will remain in 

effect: 











The anticipated duration of treatment 

The type of criminal proceeding in which the 

offender is involved 

The need for treatment information in 

dealing with the proceeding 

When the final disposition will occur 

Anything else the client, program, or 

criminal justice agency believes is relevant. 

These rules allow programs to continue to 

use a traditional expiration condition for a 

consent form that once was the only one 

allowed, namely, “when there is a substantial 

change in the client’s criminal justice system 

status.” A substantial change in status occurs 

whenever the client moves from one phase of 

the criminal justice system to the next. For 

example, if a client is on probation or parole, a 

change in criminal justice status would occur 

when the probation or parole ended, either by 

successful completion or revocation. Thus, the 

program could provide treatment or periodic 

reports to the probation or parole officer 

monitoring the client and could even testify at a 

revocation hearing if it so desired, since no 

change in criminal justice status would occur 

until after that hearing. This formula appears to 

work well. 

Concerning revocability of the consent (that 

is, the conditions under which the offender can 
Federal Confidentiality Regulations 

105

take back his or her consent), the regulations 

provide that the form may state that consent 

may not be revoked until a specified date arrives 

or condition occurs. The regulations permit the 

criminal justice system consent form to be 

irrevocable, so that a client who has agreed to 

enter treatment in lieu of prosecution or 

punishment cannot later prevent the court, 

probation department, or other agency from 

monitoring his or her progress. Although a 

criminal justice system consent may be made 

irrevocable for a specified period of time, its 

irrevocability must end no later than the final 

disposition of the criminal proceeding. 

Thereafter, the client may freely revoke consent. 

Several other considerations relating to 

criminal justice system referrals are important. 

First, any information received by one of the 

eligible criminal justice agencies from a 

treatment program may be used by that justice 

agency only in connection with its official duties 

with respect to that particular criminal 

proceeding. The information may not be used in 

other proceedings, for other purposes, or with 

respect to other individuals (§2.34(d)). Second, 

whenever possible, the judge or referring agency 

should require that a proper criminal justice 

system consent form be signed by the client at 

the time he or she is referred to the treatment 

program. If this is not possible, the treatment 

program should have the client sign a criminal 

justice system consent form at his or her first 

appointment. With a properly signed criminal 

justice consent form, the treatment program can 

communicate with the referring criminal justice 

agency, even if the client appears for assessment 

or treatment only once. This avoids the 

problems that may arise if a client mandated 

into treatment does not sign a proper consent 

form and leaves before the assessment or 

treatment has been completed. 

If a program fails to have the client sign a 

criminal justice system form and the client fails 

to complete the assessment or treatment, the 

program has few options when faced with a 

request for information from the referring 

criminal justice agency. The program could 

attempt to locate the client and ask him or her to 

sign a consent form. The client is, however, 

unlikely to do so. It is uncertain whether a court 

can issue an order to authorize the program to 

release information about a referred client who 

has left the program in this type of case, because 

the regulations allow a court to order disclosure 

of treatment information for the purpose of 

investigating or prosecuting a client for a crime 

only when the crime was “extremely serious.” 

A parole or probation violation generally will 

not meet that criterion. 

Therefore, unless the judge, criminal justice 

agency, or program obtains consent at the 

beginning of the assessment or treatment 

process, the program may be prevented from 

providing any information to the referring 

criminal justice agency. 

If a client referred by a criminal justice 

agency never applies for or receives services 

from the program, that fact may be 

communicated to the referring agency without 

client consent (§2.13(c)(2)). As soon as a client 

has made an appointment to visit the program, a 

signed consent form or a court order is needed 

for any disclosures. 

Driving While Impaired

Suppose that an intoxicated client arrives at a 

treatment program but decides not to enter 

treatment. If the client is not in condition to 

drive home, what should the program do? First, 

it can offer the client a ride home or taxi fare for 

a ride home. Second, it can maintain a room 

where such a person can “sleep it off.” (The 

program would be wise to obtain the person’s 

consent to alert his or her family.) This strategy 

can also be used by programs that do not admit 

clients who are inebriated. 

What if the client refuses both offers and 

leaves the premises, intending to drive home? 
Appendix B 

106

Does the program have a duty to call the police 

to prevent an accident? Does it risk a lawsuit if 

it fails to do so? This is a question of State law. 

In most States, it is unlikely that the program 

would be liable, particularly if it had made an 

effort to stop the client from driving. As noted 

in Chapter 5, in States that follow the Tarasoff

doctrine, liability has generally been limited to 

those situations where a client threatens to harm 

a specific person. Liability has generally not 

been imposed in situations where a client poses 

a threat to the community in general. 

Liability concerns aside, the program may 

nonetheless believe it is obligated to call the 

police if its attempts to prevent the client from 

driving fail. In doing so, it must take care not to 

violate the client’s confidentiality. For example, 

the program can call the police and tell them 

that the driver of a 1991 tan Nissan with a 

license number “XYZ 123,” who is heading 

downtown from the intersection of Maple and 

Third streets, is not in a condition to operate a 

vehicle. The program should ask the police to 

respond immediately. The program may not tell 

the police that the client has a substance abuse 

problem. This means it may not tell the police 

that the client is impaired by alcohol or drugs 

and cannot reveal the program’s name, since to 

do so would tell the police that the client has a 

substance abuse problem. 

In order to get the client’s license number 

and a description of his or her car, it may be 

necessary to detain the client. If it does so, the 

program should avoid using force, since the 

client could sue the program for battery or false 

imprisonment. 

Conducting Research 

Research about and evaluation of the efficacy of 

different methods of treatment are essential to 

advances in the field. But can programs share 

client-identifying information with researchers 

and program evaluators? The confidentiality 

regulations do permit programs to disclose 

client-identifying information to researchers, 

auditors, and evaluators without client consent, 

provided certain safeguards are met (§§2.52, 

2.53). 

Research

Treatment programs may disclose clientidentifying information to persons conducting 

“scientific research” if the program director 

determines that the researcher (1) is qualified to 

conduct the research, (2) has a protocol under 

which client-identifying information will be 

kept in accordance with the regulations’ security 

provisions (see §2.16, as described below), and 

(3) has provided a written statement from a 

group of three or more independent individuals 

who have reviewed the protocol and 

determined that it protects clients’ rights. 

Researchers are prohibited from identifying an 

individual client in any report or from otherwise 

disclosing any client identities, except back to 

the program.10

Audit and evaluation

Federal, State, and local government agencies 

that fund or are authorized to regulate a 

program, private entities that fund or provide 

third party payments to a program, and peer 

review entities performing a utilization or 

quality control review may review client records 

on the program premises in order to conduct an 

audit or evaluation.11 Any person or entity that 

reviews client records to perform an audit or 

conduct an evaluation must agree in writing that 

it will use the information only to carry out the 

audit or evaluation and that it will redisclose 

client information only (1) back to the program, 

(2) in accordance with a court order to 

investigate or prosecute the program (§2.66), or 

(3) to a government agency overseeing a 

Medicare or Medicaid audit or evaluation 

(§2.53(a), (c), (d)). Any other person or entity 

that is determined by the program director to be 

qualified to conduct an audit or evaluation and 
Federal Confidentiality Regulations 

107

that agrees in writing to abide by the restrictions 

on redisclosure also may review client records. 

Followup research

Research that follows clients for any period of 

time after they leave treatment presents a special 

challenge under the Federal regulations. The 

treatment program, researcher, or evaluator 

who seeks to contact former clients to gain 

information about how they are faring after 

leaving treatment must do so without disclosing 

to others any information about their connection 

to the treatment program. If followup contact is 

attempted by telephone, the caller must make 

sure he or she is talking to the client before 

identifying himself or herself or mentioning a 

connection to the treatment program. For 

example, asking for “William Woe,” when his 

wife or child has answered the phone, and 

announcing that one is calling from the “ABC 

Treatment Program” (or the “Drug Research 

Corporation”) violates the regulations. The 

program or research agency may form another 

entity, without a hint of drug or alcohol 

treatment in its name (for example, Health 

Research, Inc.) that can contact former clients 

without worrying about disclosing information 

simply by giving its name. When a 

representative of such an entity calls former 

clients, however, care must be taken that the 

client is actually on the line before revealing any 

connection with the treatment program. 

If followup is done by mail, the return 

address should not disclose any information 

that could lead someone seeing the envelope to 

conclude that the addressee had been in 

treatment. 

Five Other Exceptions 

To the General 

Confidentiality Rule 

Reference has been made to other exceptions the 

Federal confidentiality rules make to the general 

rule prohibiting disclosure. Presented below are 

five additional categories of exceptions to the 

general rule. 

Communications That Do Not 

Disclose Client-Identifying 

Information 

The Federal regulations permit programs to 

disclose information about a client if the 

program reveals no client-identifying 

information. Thus, a program may disclose 

information about a client if that information 

does not identify the client as a substance abuser 

or does not verify anyone else’s identification of 

the client as a substance abuser. 

A program may make a disclosure that does 

not identify a client in two ways. First, it may 

report aggregate data that give an overview of 

the clients served in the program or some 

portion of its population. For example, a 

program could tell the newspaper that in the last 

6 months it had 43 clients, 10 female and 33 

male. Second, a program may communicate 

information about a client in a way that does not 

reveal the client’s status as a drug or alcohol 

abuse client (§2.12(a)(i)). For example, a 

program that provides services to clients with 

other problems or illnesses as well as alcohol or 

drug addiction may disclose information about 

a particular client as long as the fact that the 

client has a substance abuse problem is not 

revealed. To cite a more specific example, a 

counselor from a program that is part of a 

general hospital could call the police about a 

threat a client made, as long as he or she does 

not disclose that the client has an alcohol or 

drug abuse problem or is a client of the 

treatment program. 

Programs that provide only alcohol or drug 

services or that provide a full range of services 

but are identified by the general public as drug 

or alcohol programs cannot disclose information 

that identifies a client under this exception, since 

letting someone know a counselor is calling 
Appendix B 

108

from the “XYZ Program” will automatically 

identify the client as someone who got services 

from the program. However, a freestanding 

program may sometimes make “anonymous” 

disclosures, that is, disclosures that do not 

mention the name of the program or otherwise 

reveal the client’s status as an alcohol or drug 

abuser. 

Court-Ordered Disclosures

A State or Federal court may issue an 

authorizing order that will permit a program to 

make a disclosure about a client that would 

otherwise be forbidden. A court may issue one 

of these orders, however, only after it follows 

certain special procedures and makes particular 

determinations required by the regulations. A 

subpoena, search warrant, or arrest warrant, 

even when signed by a judge, is not sufficient 

standing alone to require, or even to permit, a 

program to disclose information (§2.61).12

Before a court can issue an authorizing order, 

the program and any client whose records are 

sought must be given notice of the application 

for the order and some opportunity to make an 

oral or a written statement to the court.13

 

Generally, the application and any court order 

must use fictitious names for any known client. 

All court proceedings in connection with the 

application must remain confidential, unless the 

client requests otherwise (§§2.64(a), (b), 2.65, 

2.66). 

Before issuing an authorizing order, the court 

must find that there is “good cause” for the 

disclosure. A court may find “good cause” only 

if it determines that the public interest and the 

need for disclosure outweigh any adverse effect 

that the disclosure will have on the client, the 

doctor-client or counselor-client relationship, 

and the effectiveness of the program’s treatment 

services. Before it may issue an order, the court 

also must find that other ways of obtaining the 

information are unavailable or would be 

ineffective (§2.64(d)).14 The judge may examine 

the records before making a decision (§2.64(c)). 

There are also limits on the scope of 

disclosure that a court may authorize, even 

when it finds good cause. The disclosure must 

be limited to information essential to fulfill the 

purpose of the order and restricted to those 

persons who need the information for that 

purpose. The court also should take any other 

steps that are necessary to protect the client’s 

confidentiality, including sealing court records 

from public scrutiny (§2.64(e)). 

The court may order disclosure of 

“confidential communications” by a client to the 

program only if the disclosure is necessary to 

protect against a threat to life or of serious 

bodily injury or to investigate or prosecute an 

extremely serious crime (including child abuse), 

or is in connection with a proceeding at which 

the client has already presented evidence 

concerning confidential communications (§2.63). 

Medical Emergencies

A program may make disclosures to public or 

private medical personnel “who have a need for 

information about a client for the purpose of 

treating a condition which poses an immediate 

threat to the health of any individual.” The 

regulations define medical emergency as a 

situation that poses an immediate threat to 

health and requires immediate medical 

intervention (§2.51). 

The medical emergency exception permits 

disclosure only to medical personnel. It cannot 

be used as the basis for a disclosure to the police 

or other nonmedical personnel, including 

parents. Under this exception, however, a 

program could notify a private physician about 

a suicidal client so that medical intervention 

could be arranged. The physician, in turn, could 

notify a client’s parents or other relatives, as 

long as no mention were made of the client’s 

substance abuse problem. Whenever a 

disclosure is made to cope with a medical 
Federal Confidentiality Regulations 

109

emergency, the program must document in the 

client’s records the name and affiliation of the 

recipient of the information, the name of the 

individual making the disclosure, the date and 

time of the disclosure, and the nature of the 

emergency. 

Qualified Service Organization 

Agreements

If a program routinely needs to share certain 

information with an outside agency that 

provides services to the program, it can enter 

into a QSOA. A QSOA (Figure B-4) is a written 

agreement between a program and a person 

providing services to the program in which that 

person (1) acknowledges that in receiving, 

storing, processing, or otherwise dealing with 

any client records from the program, he or she is 

fully bound by [the Federal confidentiality] 

regulations; and (2) promises that, if necessary, 

he or she will resist in judicial proceedings any 

efforts to obtain access to client records except as 

permitted by these regulations (§§2.11, 

2.12(c)(4)). 

A QSOA should be used only when an 

agency or official outside of the program, for 

example, a clinical laboratory or data-processing 

agency, is providing a service to the program 

itself. An example is when laboratory analysis 

or data processing is performed for the program 

by an outside agency. A QSOA is not a 

substitute for individual consent in other 

situations. Disclosures under a QSOA must be 

limited to information that is needed by others 

so that the program can function effectively. 

QSOAs may not be used between programs 

providing alcohol and drug services. 

Internal Program Communications

The Federal regulations permit some 

information to be disclosed to individuals 

within the same program: 

The restrictions on disclosure in these 

regulations do not apply to communications of 

information between or among personnel 

having a need for the information in 

connection with their duties that arise out of 

the provision of diagnosis, treatment, or 

referral for treatment of alcohol or drug abuse 

if the communications are (i) within a program 

or (ii) between a program and an entity that 

has direct administrative control over that 

program. (§2.12(c)(3)) 

In other words, staff (including full- or parttime employees and unpaid volunteers) who 

have access to client records because they work 

for or administratively direct the program may 

consult among themselves or otherwise share 

information if their substance abuse work so 

requires 

Does this exception allow a treatment 

program that is part of a larger entity, such as a 

hospital, to share confidential information with 

others that are not part of the treatment unit? 

The answer to this question is quite complicated. 

In brief, there are circumstances under which 

the treatment unit may share information with 

other units that are part of the greater entity to 

which it belongs. Before such an internal 

communication system is set up within a large 

institution, however, it is essential that an expert 

in the area be consulted. 

.
Appendix B 

Figure B-4 

Qualified Service Organization Agreement

XYZ Service Center (“the Center”) and the ____________________________________________ 

__________________________________________________________________________________ 

(Name of the program) 

(“the Program”) hereby enter into a qualified service organization agreement, whereby the Center 

agrees to provide the following services: 

__________________________________________________________________________________ 

__________________________________________________________________________________ 

__________________________________________________________________________________ 

(Nature of services to be provided) 

Furthermore, the Center: 

1. Acknowledges that in receiving, storing, processing, or otherwise dealing with any information 

from the Program about the clients in the Program, it is fully bound by the provisions of the Federal 

Regulations governing Confidentiality of Alcohol and Drug Abuse Client Records, 42 C.F.R. Part 2; 

and 

2. Undertakes to resist in judicial proceedings any effort to obtain access to information pertaining 

to clients otherwise than as expressly provided for in the Federal confidentiality regulations, 42 C.F.R. 

Part 2. 

Executed this _____ day of __________, 199__. 

__________________________ _________________________ 

 President Program Director 

 XYZ Service Center (Name of Program) 

 (Address) (Address) 

110
Federal Confidentiality Regulations 

111

Other Requirements

Client Notice and Access to Records 

The Federal confidentiality regulations require 

programs to notify clients of their right to 

confidentiality and to give them a written 

summary of the regulations’ requirements. The 

notice and summary should be handed to clients 

when they enter the program or shortly 

thereafter (§2.22(a)). The regulations contain a 

sample notice that may be used for this purpose. 

Unless State law grants the right of client 

access to records, programs have the right to 

decide when to permit clients to view or obtain 

copies of their records. The Federal regulations 

do not require programs to obtain written 

consent from clients before permitting them to 

see their own records. 

Endnotes

2. Citations throughout this appendix in the 

form “§2...” refer to specific sections of 42 C.F.R., 

Part 2, Implementing the Substance Abuse and 

Mental Health Services Administration (42 

U.S.C. §290dd-2). 

3. Only clients who have “applied for or 

received” services from a program are 

protected. If a client has not personally sought 

help from the program or has not yet been 

evaluated or counseled by a program, the 

program is free to discuss the client’s drug or 

alcohol problems with others. The Federal 

regulations govern from the moment the client 

applies for services or the program first 

conducts an evaluation or begins counseling. 

4. Subpoenas and search and arrest warrants 

are discussed in Chapter 5. 

5. Although Federal and, in some cases, State 

laws may prohibit the employer from firing 

employees or taking other action simply because 

Security of Records

The Federal regulations require programs to 

keep written records in a secure room, locked 

file cabinet, safe, or other similar container. The 

program should establish written procedures 

that regulate access to and use of client records. 

The program director or a single staff person 

should be designated to process inquiries and 

requests for information (§2.16). 

Conclusion 

Administrators and staff members of substance 

abuse treatment programs should become 

thoroughly familiar with the many legal issues 

affecting their work. Such knowledge can 

prevent costly mistakes. Because legal 

requirements often vary by State and change 

over time, it is also essential that programs find 

a reliable source to whom they may turn for upto-date information, advice, and training. 

they have entered treatment, discriminatory 

practices against recovering people continue. 

6. Some States prohibit insurance companies 

from discriminating against individuals who 

have received substance abuse treatment; 

however, discriminatory practices continue. 

Insurance companies routinely share 

information about policy holders. Although the 

Federal regulations prohibit insurance 

companies from sharing information from a 

treatment program with other carriers, that 

prohibition is no guarantee that such 

redisclosure will not take place. 

7. If a client who has signed a consent form 

permitting the program to make disclosures to a 

third party payer later revokes his or her 

consent, the program can bill the third party 

payer for services provided before consent was 

revoked. A program cannot, however, make 

any disclosures to the third party payer in order 
Appendix B 

112

to receive reimbursement for services rendered 

after the client revoked consent (§2.31(a)(8)). 

8. If the State’s reporting law is intended only to 

gather information for research purposes, 

treatment programs can include clients’ names 

in their reports, if the public health department 

complies with §2.52 of the Federal regulations. 

That section permits release of client-identifying 

information to researchers when (1) they are 

qualified to conduct the research; (2) they have a 

research protocol to protect client-identifying 

information, and a group of three or more 

individuals independent of the research project 

have reviewed the protocol and found it 

adequate; and (3) they agree not to redisclose 

clients’ names or identifying information except 

back to the program and not to identify any 

client in a report. In most cases, a department of 

public health will easily satisfy the first 

requirement. The U.S. Department of Health 

and Human Services (DHSS) has suggested in 

opinion letters that the second requirement may 

not apply when the research is intended to track 

the incidence and causation of diseases. Thus, if 

the State is gathering information only for 

research purposes, the program can probably 

make reports including clients’ names, if the 

department agrees not to redisclose clients’ 

names or identifying information except back to 

the program and not to identify any client in a 

report. 

9. See Letter to Oklahoma State Department of 

Health from the Legal Adviser to the U.S. 

Alcohol, Drug Abuse, and Mental Health 

Administration, dated September 2, 1988, and 

Letter to the New York State Department of 

Health from the Acting General Counsel to the 

U.S. HHS, dated May 17, 1989. 

10. Two statutes (42 U.S.C. §241[d] and 21 

U.S.C. §872[c]), both of which cover research 

into drug use, permit the Secretary of HHS 

and the U.S. Attorney General, respectively, to 

authorize researchers to withhold the names 

and identities of research subjects. The statutes 

both state that the researcher “may not be 

compelled in any Federal, State, or local civil, 

criminal, administrative, legislative, or other 

proceeding” to identify the subjects of research 

for which such authorization was obtained. 

Such authorization is commonly called a 

“certificate of confidentiality.” Whether or not 

research investigators have obtained an 

authorization from the Attorney General or the 

Secretary of HHS, however, they must comply 

with the prohibitions on redisclosure discussed 

in this section of the chapter if they have been 

given access to clients’ records in a federally 

assisted treatment program. 

11. These particular entities also may copy or 

remove records, but only if they agree in writing 

to maintain client-identifying information in 

accordance with the regulations’ security 

requirements (see §2.16), to destroy all clientidentifying information when the audit or 

evaluation is completed, and to redisclose client 

information only (1) back to the program, (2) in 

accordance with a court order to investigate or 

prosecute the program (§2.66), or (3) to a 

government agency overseeing a Medicare or 

Medicaid audit or evaluation (§2.53(b)). 

12. For information on how to deal with 

subpoenas, see Chapter 5 and Confidentiality: A 

Guide to the Federal Law and Regulations, New 

York: Legal Action Center, 1995. 

13. If the information is being sought to 

investigate or prosecute a client, only the 

program need be notified (§2.65). If the 

information is sought to investigate or prosecute 

the program, no prior notice is required (§2.66). 

14. If the purpose of seeking the court order is 

to obtain authorization to disclose information 

in order to investigate or prosecute a client for a 

crime, the court also must find that (1) the crime 

involved was extremely serious, such as an act 

causing or threatening to cause death or serious 

injury; (2) the records sought are likely to 
Federal Confidentiality Regulations 

113

contain information of significance to the 

investigation or prosecution; (3) there is no other 

practical way to obtain the information; and (4) 

the public interest in disclosure outweighs any 

actual or potential harm to the client, the doctorclient relationship, and the ability of the 

program to provide services to other clients. 

When law enforcement personnel seek the 

order, the court also must find that the program 

had an opportunity to be represented by 

independent counsel. If the program is a 

government entity, it must be represented by 

independent counsel, §2.65(d). 
115

Appendix C 

Instruments 

This appendix reproduces the following tools: 









Abuse Assessment Screen (in English and Spanish) 

Danger Assessment 

Psychological Maltreatment of Women Inventory (PMWI) 

Revised Conflict Tactics Scale (CTS2) 

Although these instruments have been used extensively in research settings, they have not been 

validated as clinical tools; nor do they have instructions for scoring. The PMWI and the CTS2, in 

particular, were designed as research tools, not clinical tools, and do not have cutting scores (the score 

beyond which a person has a problem). All the instruments in this appendix can, however, serve to open 

dialogue with a client, elicit information, promote discussion, and help evaluate a program. 
Appendix C 

116

Abuse Assessment Screen (English Version)

1. WITHIN THE LAST YEAR, have you been hit, slapped, kicked, 

or otherwise physically hurt by someone? YES NO 

 If YES, by whom?____________________________________ 

 Total number of times ________________________________ 

2. SINCE YOU’VE BEEN PREGNANT, have you been hit, 

slapped, kicked, or otherwise physically hurt by someone? YES NO 

 If YES, by whom? ____________________________________ 

 Total number of times ________________________________ 

MARK THE AREA OF INJURY ON THE BODY MAP, SCORE 

EACH INCIDENT ACCORDING TO THE FOLLOWING 

SCALE: 

SCORE 

 1 = Threats of abuse including use of a weapon 

 2 = Slapping, pushing; no injuries and/or lasting pain 

 3 = Punching, kicking, bruises, cuts and/or continuing pain 

 4 = Beating up, severe contusions, burns, broken bones 

 5 = Head injury, internal injury, permanent injury 

 6 = Use of weapon; wound from weapon 

 If any of the descriptions for the higher number apply, use the

higher number. 

3. WITHIN THE LAST YEAR, has anyone forced you to have 

sexual activities? YES NO 

 If YES, by whom? ___________________________________ 

_______ 

_______ 

_______ 

_______ 

_______ 

_______ 

 
Instruments 

Encuesta Sobre El Maltrato (Spanish Version)

1. DURANTE EL ÚLTIMO AÑO, fué golpeada, bofeteada, 

pateada, o lastimada fisicamente de alguna otra manera por 

alguien? SI NO 

 Si la respuesta es “SI” por quien(es)?___________________ 

 Cuantas veces?______________________________________ 

2. DESDE QUE SALIO EMBARAZADA, ha sido golpeada, 

bofeteada, pateada, o lastimada fisicamente de alguna otra 

manera por alguien?__________________________________ SI NO 

 Si la respuesta es “SI” por quien(es)? ___________________ 

 Cuantas veces?______________________________________ 

PARTES DE SU CUERPO QUE HAN SIDO GRADO 

LASTIMADAS. VALORE CADA INCIDENTE USANDO

LAS SIGUIENTE ESCALA: 

 1 = Amenazas de maltrato que incluyen el uso de un arma 

 2 = Bofeteadas, permanentel ompujones sin lesiones fisicas o

dolor permanente 

 3 = Moquestos, patadas, moretones, heridas y/o dolor 

continuo 

 4 = Molida a palos, contusiones severas, quemaduras, 

fracturas de huesos 

 5 = Heridas en la cabeza, lesiones internas, lesiones 

permanentes 

 6 = Uso de armas, herida por arma 

EN EL DIAGRAMA ANATÓMICO, MARQUE LAS 

_

_

_

_

______

______

______

______

_______

_______

117
Appendix C 

118

 Si cualquiera de las situaciones valora un numero alto en la 

escala, úselo. 

3. DURANTE EL ÚLTIMO AÑO, fué forzada a tener relaciones 

sexuales? SI NO 

 Si la respuesta es “SI” por quien(es)_____________________ 

 Cuantas veces?______________________________________ 

Developed by the Nursing Research Consortium on Violence and Abuse. 

Reproduced with permission from J. McFarlane & B. Parker (1994). Abuse During Pregnancy: A Protocol for 

Prevention and Intervention. White Plains, NY: The March of Dimes Birth Defects Foundation, pp. 22–23. 
Instruments 

119

Danger Assessment 

Several risk factors have been associated with homicides (murders) of both batterers and battered women 

in research conducted after the murders have taken place. We cannot predict what will happen in your 

case, but we would like you to be aware of the danger of homicide in situations of severe battering and 

for you to see how many of the risk factors apply to your situation. 

Using the calendar, please mark the approximate dates during the past year when you were beaten by 

your husband or partner. Write on that date how bad the incident was according to the following scale 

(if any of the descriptions for the higher number apply, use the higher number): 

1. Slapping, pushing; no injuries and/or lasting pain 

2. Punching, kicking; bruises, cuts, and/or continuing pain 

3. “Beating up”; severe contusions, burns, broken bones 

4. Threat to use weapon; head injury, internal injury, permanent injury 

5. Use of weapon; wounds from weapon 

Mark YES or NO for each of the following. (“He” refers to your husband, partner, ex-husband, expartner, or whoever is currently physically hurting you.) 

1. Has the physical violence increased in frequency over the past year? 

2. Has the physical violence increased in severity over the past year and/or has a weapon or 

threat from a weapon ever been used? 

3. Does he ever try to choke you? 

4. Is there a gun in the house? 

5. Has he ever forced you to have sex when you did not wish to do so? 

6. Does he use drugs? By drugs, I mean “uppers” or amphetamines, speed, angel dust, 

cocaine, “crack,” street drugs, or mixtures. 

7. Does he threaten to kill you and/or do you believe he is capable of killing you? 

8. Is he drunk every day or almost every day? (In terms of quantity of alcohol.) 

9. Does he control most or all of your daily activities? For instance: Does he tell you who you 

can be friends with, how much money you can take with you shopping, or when you can 

take the car? (If he tries, but you do not let him, check here: . ) 

10. Have you ever been beaten by him while you were pregnant? (If you have never been 

pregnant by him, check here: . ) 

11. Is he violently and constantly jealous of you? (For instance, does he say, “If I can’t have 

you, no one can.”) 

12. Have you ever threatened or tried to commit suicide? 

13. Has he ever threatened or tried to commit suicide? 

14. Is he violent toward your children? 

15. Is he violent outside of the home? 

 Total “Yes” Answers 

Thank you. Please talk to your nurse, advocate, or counselor about 

what the Danger Assessment means in terms of your situation. 
Appendix C 

120

Reproduced with permission. Copyright Jacquelyn C. Campbell, Ph.D., R.N., 1985, 1988. 

Please share with the author the results of any research (raw or coded data) that is done with the 

instrument and/or an approximate number of women with whom the instrument was used, a 

description of their demographics, their mean score, and the setting in which data were collected. Please 

send this information within the next year. Also please send comments (positive and negative) and 

suggestions for improvement from battered women themselves, advocates, and professionals who are 

involved in its use. 

Sources: 

Campbell, J. Nursing assessment for risk of homicide in battered women. Advances in Nursing Science

8:36−51, 1986. 

Campbell, J.C. Prediction of homicide of and by battered women. In: Campbell, J.C., ed. Assessing 

Dangerousness. Violence by Sexual Offenders, Batterers, and Child Abusers. Thousand Oaks, CA: Sage 

Publications, Inc., 1995. 
Instruments 

121

The Psychological Maltreatment 

Of Women Inventory (PMWI) 

The PMWI is a 58-item test designed to measure the extent and nature of abuse toward women in a 

relationship. The questionnaire below is given to women survivors of abuse. The version for male 

perpetrators includes identical behaviors but reverses the pronouns and direction of abuse. 

Women’s Scale Items 

How often, if at all, did the behavior described in each item occur in the past six months (never, rarely, 

sometimes, frequently, or very frequently)? 

1. My partner put down my physical appearance. 

2. My partner insulted me or shamed me in front of others. 

3. My partner treated me like I was stupid. 

4. My partner was insensitive to my feelings. 

5. My partner told me I couldn’t manage or take care of myself without him. 

6. My partner put down my care of the children. 

7. My partner criticized the way I took care of the house. 

8. My partner said something to spite me. 

9. My partner brought up something from the past to hurt me. 

10. My partner called me names. 

11. My partner swore at me. 

12. My partner yelled and screamed at me. 

13. My partner treated me like an inferior. 

14. My partner sulked or refused to talk about a problem. 

15. My partner stomped out of the house or yard during a disagreement. 

16. My partner gave me the silent treatment, or acted as if I wasn’t there. 

17. My partner withheld affection from me. 

18. My partner did not let me talk about my feelings. 

19. My partner was insensitive to my sexual needs and desires. 

20. My partner demanded obedience to his whims. 

21. My partner became upset if dinner, housework, or laundry was not done when he thought 

it should be. 

22. My partner acted like I was his personal servant. 

23. My partner did not do a fair share of household tasks. 

24. My partner did not do a fair share of child care. 

25. My partner ordered me around. 

26. My partner monitored my time and made me account for where I was. 

27. My partner was stingy in giving me money to run our home. 

28. My partner acted irresponsibly with our financial resources. 

29. My partner did not contribute enough to supporting our family. 

30. My partner used our money or made important financial decisions without talking to me 

about it. 
Appendix C 

122

31. My partner kept me from getting medical care that I needed. 

32. My partner was jealous or suspicious of my friends. 

33. My partner was jealous of other men. 

34. My partner did not want me to go to school or other self-improvement activities. 

35. My partner did not want me to socialize with my female friends. 

36. My partner accused me of having an affair with another man. 

37. My partner demanded that I stay home and take care of the children. 

38. My partner tried to keep me from seeing or talking to my family. 

39. My partner interfered in my relationships with other family members. 

40. My partner tried to keep me from doing things to help myself. 

41. My partner restricted my use of the car. 

42. My partner restricted my use of the telephone. 

43. My partner did not allow me to go out of the house when I wanted to go. 

44. My partner refused to let me work outside of the home. 

45. My partner told me my feelings were irrational or crazy. 

46. My partner blamed me for his problems. 

47. My partner tried to turn our family, friends, and children against me. 

48. My partner blamed me for causing his violent behavior. 

49. My partner tried to make me feel like I was crazy. 

50. My partner’s moods changed radically, from calm to angry, or vice versa. 

51. My partner blamed me when he was upset about something, even when it had nothing to 

do with me. 

52. My partner tried to convince my friends, family, or children that I was crazy. 

53. My partner threatened to hurt himself if I left him. 

54. My partner threatened to hurt himself if I didn’t do what he wanted me to do. 

55. My partner threatened to have an affair with someone else. 

56. My partner threatened to leave the relationship. 

57. My partner threatened to take the children away from me. 

58. My partner threatened to have me committed to a mental institution. 

Source: Tolman, R.M. The development of a measure of psychological maltreatment of women by their 

male partners. Violence and Victims 4(3):159177, 1989. 

Reproduced with permission of the author. 
Instruments 

123

The Revised Conflict Tactics Scale (CTS2) (for Couples) 

Copyrights 

The Revised Conflict Tactics Scale (CTS2) is copyrighted by the test authors and may be reproduced only 

with their express permission. Permission will be granted on the basis of completing a one-page 

permission form and signing a user agreement. The agreement commits the user to either (1) carry out 

and publish, or make available to the test authors, psychometric analyses, including frequency 

distribution, mean, standard deviation, and alpha coefficient of reliability for each scale; or (2) provide 

the test authors with the raw data for each subject tested in a form that will enable the test authors to 

compute these statistics, together with as much demographic information as possible for each subject. 

The test authors agree to only use this information for psychometric analyses and to acknowledge the 

source of the data. The user providing the information retains the sole right to use the data for 

substantive purposes. Copies of the permission form and user agreement are available from Murray A. 

Straus, Family Research Laboratory, University of New Hampshire, Durham, NH 03824; e-mail: 

mas2@christic.unh.edu; telephone: (603) 862-2594; fax: (603) 862-1122. 

Relationship Behaviors 

No matter how well a couple gets along, there are times when they disagree, get annoyed with the other 

person, want different things from each other, or just have spats or fights because they are in a bad mood, 

are tired, or for some other reason. Couples also have many different ways of trying to settle their 

differences. This is a list of things that might happen when you have differences. Please circle how many 

times you did each of these things in the past year, and how many times your partner did them in the 

past year. If you or your partner did not do one of these things in the past year, but it happened before 

that, circle “7.” 

How often did this happen? 

1 = Once in the past year 5 = 11–20 times in the past year 

2 = Twice in the past year 6 = More than 20 times in the past year 

3 = 3–5 times in the past year 7 = Not in the past year, but it did happen before 

4 = 6–10 times in the past year 0 = This has never happened 

1. I showed my partner I cared even though we disagreed. 1 2 3 4 5 6 7 0 

2. My partner showed care for me even though we disagreed. 1 2 3 4 5 6 7 0 

3. I explained my side of a disagreement to my partner. 1 2 3 4 5 6 7 0 

4. My partner explained his or her side of a disagreement to me. 1 2 3 4 5 6 7 0 

5. I insulted or swore at my partner. 1 2 3 4 5 6 7 0 

6. My partner did this to me. 1 2 3 4 5 6 7 0 

7. I threw something at my partner that could hurt. 1 2 3 4 5 6 7 0 

8. My partner did this to me. 1 2 3 4 5 6 7 0 

9. I twisted my partner’s arm or hair. 1 2 3 4 5 6 7 0 

10. My partner did this to me. 1 2 3 4 5 6 7 0 

11. I had a sprain, bruise, or small cut because of a fight with my 1 2 3 4 5 6 7 0 
Appendix C 

124

partner. 

12. My partner had a sprain, bruise, or small cut because of a fight 1 2 3 4 5 6 7 0 

with me. 

13. I showed respect for my partner’s feelings about an issue. 1 2 3 4 5 6 7 0 

14. My partner showed respect for my feelings about an issue. 1 2 3 4 5 6 7 0 

15. I made my partner have sex without a condom. 1 2 3 4 5 6 7 0 

16. My partner did this to me. 1 2 3 4 5 6 7 0 

17. I pushed or shoved my partner. 1 2 3 4 5 6 7 0 

18. My partner did this to me. 1 2 3 4 5 6 7 0 

19. I used force (like hitting, holding down, or using a weapon) to 1 2 3 4 5 6 7 0 

make my partner have oral or anal sex. 

20. My partner did this to me. 1 2 3 4 5 6 7 0 

21. I used a knife or gun on my partner. 1 2 3 4 5 6 7 0 

22. My partner did this to me. 1 2 3 4 5 6 7 0 

23. I passed out from being hit on the head by my partner in a fight. 1 2 3 4 5 6 7 0 

24. My partner passed out from being hit on the head in a fight with 1 2 3 4 5 6 7 0 

me. 

25. I called my partner fat or ugly. 1 2 3 4 5 6 7 0 

26. My partner called me fat or ugly. 1 2 3 4 5 6 7 0 

27. I punched or hit my partner with something that could hurt. 1 2 3 4 5 6 7 0 

28. My partner did this to me. 1 2 3 4 5 6 7 0 

29. I destroyed something belonging to my partner. 1 2 3 4 5 6 7 0 

30. My partner did this to me. 1 2 3 4 5 6 7 0 

31. I went to a doctor because of a fight with my partner. 1 2 3 4 5 6 7 0 

32. My partner went to a doctor because of a fight with me. 1 2 3 4 5 6 7 0 

33. I choked my partner. 1 2 3 4 5 6 7 0 

34. My partner did this to me. 1 2 3 4 5 6 7 0 

35. I shouted or yelled at my partner. 1 2 3 4 5 6 7 0 

36. My partner did this to me. 1 2 3 4 5 6 7 0 

37. I slammed my partner against a wall. 1 2 3 4 5 6 7 0 

38. My partner did this to me. 1 2 3 4 5 6 7 0 

39. I said I was sure we could work out a problem. 1 2 3 4 5 6 7 0 

40. My partner was sure we could work it out. 1 2 3 4 5 6 7 0 

41. I needed to see a doctor because of a fight with my partner, 1 2 3 4 5 6 7 0 

but I didn’t. 

42. My partner needed to see a doctor because of a fight with me, 1 2 3 4 5 6 7 0 

but didn’t. 

43. I beat up my partner. 1 2 3 4 5 6 7 0 

44. My partner did this to me. 1 2 3 4 5 6 7 0 

45. I grabbed my partner. 1 2 3 4 5 6 7 0 

46. My partner did this to me. 1 2 3 4 5 6 7 0 

47. I used force (like hitting, holding down, or using a weapon) to 1 2 3 4 5 6 7 0 

make my partner have sex. 

48. My partner did this to me. 1 2 3 4 5 6 7 0 
Instruments 

125

49. I stomped out of the room or house or yard during a 1 2 3 4 5 6 7 0 

disagreement. 

50. My partner did this to me. 1 2 3 4 5 6 7 0 

51. I insisted on sex when my partner did not want to (but did not 1 2 3 4 5 6 7 0 

use physical force). 

52. My partner did this to me. 1 2 3 4 5 6 7 0 

53. I slapped my partner. 1 2 3 4 5 6 7 0 

54. My partner did this to me. 1 2 3 4 5 6 7 0 

55. I had a broken bone from a fight with my partner. 1 2 3 4 5 6 7 0 

56. My partner had a broken bone from a fight with me. 1 2 3 4 5 6 7 0 

57. I used threats to make my partner have oral or anal sex. 1 2 3 4 5 6 7 0 

58. My partner did this to me. 1 2 3 4 5 6 7 0 

59. I suggested a compromise to a disagreement. 1 2 3 4 5 6 7 0 

60. My partner did this to me. 1 2 3 4 5 6 7 0 

61. I burned or scalded my partner on purpose. 1 2 3 4 5 6 7 0 

62. My partner did this to me. 1 2 3 4 5 6 7 0 

63. I insisted my partner have oral or anal sex (but did not use 1 2 3 4 5 6 7 0 

physical force). 

64. My partner did this to me. 1 2 3 4 5 6 7 0 

65. I accused my partner of being a lousy lover. 1 2 3 4 5 6 7 0 

66. My partner accused me of this. 1 2 3 4 5 6 7 0 

67. I did something to spite my partner. 1 2 3 4 5 6 7 0 

68. My partner did this to me. 1 2 3 4 5 6 7 0 

69. I threatened to hit or throw something at my partner. 1 2 3 4 5 6 7 0 

70. My partner did this to me. 1 2 3 4 5 6 7 0 

71. I felt physical pain that still hurt the next day because of a fight 1 2 3 4 5 6 7 0 

with my partner. 

72. My partner still felt physical pain the next day because of a fight 1 2 3 4 5 6 7 0 

we had. 

73. I kicked my partner. 1 2 3 4 5 6 7 0 

74. My partner did this to me. 1 2 3 4 5 6 7 0 

75. I used threats to make my partner have sex. 1 2 3 4 5 6 7 0 

76. My partner did this to me. 1 2 3 4 5 6 7 0 

77. I agreed to try a solution to a disagreement my partner 1 2 3 4 5 6 7 0 

suggested. 

78. My partner agreed to try a solution I suggested. 1 2 3 4 5 6 7 0 
Appendix C 

126

Scoring 

The principles for scoring the CTS2 have been previously described in the CTS1 manual (Straus, 1995) 

and in Straus and Gelles (1990). Therefore, only the most basic aspects of scoring are presented here. The 

reader is referred to these other sources for further information. 

The CTS2 is scored by adding the response number (i.e., the number of times something happened) 

midpoint for each category chosen by the participant. Categories 0, 1, and 2 do not have midpoints, and 

responses for these categories are scored 0, 1, and 2, respectively. For Category 3 (3–5 times), the 

midpoint is 4; for Category 4 (6–10 times), the midpoint is 8; and for Category 5 (11–20 times), it is 15. 

The assigned scores for responses to Categories 3, 4, and 5 are, respectively, 4, 8 , and 15. For Category 6 

responses (20 times in the past year), the authors recommend assigning a score of 25. 

Responses for Category 7 (“Not in the past year, but it did happen before”) may be used in two ways: 

(1) When scores for the previous year are desired (the usual use of the CTS2), Category 7 is assigned a 

score of 0; and (2) to obtain a relationship prevalence measure of physical assault (i.e., Did an assault ever 

occur?), respondents who answer 1–7 are assigned a score of 1 (“yes”). 

When the CTS2 is used for research with any type of sample except cases known to be violent (e.g., 

men in a batterer treatment program), the test authors recommend that two variables be created for the 

physical assault, sexual coercion, and physical injury scales: a prevalence variable and a chronicity 

variable. The prevalence variable is a 0-or-1 dichotomy, with a score of 1 assigned if one or more of the 

acts in the scale occurred. The chronicity variable is the number of times the act(s) in the scale occurred 

among those who engaged in at least one of the acts in the scale. If the CTS2 is used with a person (or 

group member) who is known to be violent, separate prevalence and chronicity variables are not required 

because prevalence is already known. 

Source 

Straus, M.A.; Hamby, S.L.; Boney-McCoy, S.; and Sugarman, D.B. The Revised Conflict Tactics Scale 

(CTS2): Development and preliminary psychometric data. Journal of Family Issues 17(3):283–316, 1996. 

References 

Straus, M.A. Manual for the Conflict Tactics Scales. Durham, NH: Family Research Laboratory, University 

of New Hampshire, 1995. 

Straus, M.A., and Gelles, R.J. Physical Violence in American Families: Risk Factors and Adaptations to Violence 

in 8,145 Families. New Brunswick, NJ: Transaction Publishing, 1990. 

NOTE: Copyright 1995 Straus, Hamby, Boney-McCoy, and Sugarman. Reprinted with permission. 
127

Appendix D 

Sample Personalized Safety Plan 

For Domestic Violence 

Survivors 
Appendix D 

Name: _________________________ 

Date: __________________________ 

Review dates: ___________________ 

________________________________ 

________________________________ 

Personalized Safety Plan 

The following steps represent my plan for increasing my safety and preparing in advance for the 

possibility for further violence. Although I do not have control over my partner’s violence, I do have a 

choice about how to respond to him/her and how to best get myself and my children to safety. 

Step 1: Safety during a violent incident. Women cannot always avoid violent incidents. In order to 

increase safety, battered women may use a variety of strategies. 

I can use some or all of the following strategies: 

A. If I decide to leave, I will ______________________. (Practice how to get out safely. What doors, 

windows, elevators, stairwells, or fire escapes would you use?) 

B. I can keep my purse and car keys ready and put them (place) ____________________ in order to 

leave quickly. 

C. I can tell ____________________ about the violence and request they call the police if they hear 

suspicious noises coming from my house. 

 

I can also tell ___________________________________ about the violence and request they call the 

police if they hear suspicious noises coming from my house. 

D. I can teach my children how to use the telephone to contact the police and the fire department. 

E. I will use __________________________ as my code word with my children or my friends so they 

can call for help. 

F. If I have to leave my home, I will go ___________________________. (Decide this even if you don’t 

think there will be a next time.) 

If I cannot go to the location above, then I can go to _____________________________ or 

_______________________. 

G. I can also teach some of these strategies to some/all of my children. 

H. When I expect we are going to have an argument, I will try to move to a space that is lowest risk, 

such as _______________________________________________. (Try to avoid arguments in the 

bathroom, garage, kitchens, near weapons or in rooms without access to an outside door.) 

I. I will use my judgment and intuition. If the situation is very serious, I can give my partner what 

he/she wants to calm him/her down. I have to protect myself until I/we are out of danger. 

128
Personalized Safety Plan 

129

Step 2: Safety when preparing to leave. Battered women frequently leave the residence they share with 

the battering partner. Leaving must be done with a careful plan in order to increase safety. Batterers 

often strike back when they believe that a battered woman is leaving a relationship. 

I can use some or all of the following safety strategies: 

A. I will leave money and an extra set of keys with ____________________ so I can leave quickly. 

B. I will keep copies of important documents or keys at ___________________________. 

C. I will open a savings account by ______________________ (date), to increase my independence. 

D. Other things I can do to increase my independence include: 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

___________________________________________________________________________________ 

E. The domestic violence program’s hotline number is ________________________. 

I can seek shelter by calling this hotline. 

F. I can keep change for phone calls on me at all times. I understand that if I use my telephone credit 

card, the following month the telephone bill will tell my batterer those numbers that I called after I 

left. To keep my telephone communications confidential, I must either use coins or I might get a 

friend to permit me to use their telephone credit card for a limited time when I first leave. 

G. I will check with ___________________ and ___________________ to see who would be able to let me 

stay with them or lend me some money. 

H. I can leave extra clothes with _____________________________________________. 

I. I will sit down and review my safety plan every ____________________________ in order to plan the 

safest way to leave the residence. ____________________________ (domestic violence advocate or 

friend) has agreed to help me review this plan. 

J. I will rehearse my escape plan and, as appropriate, practice it with my children. 

Step 3: Safety in my own residence. There are many things that a woman can do to increase her safety in 

her own residence. It may impossible to do everything at once, but safety measures can be added step by 

step. 

Safety measures I can use include: 

A. I can change the locks on my doors and windows as soon as possible. 

B. I can replace wooden doors with steel/metal doors. 

C. I can install security systems including additional locks, window bars, poles to wedge against doors, 

an electronic system, etc. 

D. I can purchase rope ladders to be used for escape from second floor windows. 

E. I can install smoke detectors and purchase fire extinguishers for each floor in my house/apartment. 
Appendix D 

130

F. I can install an outside lighting system that lights up when a person is coming close to my house. 

. 

G. I will teach my children how to use the telephone to make a collect call to me and to 

(friend/minister/other) in the event that my partner takes the children. 

H. I will tell people who take care of my children which people have permission to pick up my children 

and that my partner is not permitted to do so. The people I will inform about pick-up permission 

include 

___________________________________________________________ (school),

_____________________________________________________ (day care staff),

________________________________________________________ (babysitter),

_____________________________________________ (Sunday school teacher),

__________________________________________________________ (teacher),

_______________________________________________________ and (others).

I. I can inform ________________________________________________ (neighbor), 

________________________________ (pastor), and _________________________ (friend) that my 

partner no longer resides with me and they should call the police if he is observed near my residence. 

Step 4: Safety with a protection order. Many batterers obey protection orders, but one can never be sure 

which violent partner will obey and which will violate protection orders. I recognize that I may need to 

ask the police and the courts to enforce my protection order. 

The following are some steps that I can take to help the enforcement of my protection order: 

A. I will keep my protection order _________________________ (location). (Always keep it on or near 

your person. If you change purses, that’s the first thing that should go in.) 

B. I will give my protection order to police departments in the community where I work, in those 

communities where I usually visit family or friends, and in the community where I live. 

C. There should be a county registry of protection orders that all police departments can call to confirm 

a protection order. I can check to make sure that my order is in the registry. The telephone number 

for the county registry of protection orders is __________________. 

D. For further safety, if I often visit other counties in my state, I might file my protection order with the 

court in those counties. I will register my protection order in the following counties: 

__________________, __________________________, and _________________________. 

E. I can call the local domestic violence program if I am not sure about B, C, or D above or if I have 

some problem with my protection order. 

F. I will inform my employer, my minister, my closest friend and ___________________ and 

_____________________ that I have a protection order in effect. 

G. If my partner destroys my protection order, I can get another copy from the courthouse by going to 

[the office] located at __________________________ 
Personalized Safety Plan 

131

H. If my partner violates the protection order, I can call the police and report a violation, contact my 

attorney, call my advocate, and/or advise the court of the violation. 

I. If the police do not help, I can contact my advocate or attorney and will file a complaint with the 

chief of the police department. 

J. I can also file a private criminal complaint with the district justice in the jurisdiction where the 

violation occurred or with the district attorney. I can charge my battering partner with a violation of 

the protection order and all the crimes that he commits in violating the order. I can call the domestic 

violence advocate to help me with this. 

Step 5: Safety on the job and in public. Each battered woman must decide if and when she will tell 

others that her partner has battered her and that she may be at continued risk. Friends, family and 

coworkers can help to protect women. Each woman should consider carefully which people to invite to 

help secure her safety. 

I might do any or all of the following: 

A. I can inform my boss, the security supervisor and _____________________________ at work of my 

situation. 

B. I can ask ________________________________________ to help screen my telephone calls at work. 

C. When leaving work, I can _______________________________________________. 

D. When driving home if problems occur, I can _________________________________. 

E. If I use public transit, I can ______________________________________________. 

F. I can use different grocery stores and shopping malls to conduct my business and shop at hours that 

are different than those when residing with my battering partner. 

G. I can use a different bank and take care of my banking at hours different from those I used when 

residing with my battering partner. 

H. I can also __________________________________________________________. 

Step 6: Safety and drug or alcohol use. Most people in this culture use alcohol. Many use mood-altering 

drugs. Much of this use is legal and some is not. The legal outcomes of using illegal drugs can be very 

hard on a battered woman, may hurt her relationship with her children and put her at a disadvantage in 

other legal actions with her battering partner. Therefore, women should carefully consider the potential 

cost of the use of illegal drugs. But beyond this, the use of any alcohol or other drugs can reduce a 

woman’s awareness and ability to act quickly to protect herself from her battering partner. Furthermore, 

the use of alcohol or other drugs by the batterer may give him/her an excuse to use violence. Therefore, 

in the context of drug or alcohol use, a woman needs to make specific safety plans. 

If drug or alcohol use has occurred in my relationship with the battering partner, I can enhance my safety 

by some or all of the following: 

A. If I am going to use, I can do so in a safe place and with people who understand the risk of violence 

and are committed to my safety. 

B. I can also _______________________________________________________. 
Appendix D 

132

C. If my partner is using, I can _______________________________________. 

D. I might also _____________________________________________________. 

E. To safeguard my children, I might _________________________________ and 

_________________________. 

Step 7: Safety and my emotional health. The experience of being battered and verbally degraded by 

partners is usually exhausting and emotionally draining. The process of building a new life for myself 

takes much courage and incredible energy. 

To conserve my emotional energy and resources and to avoid hard emotional times, I can do some of the 

following: 

A. If I feel down and ready to return to a potentially abusive situation, I can 

______________________________. 

B. When I have to communicate with my partner in person or by telephone, I can 

_________________________________________________________. 

C. I can try to use “I can . . .” statements with myself and to be assertive with others. 

D. I can tell myself, “____________________________________________” whenever I feel others are 

trying to control or abuse me. 

E. I can read ___________________________ to help me feel stronger. 

F. I can call ______________________________, ______________________________ and 

_______________________________ as other resources to be of support to me. 

G. Other things I can do to help me feel stronger are _______________________, ____________________, 

and __________________________________. 

H. I can attend workshops and support groups at the domestic violence program or 

__________________________________, __________________________ , or 

_________________________________ to gain support and strengthen my relationships with other 

people. 

Step 8: Items to take when leaving. When women leave partners, it is important to take certain items 

with them. Beyond this, women sometimes give an extra copy of papers and an extra set of clothing to a 

friend just in case they have to leave quickly. 

Items with asterisks on the following list are the most important to take. If there is time, the other items 

might be taken, or stored outside the home. 

These items might best be placed in one location, so that if we have to leave in a hurry, I can grab them 

quickly. 
Personalized Safety Plan 

133

When I leave, I should take: 

* Identification for myself 

* Children’s birth certificates 

* My birth certificate 

* Social Security cards 

* School and vaccination records 

* Money 

* Checkbook, ATM (Automatic Teller Machine) card 

* Credit cards 

* Keys—house/car/office 

* Driver’s license and registration 

* Medications 

Welfare identification 

 Work permits 

Green card 

 Passport(s) 

Divorce papers 

 Medical records—for all family members 

Lease/rental agreement, house deed, mortgage payment book 

 Bank books 

Insurance papers 

 Small saleable objects 

Address book 

 Pictures 

Jewelry 

 Children’s favorite toys and/or blankets 

Items of special sentimental value 

Telephone Numbers I Need to Know: 

Police department—home 

Police department—school 

Police department—work 

Battered women’s program 

County registry of protection orders 

Work number 

Supervisor’s home number 

Minister 

Other 

Reproduced with permission from Barbara Hart and Jane Stuehling, Pennsylvania Coalition Against Domestic 

Violence, Harrisburg, Pennsylvania, 1992. 

Adapted from “Personalized Safety Plan,” Office of the City Attorney, City of San Diego, California, April 1990. 
Hotlines and Other Resources 

135

Appendix E 

Hotlines and Other Resources 

For Domestic Violence and 

Related Issues 

This appendix provides addresses, phone numbers, and information on three types of domestic violence 

organizations and groups in related fields such as rape, child abuse and neglect, and victimization. 

Hotlines provide crisis counseling and referrals to victims and those in crisis and usually supply general 

information either by mail or over the phone. General resources send bulletins, pamphlets, manuals, and 

other publications by mail (sometimes at cost); sometimes they give information over the phone. They 

also may provide additional services, such as referrals. Most of them serve the general public, although 

some target professionals in specific fields. The other services category includes research and policy 

groups and those that provide technical assistance, training, and advocacy. Unlike those in the previous 

category, other services tend to target professionals in specific fields, as indicated, and are not resources for 

the general public. Many of the programs and organizations listed below provide more than one type of 

service, so they are categorized by their primary purpose. 

Hotlines 

National Domestic Violence Hotline 

(800) 799-SAFE 

(800) 787-3224 (TDD) 

Suite 101–297 

3616 Far West Boulevard 

Austin, TX 78731-3074 

The National Domestic Violence Hotline links individuals and services using a nationwide database of 

domestic violence and other emergency shelters, legal advocacy and assistance programs, and social 
Appendix E 

136

services programs. The hotline provides crisis intervention, information about sources of assistance, and 

referrals to battered women’s shelters. 

Rape, Abuse, and Incest National Network (RAINN) 

(800) 656-4673 

RAINN links 628 rape crisis centers nationwide. Sexual assault survivors who call will be automatically 

connected to a trained counselor at the closest center in their area. 

Childhelp USA/National Child Abuse Hotline 

(800) 4A-CHILD 

15757 North 78th Street 

Scottsdale, AZ 85260 

(602) 922-8212 

With a focus on children and the prevention of child abuse, this hotline provides crisis counseling, referrals, 

and reporting guidance to callers in crisis, including children, troubled parents, and adult survivors of 

abuse. All calls are answered by a staff of professional counselors. In addition, statistical and other 

informative materials can be ordered through this number. Access to information on partner violence is 

limited. 

Childhelp, one of the largest national, nonprofit child abuse treatment and prevention agencies in the 

country, also runs the nation’s first residential treatment facility for abused children, provides prevention 

services and training, and participates in advocacy and education efforts. 

General Resources 

American College of Obstetricians and Gynecologists (ACOG) 

ACOG Resource Center 

409 12th Street, S.W. 

Washington, DC 20024-2188 

(202) 638-5577 

ACOG has patient education pamphlets and bulletins for medical professionals on both domestic 

violence and substance abuse. 
Hotlines and Other Resources 

137

American Medical Association (AMA) 

Department of Mental Health 

515 State Street 

Chicago, IL 60610 

Contact: Jean Owens 

(312) 464-5000 

(312) 464-5066 (to order resources) 

(312) 464-4184 (fax) 

The AMA educates physicians through publications, conferences, and by serving as a resource center for 

physicians and other concerned professionals. Among its publications are six diagnostic and treatment 

guidelines on child physical abuse and neglect, child sexual abuse, domestic violence, elder abuse and 

neglect, mental health effects of domestic violence, treatment and prevention of sexual assault, and media 

violence. 

March of Dimes Birth Defects Foundation 

1275 Mamaroneck Avenue 

White Plains, NY 10605 

Attn: Resource Center 

(914) 428-7100 

The March of Dimes provides general information on prenatal care and on the first few years of life 

through its resource center and its fulfillment center. The March of Dimes does not have a hotline.

March of Dimes Resource Center 

(888) 663-4637 

(914) 997-4763 (fax) 

resourcecenter@modimes.org 

Contact: Beverly Robertson, Director 

Callers to this number can speak to someone about pregnancy, prepregnancy, drug use during 

pregnancy, birth defects, genetics, and other issues related to prenatal care. 

March of Dimes Fulfillment Center 

(800) 367-6630 

Callers to this number can only place an order for materials. Two domestic violence materials are 

available at cost: Abuse During Pregnancy Nursing Module, which provides continuing education units to 

nurses, and a video titled Crime Against the Future. 
Appendix E 

138

National Center for Missing or Exploited Children (NCMEC) 

Suite 550 

2101 Wilson Boulevard 

Arlington, VA 22201-3052 

Hotline: (800) THE LOST, (800) 843-5678, (800) 826-7653 (TDD) 

Business office: (703) 235-3900, (703) 235-4067 (fax) 

NCMEC leads national efforts to locate and recover missing children and raises public awareness about 

ways to prevent child abduction, molestation, and sexual exploitation. The hotline is available to report 

information on missing or exploited children or to request information or assistance. NCMEC publishes 

materials, including handbooks, pamphlets containing parental and professional guidelines on runaways 

and missing or exploited children, and publication packages aimed toward families, child care and social 

service practitioners, and law enforcement, legal, and criminal justice professionals. 

National Clearinghouse on Child Abuse and Neglect 

P.O. Box 1182 

Washington, DC 20013-1182 

(800) FYI-3366 

(703) 385-7565 

(703) 385-3206 (fax) 

nccanch@calib.com 

This clearinghouse offers child abuse and neglect information in the form of manuals, research reports, 

studies, directories, grant compendia, literature reviews, annotated bibliographies, fact sheets, database 

searches, CD ROM databases, and on-line services. It is sponsored by the National Center on Child 

Abuse and Neglect. 

National Coalition Against Domestic Violence 

P.O. Box 18749 

Denver, CO 80218 

(303) 839-1852 

(303) 831-9251 (fax) 

The National Coalition Against Domestic Violence serves as an information and referral center for the 

general public, the media, battered women and their children, and agencies and organizations. Among 

its purposes are to enhance coalition-building at the local, State, and national levels; support the 

provision of community-based, nonviolent alternatives such as safe homes and shelters for battered 

women and their children; provide information and referral services, public education, and technical 
Hotlines and Other Resources 

139

assistance; and develop public policy and innovative legislation. The coalition maintains a public policy 

office in Washington, DC, and maintains a National Directory of Domestic Violence Programs. 

National Sheriffs ‘Association 

1450 Duke Street 

Alexandria, VA 22314 

(800) 424-7827 

(703) 836-7827 

The National Sheriffs’ Association has developed a handbook on victim’s assistance for law enforcement 

officers who deal with all types of victims, including those of domestic violence. It provides training in 

dealing with victims sensitively, finding resources in one’s community to help them, and setting up a 

victim assistance program. 

National Victim Center (NVC)/INFOLINK 

(800) FYI-CALL 

(703) 276-2880 

www.nvc.org 

NVC operates an information and referral program called INFOLINK, which provides a toll-free source 

of comprehensive crime and victim-related information as well as referrals to over 8,000 victim assistance 

programs across the nation. Each caller can receive up to 5 of the 70 information bulletins free of charge. 

In addition, all INFOLINK bulletins, as well as other important information, are available on NVC’s 

website. 

Other Services 

Center for the Prevention of Sexual and Domestic Violence 

Suite 200 

936 North 34th Street 

Seattle, WA 98103 

(206) 634-1903 

(206) 634-0115 (fax) 

cpsdv@cpsdv.seanet.com 

http://www.cpsdv.org 

The Center for the Prevention of Sexual and Domestic Violence is the only national organization working 

with and within religious communities on issues of sexual and domestic violence. Although the center’s 
Appendix E 

140

constituency includes those in the fields of law, health care, social services, counseling, and other fields, 

the center primarily targets religious professionals and teaches them how to effectively respond to and 

prevent sexual abuse and domestic violence. Services and products include trainings, workshops, and 

seminars; consultations; videos; specialized curriculum materials; and publications. 

Colorado Coalition Against Domestic Violence 

P.O. Box 18902 

Denver, CO 80218 

(303) 831-9632 

This group does public policy work and provides community education and training, information in the 

form of statistics and brochures, and technical assistance to domestic violence programs. 

Domestic Violence Project/Face-to-Face 

(800) 842-4546 

This project, sponsored by the American Academy of Facial Plastic and Reconstructive Surgery, offers 

free facial reconstructive surgery to anyone who has been physically disfigured due to domestic violence. 

Domestic Violence Training Project (DVTP) 

900 State Street 

New Haven, CT 06511 

(203) 865-3699 

DVTP, a project for health professionals, runs enhanced education, early intervention, and advocacy 

programs to end domestic violence. Ongoing programs and services include seminars, conferences, 

consultation services, and case reviews. Project SAFE (Safety Assessment for Everyone) is an education 

campaign to raise health care professionals’ awareness of domestic violence as a significant health 

problem and increase their collaboration with community-based domestic violence advocates. 

Family Violence and Sexual Assault Institute 

Suite 130 

1121 ESE Loop 323 

Tyler, TX 75701 

(903) 534-5100 

(903) 534-5454 (fax) 

fvsai@e-tex.com 
Hotlines and Other Resources 

141

To improve networking among researchers, practitioners, and agencies, the Family Violence and Sexual 

Assault Institute maintains an international clearinghouse, reviews its materials, and disseminates the 

information through its Family Violence and Sexual Assault Bulletin. This independent, nonprofit 

corporation helps crisis centers, agencies, universities, and counseling clinics develop treatment programs 

for partner and sexual abuse and has published several books and bibliographies as a result of this 

research. The institute also provides training and consultation in the form of program evaluation, 

research, and technical assistance. 

National Center on Elder Abuse (NCEA) 

Suite 500 

810 First Street, N.E. 

Washington, DC 20002-4267 

(202) 682-2470 

(202) 289-6555 (fax) 

NCEA performs clearinghouse functions, develops and disseminates information, provides training and 

technical assistance, and conducts research and demonstration projects of national significance. In 

addition, NCEA runs the country’s only automated, elder abuse literature search and retrieval system. 

Four organizations comprise the NCEA: the American Public Welfare Association, the National 

Association of State Units on Aging, the University of Delaware College of Human Resources, and the 

National Committee for Prevention of Elder Abuse. 

National Clearinghouse on Marital and Date Rape 

http://www.ncmdr.org/

The National Clearinghouse on Marital and Date Rape provides fee-based phone consultations for 

information, referrals, strategies, and advocacy. The website contains fee and membership information. 

National Criminal Justice Reference Service (NCJRS) 

P.O. Box 6000 

Rockville, MD 20847-6000 

(800) 851-3420 

(301) 251-5500 

askncjrs@ncjrs.org 

NCJRS, one of the most extensive sources of information on criminal and juvenile justice in the world, 

provides services to an international community of policymakers and professionals. NCJRS is a 
Appendix E 

142

collection of clearinghouses supporting all bureaus of the U.S. Department of Justice, Office of Justice 

Programs. It also supports the Office of National Drug Control Policy. Information is available through 

information specialists, on-line services, or its CD ROM database. NCJRS does not provide counseling or 

legal advice. 

National Network to End Domestic Violence 

Suite 900 

701 Pennsylvania Avenue, N.W. 

Washington, DC 20004 

(202) 347-9520 

A member organization of State domestic violence coalitions, the National Network to End Domestic 

Violence supports 2,000 programs and services, provides training, and focuses on public policy issues. 

The Domestic Violence Resource Network 

The Domestic Violence Resource Network comprises four entities: the Resource Center on Domestic 

Violence: Child Protection and Custody; the National Resource Center on Domestic Violence; the Health 

Resource Center on Domestic Violence; and the Battered Women’s Justice Project (a collaboration of three 

organizations). 

Resource Center on Domestic Violence: Child Protection and Custody 

Project of the National Council of Juvenile and Family Court Judges (NCJFCJ) Violence Project 

P.O. Box 8970 

Reno, NV 89507 

(800) 527-3223 

(702) 784-6160 (fax) 

NCJFCJ, a national judicial membership organization, runs the Family Violence Project with the goal of 

developing, testing, and promoting criminal, civil, and family court procedures that better respond to 

domestic violence. The Resource Center, a component of the Family Violence Project, provides 

immediate access to information and training for judges, court workers, advocates, lawyers, child 

protective workers, law enforcement personnel, and other professionals dealing with child 

protection/custody issues in the context of domestic violence. Callers can receive accurate, up-to-date 

information and technical assistance over the phone or can request information packets, program 

materials, and other resources. 

The Family Violence Project developed—through a committee of domestic violence experts including 

judges, attorneys, battered women’s advocates, health care professionals, and law enforcement 
Hotlines and Other Resources 

143

personnel—the Model State Code on Domestic and Family Violence. The project provides technical assistance 

to implement the model code. 

National Resource Center on Domestic Violence 

Project of the Pennsylvania Coalition Against Domestic Violence 

Suite 1300 

6400 Flank Drive 

Harrisburg, PA 17112 

(800) 537-2238 

(717) 545-9456 (fax) 

The National Resource Center on Domestic Violence (NRC), operated by the Pennsylvania Coalition 

Against Domestic Violence, is a source of comprehensive information, training, and technical assistance 

on domestic violence prevention and intervention. NRC serves as a central resource for the collection, 

preparation, analysis, and dissemination of information on domestic violence; identifies and supports the 

development of innovative and exemplary intervention and prevention resources; and maintains a 

comprehensive database of information to coordinate resource development and technical assistance 

throughout the nation. Although its target groups are domestic violence programs and State coalitions, 

NRC also serves government agencies, policy leaders, media, and other professionals and organizations 

involved in the prevention or response to domestic violence. 

Health Resource Center on Domestic Violence 

Project of the Family Violence Prevention Fund 

Suite 304 

383 Rhode Island Street 

San Francisco, CA 94103-5133 

toll free (888) Rx ABUSE, weekdays 9 a.m. to 5 p.m., P.S.T. 

(415) 252-8991 (fax) 

The Health Resource Center, which focuses on strengthening the health care response to domestic 

violence, provides resources and training materials, technical assistance, and information and referrals to 

health care professionals and others who help victims of domestic violence. Its products and services 

include comprehensive resource manuals providing the tools for an effective multidisciplinary response; 

multidisciplinary protocols emphasizing routine screening and identification of domestic violence; 

assistance with health care training programs and protocol development; models for local, State, and 

national health policymaking; a national network of experts for public speaking, training, and 

consultation; and educational materials specifically developed for health care providers. 
Appendix E 

144

Battered Women's Justice Project (BWJP) 

4032 Chicago Avenue, South 

Minneapolis, MN 55407 

(800) 903-0111 

(612) 824-8965 (fax) 

The BWJP serves as a resource center and national toll-free information line regarding domestic violence 

issues in the criminal and civil justice systems. A collaboration of three organizations, the BWJP responds 

to specific requests for information or technical assistance from people who work with battered women. 

Each component specializes in certain areas of law and responds to questions about training, practices, 

and policies in those areas. BWJP develops resources such as bibliographies, various resource packets, 

and information about model programs, protocols, curricula, experts in the field, and training materials. 

The project is funded by a grant from the U.S. Department of Health and Human Services. The three 

organizations can be reached through the same toll-free number listed above; each has its own extension. 

Extension 1: 

The Criminal Justice Center—Domestic Abuse Intervention Project: for information about criminal 

justice responses to domestic violence. 

The Criminal Justice Center responds to questions on the criminal justice system, including law 

enforcement, prosecution, sentencing, probation, batterer’s counseling programs, coordinated 

community/court responses, and victim advocacy. This office also handles information requests 

about domestic violence and the military and intervention strategies within Native American 

communities. 

4032 Chicago Avenue, South 

Minneapolis, MN 55407 

(612) 824-8768 

(612) 824-8965 (fax) 

Extension 2:

Civil Access and Representation Center—Pennsylvania Coalition Against Domestic Violence: For 

information about civil court access and legal representation issues of battered women. 

The Civil Access and Legal Center aims to enhance justice for battered women and their children by 

increasing their access to civil court options and legal representation. With special expertise in stateof-the-art legal approaches and model protocols, legal staff provide assistance to advocates, 

attorneys, court personnel, and policymakers. 
Hotlines and Other Resources 

145

Suite 1300 

6400 Flank Drive 

Harrisburg, PA 17112 

(717) 545-6400 

(717) 545-9456 (fax) 

Extension 3: 

The Self-Defense Center—National Clearinghouse for the Defense of Battered Women: For 

information about issues that arise when battered women are charged with crimes. 

The Self-Defense Center provides technical assistance to battered women charged with crimes and to 

their defense teams: attorneys, battered women’s advocates, and expert witnesses; works with 

incarcerated battered women filing appeals or applying for parole or clemency; coordinates a 

national network of advocates and other professionals assisting battered women defendants; 

maintains a resource library of relevant articles and case law; and conducts community and 

professional training seminars. 

Suite 302 

125 South 9th Street 

Philadelphia, PA 19107 

(215) 351-0010 

(215) 351-0779 (fax) 
147

Appendix F 

Resource Panel 

Marilyn Benoit, M.D. 

American Academy of Child and Adolescent 

Psychiatry 

Washington, D.C. 

Ruth H. Carlsen Kahn, D.N.Sc. 

Health Manpower Specialist 

Bureau of Health Professionals 

Division of Medicine 

Health Resources and Services 

Administration 

Rockville, Maryland 

Johanna Clevenger, M.D. 

Chief 

Alcoholism and Substance Abuse Program 

Branch 

Indian Health Service 

Rockville, Maryland 

Joel A. Egertson 

Senior Advisor to the Director 

Medications Development Division 

National Institute on Drug Abuse 

Rockville, Maryland 

Jennifer Fiedelholtz 

Associate Administrator 

Office for Women's Services 

Substance Abuse and Mental Health Services 

Administration 

Rockville, Maryland 

Sally Flanzer, Ph.D. 

Acting Director 

Program Policy and Planning Division 

National Center on Child Abuse and Neglect 

Children's Bureau 

Department of Health and Human Services 

Washington, D.C. 

Janet S. Hartnett 

Deputy Director 

Office of Planning, Research, and Evaluation 

Administration for Children and Families 

Department of Health and Human Services 

Washington, D.C. 

Gil Hill 

Director 

Office of Substance Abuse 

American Psychological Association 

Washington, D.C. 

Denise Johnson, M.S. 

Team Leader 

Family and Intimate Violence Prevention 

Team 

Division of Violence Prevention 

National Center for Injury Prevention and 

Control 

Centers for Disease Control and Prevention 

Atlanta, Georgia 
Appendix F 

148

Pat Paluzzi, C.N.M., M.P.H. 

Senior Technical Advisor 

Special Projects Section 

American College of Nurse-Midwives 

Washington, D.C. 

Carolyn Peake 

Program Manager 

National Institute of Justice 

Washington, D.C. 

Gwen Rubinstein 

Deputy Director of National Policy 

Legal Action Center 

Washington, D.C. 

Jolene Sanders 

Program Specialist 

Quality Assurance Programs 

National Association of State Alcohol and 

Drug Abuse Directors, Inc. 

Washington, D.C. 

Irene Sandvold, Dr.P.H., C.N.M. 

Nurse Consultant 

Division of Nursing 

Health Resources and Services 

Administration 

Department of Health and Human Services 

Rockville, Maryland 

Eleanor Sargent 

Director 

Clinical Issues 

The National Association of Alcoholism and 

Drug Abuse Counselors 

Arlington, Virginia 

Richard T. Suchinsky, M.D. 

Associate Director 

Addictive Disorders 

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, D.C. 

Mary Randolf Turner 

 Public Relations Specialist 

American Academy of Child and Adolescent 

Psychiatry 

Washington, D.C. 
149

Appendix G 

Field Reviewers 

Becci Akin 

Research Assistant 

School of Social Welfare 

Twente Hall 

University of Kansas 

Lawrence, Kansas 

Judy Atkin 

High Risk Coordinator 

Providence Prenatal Center 

Holyoke, Massachusetts 

Kathleen Austin, C.D.C. III, N.C.A.C. II 

Alcohol Therapist II 

Adult Medicine/Ambulatory Care 

Harborview Medical Center 

Seattle, Washington 

Kristen Barry, Ph.D. 

Associate Research Scientist 

Health Services Reseach and Development 

Field Program 

Ann Arbor, Michigan 

Rosalind Brannigan 

Vice President 

Drug Strategies 

Washington, D.C. 

Donna L. Caldwell, Ph.D. 

Senior Research Associate 

National Perinatal Information Center 

Providence, Rhode Island 

Jacquelyn C. Campbell, R.N., Ph.D. 

Graduate Academic Programs 

School of Nursing 

Johns Hopkins University 

Baltimore, Maryland 

Peter J. Cohen, M.D., J.D. 

Special Expert 

Medications Development Division 

National Institute on Drug Abuse 

Rockville, Maryland 

Carol Colleran, C.A.P., I.C.A.D.C. 

Director 

Older Adult Services 

Hanley-Hazelden 

Hazelden Foundation 

West Palm Beach, Florida 

James Collins, Ph.D. 

Senior Program Director 

Health and Social Policy Division 

Research Triangle Institute 

Research Triangle Park, North Carolina 

Martin C. Doot, M.D. 

Chief 

Division of Addiction Medicine 

Addiction Medicine/ Family Practice 

Lutheran General Hospital Advocate 

Park Ridge, Illinois 
Appendix G 

150

Joel A. Egertson 

Senior Advisor to the Director 

Medications Development Division 

National Institute on Drug Abuse 

Rockville, Maryland 

Jerry P. Flanzer, D.S.W. 

Director 

Recovery and Family Treatment, Inc. 

Alexandria, Virginia 

Sally Flanzer, Ph.D. 

Acting Director 

Program Policy and Planning Division 

National Center on Child Abuse and Neglect 

Children's Bureau 

Department of Health and Human Services 

Washington, D.C. 

Sandra Handley, Ph.D., R.N., C.A.R.N. 

Consultant 

Addiction Training Center 

University of Missouri-Kansas City 

Kansas City, Missouri 

Susan Hernandez 

Assessment Supervisor 

Southwest Migrant Farm Workers and 

Native American (TIGUA) Assistance 

Program 

West Texas Council on Alcoholism and Drug 

Abuse 

El Paso, Texas 

Flo Hilliard, M.H.S. 

Community Outreach Specialist 

Rural South Central Wisconsin Perinatal 

 Substance Abuse Project 

Health and Human Issues 

University of Wisconsin 

Madison, Wisconsin 

Lt. Col. Kenneth J. Hoffman, M.D., M.P.H., 

M.C.F.S. 

Director, Center for Addiction Medicine 

Center for Training and Education in 

Addiction Medicine (C-Team) 

Department of Preventive 

Medicine/Biometrics 

Uniformed Services University of the Health 

Sciences 

Bethesda, Maryland 

Nancy Holmberg, M.S. 

Licensing Specialist 

Division of Children and Family Services 

Wisconsin Department of Health and Family 

Services 

Madison, Wisconsin 

The Honorable Peggy Fulton Hora 

Judge 

County of Alameda 

Municipal Court of California 

Hayward, California 

Frank J. Jans, M.A., C.C.S. 

Manager of Outpatient Psychiatry 

Department of Psychiatry 

Allegheny General Hospital 

Pittsburgh, Pennsylvania 

Denise Johnson, M.S. 

Team Leader 

Family and Intimate Violence Prevention 

Team 

Division of Violence Prevention 

National Center for Injury Prevention and 

Control 

Centers for Disease Control and Prevention 

Atlanta, Georgia 

Gerald A. Juhnke, Ed.D., L.P.C., N.C.C., M.A.C. 

Assistant Professor 

Department of Counseling and Educational 

Development 

University of North Carolina at Greensboro 

Greensboro, North Carolina 
Field Reviewers 

151

Dennis Kennedy 

PAVE 

Denver, Colorado 

Joan Kub, Ph.D., R.N. 

Assistant Professor 

School of Nursing 

Johns Hopkins University 

Baltimore, Maryland 

Jeffrey N. Kushner 

Drug Court Administrator 

22nd Judicial District 

Municipal Court of Saint Louis 

Saint Louis, Missouri 

Mary Jane Landry 

Executive Director 

Alcohol and Other Drug Council of Kenosha 

County Inc. 

Kenosha, Wisconsin 

Sandra C. Lapham, M.D. 

Director 

Substance Abuse Research Programs 

Lovelace Institutes 

Institute for Health and Population Research 

Albuquerque, New Mexico 

Kenneth E. Leonard, Ph.D. 

Senior Research Scientist 

Research Institute on Addictions 

Buffalo, New York 

Judith Levy, Ph.D. 

Associate Professor 

School of Public Health 

University of Illinois 

Chicago, Illinois 

Jane M. Liebshutz, M.D. 

Clinical Instructor of Medicine 

Section of General Internal Medicine 

Boston City Hospital 

Boston University School of Medicine 

Boston, Massachusetts 

Sheila P. Litzky, M.A. 

Statewide Coordinator for Women's Services 

Alcohol and Drug Abuse Administration 

Baltimore, Maryland 

N. Ann Lowrance, M.S. 

Deputy Commissioner 

Victim Services 

Oklahoma Department of Mental Health and 

Substance Abuse Services 

Oklahoma City, Oklahoma 

Colleen R. McLaughlin, Ph.D. 

Research Analyst 

Substance Abuse Unit 

Virginia Department of Juvenile Justice 

Richmond, Virginia 

Cassandra Newkirk, M.D. 

Deputy Commissioner of Offender Services 

Department of Corrections 

Atlanta, Georgia 

Virginia O'Keeffe, C.C.D.C. III, O.P.S. 

Executive Director 

Amethyst, Inc. 

Columbus, Ohio 

Christine D. Olson, M.S. 

Director 

Services for Families, Women, and Children 

Colorado Alcohol and Drug Abuse Division 

Denver, Colorado 

Paula Ortiz Smith, L.M.S.W. 

Social Services Coordinator 

Ben Archer Health Center 

Hatch, New Mexico 

Gennaro Ottomanelli, Ph.D. 

Director 

Division of Drug Dependence 

Kings County Addictive Disease Hospital 

Brooklyn, New York 
Appendix G 

152

Pat Paluzzi, C.N.M., M.P.H. 

Senior Technical Advisor 

Special Projects Section 

American College of Nurse-Midwives 

Washington, D.C. 

Carolyn Peake 

Program Manager 

National Institute of Justice 

Washington, D.C. 

Richard A. Rawson, Ph.D. 

Executive Director 

Matrix Center 

Los Angeles, California 

Charles Ray 

Executive Director 

National Community Mental Healthcare 

Council 

Rockville, Maryland 

Geri M. Redden, M.Ed. 

Executive Director 

Educational Center on Family Violence 

St. Louis, Missouri 

Hila Richardson, Dr.P.H. 

Deputy Director 

Medical Research and Practice Policy 

National Center on Addiction and Substance 

Abuse 

Columbia University 

New York, New York 

Josie T. Romero, M.S.W., L.C.S.W. 

Executive Director 

Hispanic Institute for Family Development 

San Jose, California 

Gwen Rubinstein 

Deputy Director of National Policy 

Legal Action Center 

Washington, D.C. 

Eleanor Sargent 

Director 

Clinical Issues 

The National Association of Alcoholism and 

Drug Abuse Counselors 

Arlington, Virginia 

Gerald Silverman 

Senior Policy Analyst 

U.S. Department of Health and Human 

Services 

Office of the Assistant Secretary for Planning 

and Evaluation 

Washington, D.C. 

Richard T. Suchinsky, M.D. 

Associate Director 

Addictive Disorders 

Mental Health and Behavioral Sciences 

Services 

Department of Veterans Affairs 

Washington, D.C. 

Sue Thau 

Community Anti-Drug Coalitions of 

America (CADCA) 

Washington, D.C. 

Daphne Walker-Thoth, M.Ed. 

Project Manager 

St. Louis Target Cities Project 

Missouri Division of Alcohol and Drug 

Abuse 

Missouri Department of Mental Health 

Saint Louis, Missouri 

Shirley Whitney 

Director 

Preventive Services Development 

Administration of Children Services 

New York, New York 

Theresa M. Zubretsky 

Director 

Human Services Policy and Planning 

New York State Office for the Prevention of 

Domestic Violence 

Rensselaer, New York 
The TIPs Series 

TIP 2 Pregnant, Substance-Using Women BK

TIP 5 Improving Treatment for Drug-Exposed 

TIP 6 Screening for Infectious Diseases Among 

TIP 11 Simple Screening Instruments for Outre

TIP 13 The Role and Current Status of Patient 

TIP 14 Developing State Outcomes Monitoring 

TIP 16 Alcohol and Other Drug Screening of H

TIP 18 The Tuberculosis Epidemic: Legal and Et

TIP 21 Combining Alcohol and Other Drug Ab

TIP 23 Treatment Drug Courts: Integrating Su

TIP 24 A Guide to Substance Abuse Services fo

TIP 25 Substance Abuse Treatment and Domest

TIP 26 Substance Abuse Among Older Adults 

TIP 27 Comprehensive Case Management for S

TIP 29 Substance Use Disorder Treatment for P

TIP 30 Continuity of Offender Treatment for Su

TIP 31 Screening and Assessing Adolescents for 

TIP 32 Treatment of Adolescents With Substanc

TIP 33 Treatment for Stimulant Use Disorders 

TIP 34 Brief Interventions and Brief Therapies f

TIP 35 Enhancing Motivation for Change in Su

TIP 36 Substance Abuse Treatment for Persons 

TIP 37 Substance Abuse Treatment for Persons 

TIP 38 Integrating Substance Abuse Treatment 

TIP 39 Substance Abuse Treatment and Family 

TIP 40 Clinical Guidelines for the Use of Bupren

TIP 41 Substance Abuse Treatment: Group Ther

TIP 42 Substance Abuse Treatment for Persons 

TIP 43 Medication-Assisted Treatment for Opio

TIP 44 Substance Abuse Treatment for Adults i

TIP 45 Detoxification and Substance Abuse Tre

TIP 46 Substance Abuse: Administrative Issues 

TIP 47 Substance Abuse: Clinical Issues in Out

TIP 48 Managing Depressive Symptoms in Sub

TIP 49 Incorporating Alcohol Pharmacotherapie

TIP 50 Addressing Suicidal Thoughts and Beha

TIP 51 Substance Abuse Treatment: Addressing 

TIP 52 Supervision and the Professional Develo

TIP 53 Addressing Viral Hepatitis in People W

TIP 54 Managing Chronic Pain in Adults Wit

Other TIPs may be ordered by calling 1-877-

SVZMWMXMRKLXXTWXSVIWEQLWEKSZ

HHS Publication No. (SMA) 12-4076

Substance Abuse and Mental Health Service

First Printed 1997

Revised 2000, 2002, 2003, 2005, 2008, and 20