Overcoming Addiction as a Coping Response to PTSD for Victims of Domestic Violence

Introduction

Family victimization is a national crisis for women and children. These victims may be immobilized and rendered helpless, with an attendant loss of self-respect, but often they suffer much more serious consequences. Family victims are characteristically “trapped, cornered, or overpowered, physically or psychologically, and they cannot function” (Boss, 2002, p. 161). The impacts of being battered include high rates of medical problems, head and neck injuries, broken bones, contusions, abrasions, lacerations, miscarriages, depression, and suicide attempts. (Hamberger & Phelan, 2004; Roberts, 2006). Victim’s symptoms can include persistent acute and chronic reexperiencing of the traumatic events of victimization, persistent symptoms of physical and emotional arousal, and avoiding stimuli associated with the trauma through a numbing of general responsiveness – often facilitated through the abuse of alcohol and other substances. All of these can seriously impair the individual’s functioning. Females suffering from battered woman syndrome often meet the same DSM-IV (2000) diagnostic criteria for post traumatic stress disorders (PTSD) as do veterans returning from foreign wars.

Many victims of domestic violence are dually diagnosed with PTSD and substance dependence (SD): “The literature is clear that there is a strong link between victimization or traumatization in women and substance abuse and dependence disorders.” (Covington, Burke, Keaton, & Norcott, 2008, p. 388). Both PTSD and SD are associated with increased rates of self-harm, suicidal ideation, and suicide attempts. (Harned, Najavits, & Weiss, 2006).

Moreover, the response consequences to victims of domestic violence predict and often accompany involvement in the criminal justice system. A significant body of research shows that women who are jailed reported elevated rates of physical, emotional, and sexual abuse, particularly abuse as children. (Green, Miranda, Daroowalla, & Siddique, 2005). The criminal justice system is philosophically predisposed to addressing issues characteristic of male criminal offenders. It is not adequate to serving these women who find themselves incarcerated – often for drug possession of related offenses. Substance abuse itself leads to a number of risky behaviors beyond criminality, including the transmission of AIDS and other sex related diseases. Since a majority of these incarcerated women are mothers, this has profound social implications. Investigation suggests that children benefit from treatment programs that target mothers who are abused. (McFarlane, Groff, O’Brien, & Watson, 2005).

A substantial segment of the population of victims of intimate partner violence ends up with dual diagnoses that traditional crisis intervention models may fail to address. It is imperative that therapists and paraprofessionals practicing crisis intervention for women that are victims of intimate partner violence include treatments that are sensitized to the dual diagnoses of PTSD and SD. Treatment options for such women are limited, in jails and in shelters. Several models for such treatment are beginning to show empirical support, and merit further study.

Assessing Woman Battering

An empirical examination of family violence is relevant to formulating social policies and crime legislation. Yet because there is disagreement over what constitutes a family system, the data can be difficult to track. For example, for purposes of the information supplied by law enforcement agencies to the Uniform Crime Reporting Program under the FBI’s National Incident-Based Reporting System (NIBRS) in 1995, family violence was defined as a crime against a person or property where the relationship of the victim to the offender is identified as within these relationships: spouse, common-law spouse, parent, sibling, child, grandparent, grandchild, in-law, stepparent, stepchild, stepbrother or stepsister, or other family member. Boyfriends, girlfriends, ex-spouses, ex-boyfriends, and ex-girlfriends were excluded. Even with this limitation, the FBI concluded that in 1995, of the 214,464 reported victims of violent offenses within the United States 57,985, or about twenty-seven percent, were related to one or more of their offenders. These offenses included murder, forcible rape, robbery, aggravated assault, simple assault, intimidation, and unspecified other offenses. In terms of demographics, these victims of “family violence” varied from overall crimes of violence. The victims are slightly older (83 percent above the age of eighteen) and overwhelmingly female (73 percent). In 46 percent of the cases the victims were marital or common-law spouses of the perpetrator. Yet these figures are not reflective of real world intimate partner violence.

In 2002 the U.S. Department of Justice issued its Bureau of Justice Statistics Special Report (Rennison & Welchans, 2000) on intimate partner violence, examining the period from 1976 to 1998. These authors defined “intimate relationships” as involving current or former spouses, boyfriends, or girlfriends including individuals of the same gender. The statistics were concerned with violent acts including murder, rape, sexual assault, robbery, aggravated assault, and simple assault. Several conclusions were drawn: (1) 85% of victimizations by intimate partners in 1998 were against women; (2) intimate partner violence made up twenty-two percent of violent crime against women between 1993 and 1998, as compared to three percent of the violence against men for the same period; (3) women experienced intimate partner violence in lower rates in 1998 than in 1993, falling from 9.8 to 7.5 per 1,000 women; and (4) intimate partners committed fewer murders in each of the three years 1996, 1997, and 1997 than in any other year since 1976.

As observed by Roberts (2006, p. 521) using survey information provided by Tjaden and Thoennes (2000), “[f]amily violence is a prevalent, dangerous, and often life-threatening social and public health problem. It is an indiscriminating crime that knows few boundaries, as recent annual estimates indicate that over 8.7 million women are battered by husbands, boyfriends, and other intimate partners.” This translates to a woman being battered, in the United States alone, by someone she knows on average once every nine seconds.

The literature assumes that governmental statistics and estimates are unreliable because of privacy issues that result in an under-reporting of the true numbers, or victim’s fears of retaliation, “as well as lost police records due to computer crashes.” (Roberts, 2006, p. 521). Many women never make police reports and may stay in battering relationships for extended periods. All of this is the so-called “dark figure” of domestic violence. This is likely the case when we speak to statistics relating to family and intimate partner violence.

Domestic Violence and PTSD

In 2001 Jones, Hughes and Untersaller undertook a review of the academic literature concerning PTSD syndrome for women as a result of the domestic violence these women had encountered. Their broad conclusions (p. 100) include the following:

· The symptoms shown by battered women are consistent with the major indicators of PTSD as currently defined by the DSM-IV. Findings across varied samples including shelters, hospitals, and community agencies is that 31% to 84% of victimized women exhibit PTSD symptoms

· The domestic violence shelter population is at higher risk for PTSD than those similarly victimized women who are not in shelters, with estimates ranging from 40% to 84% of the shelter population.

· Having multiple victimizations over time (childhood abuse, especially sexual abuse, and adult sexual abuse) increases the likelihood of PTSD and other psychiatric disorders.

· The extent, severity, and type of abuse is connected with the intensity of PTSD. The more life threatening the abuse, the more traumatic the effects. Women need not experience severe violence to suffer PTSD symptoms, but experiencing severe violence exacerbates symptoms. Psychological abuse may be as damaging as physical abuse.

· Depression and dysthymia in particular tend to accompany PTSD victims of domestic violence.

· Suicide is a risk for domestic violence victims of display PTSD symptoms.

· In a high percentage of victimized women, substance abuse was reported. Women who reported being victims of child abuse and adult victimization had significantly more lifetime drug and alcohol dependence than women not reporting abuse.

· Younger, unemployed women with a relatively large number of children, low income, and poor levels of social support are more at risk for experiencing PTSD symptoms.

Treatments exist for persons in the acute aftermath of trauma; however, traditional treatment responses to PTSD have been criticized by some as being contraindicated for battered women, especially women in shelters. (Johnson & Zletnick, 2009). The first-line treatments for trauma victims suffering PTSD are primarily exposure-based. Since battered women in shelters have multiple safety concerns that can lead to increased anxiety (e.g., homelessness, children, risks of re-victimization), such anxiety if overwhelming can impede the efficacy of these techniques in this population of PTSD sufferers.

Johnson and Zletnick (2009) have proposed one treatment model using cognitive-behavioral theories. They have developed “HOPE” for treating PTSD in battered women in shelters, an acronym for Helping to Overcome PTSD through Empowerment. HOPE was designed for battered women with ongoing safety concerns; however, Johnson and Zletnick (2009, p. 237) warn that “HOPE is unsuitable for women with significant pathology (i.e., suicidality, a bipolar or psychotic disorder, and/or active substance dependence) who need more intensive and specialized treatment.” Hence, there is no HOPE for dual diagnosis victims. This is unfortunate since the literature strongly supports conclusions of a nexus between drug and alcohol abuse and the stress of domestic violence. (Eby, 2004).

Effects and Characteristics of Comorbid PTSD and Substance Abuse

There is a long established correlation between women with PTSD and SD with self-harm and suicidal behavior. Harned et al. (2006) postulate that “individuals with comorbid PTSD and SD may be at high risk for self-harm and suicidal behavior. Indeed, two studies have found that women with this dual diagnosis report a higher number of lifetime suicide attempts than women with either PTSD or SD alone” (p. 392). Their findings were that twenty-one percent of the women in their sample with comorbid PTSD and SD had engaged in self-harm behavior in the past three months, a rate comparable to life-time prevalence rates of self-harm reported in studies of women with substance use disorders. The rate of suicide attempts in the prior three months was lower than previous studies of PTSD-SD patients, but these prior studies assessed life-time rather than recent suicide attempts. Their results also suggested that PTSD and SD were each perceived as contributing to self-harm and suicidal behavior. Almost 62 percent of the women who had made a suicide attempt and/or harmed themselves in the prior three months reported using alcohol or drugs immediately before or during the episode. “These findings are consistent with research indicating that self-harm and suicide attempts often regulate overwhelming internal experiences, such as unwanted emotions, flashbacks, and unpleasant thoughts” (p. 394).

Women who had not engaged in self-harming behaviors were more likely to report that concerns about children, a belief in their ability to cope, and a wish to survive helped them to stay safe (p. 395). Those results were consistent with the research indicating that similar reasons for living best differentiate suicidal and nonsuicidal groups.

Dual diagnosis of PTSD and SD dramatically increases the likelihood that women will become incarcerated within the criminal justice system. This has profound sociological implications since 70% of jailed women are mothers, and the consequences to these children are extremely negative. As Green et al. (2005, p. 341) note, according to U.S. Department of Justice statistics released in 2003, there has been a dramatic growth in the increase of the female population in the nation’s jails, mostly attributed to increases in illicit drug use among women and an increase in drug related convictions and mandatory sentencing. Women prisoners have been shown to have had a very high exposure to a variety of trauma experiences, most notably interpersonal violence including childhood physical and sexual abuse with some studies suggesting that this exposure may be as high as between 77% and 90%. (Battle, Zlotnick, Najavits, Gutierrez, & Winson, 2003, as cited by Green et al., 2005).

Potential Treatment Limitations of Domestic Violence Shelters

Battered woman syndrome is a culturally recognized type of PTSD that crisis counselors need to address and to consider in light of its common symptoms which one author (Kanel, 2007, p. 225) has summarized as follows:

1. PTSD Symptoms. The traumatic effects of victimization by violence, particularly

from intimate partners, causes various symptoms to develop as identified by the DSM IV.

2. Learned Helplessness. The failure of the social system to help the victim may

train her to defend by learning to survive rather than by escaping he battering.

3. Self-Destructive Coping Responses to Violence. Because the victim may believe that her only choice is to stay, or in order to adapt to the experience itself, she often uses drugs and alcohol to escape or she may attempt suicide.

Often, the only safe place for these women to turn is one of the 2,000 community-based shelter programs throughout the United States that provide emergency shelter. The experience of battered women in shelters can be quite different from community women in that the women who enter shelters are often coming directly following an acute battering incident, have high levels of on-going safety concerns, and remain at high risk for returning to the abusive relationship. Although research suggests that “a prime time to intervene is when a woman is a resident of a battered woman’s shelter, considering that many battered women seek help from the shelters and have instituted changes in their lives” (Johnson & Zletnick, 2009, p. 235), traditional PTSD treatment involving exposure modalities appear to not be appropriate – and cognitive-behavioral based therapies that might work for PTSD alone are not indicated for a substantial element of the shelter population exhibiting dual diagnoses including SD.

Many shelters are not prepared to deal with substance abuse or PTSD issues, especially when substance abuse problems persist. Many shelters have strict guidelines concerning compliance with case plans and shelter rules (e.g., no drug use or alcohol), and women who are not compliant with the rules may be asked to leave prematurely. This is especially true in today’s economics, where shelter facilities are being forced to cut staff and services and are unable to expand them.

New Paradigms for Treating Dual Diagnosis Battered Women

Covington and Bloom (2006) argue for “gender responsiveness” in the treatment of women trauma victims. They argue that in order for treatment of females victims of domestic violence to be effective, treatment must reflect “an understanding of the realities of women’s and girl’s lives and [be] responsive to their strengths and challenges.” Because traditional therapy usually reflects the dominant male culture, one result is that programs called “gender neutral” are really male based. Covington et al. (2008) conclude that since the lives of many women in substance abuse treatment and mental health treatment include trauma it is essential that materials used be “trauma-informed.”

A paradigm that was developed by Dr. Stephanie Covington to begin addressing these concerns is the Women’s Integrated Treatment (WIT), under which two gender responsive curricula have been designed which attempt to integrate trauma and substance abuse treatment. These curricula are termed Beyond Trauma (BT) and Helping Women Recover (HWR).

HWR is a manualized curriculum designed for use in a variety of settings that are intended to include outpatient and residential substance abuse treatment programs, domestic violence shelters, mental health clinics, jails and prisons, and community correction facilities. “HWR is founded on research, theory, and clinical practice and is grounded in the theories of addiction, trauma, and women’s psychological development” (p. 390). BT is similarly manualized, but the materials are intended to be trauma-specific. “The connection between trauma and substance abuse is recognized and integrated throughout the curriculum.” (Covington et al., 2008, p. 391).

Both of these programs rely upon implementation by trained staff utilizing user friendly materials which are self-instructive. Instructor’s manuals are provided for running groups, and the staff themselves are first trained in how to conduct the program. Sessions include an overview of the materials to be covered, a teaching component, an interactive component that includes supportive exercises, and a closing used to focus questions for women to think about for the next session. Video instruction for facilitators and clients is included. HWR and BT is usually provided sequentially.

Noting that gender-responsive, trauma-informed services for women have only been developed in the last ten years, in their study of 200 women using both HWR and BT, Covington et al. (2008) preliminarily concluded that their findings show significant improvement among the women involved with WIT as compared to traditional treatments. “Research has demonstrated that the greatest risks to addiction recovery are present in women with histories of victimization and/or trauma. As a result, interventions must approach such individuals with a dual purpose” (p. 197). Randomized women who engaged in the WIT program utilizing both HWR and BT made notable positive gains in areas of symptoms associated with trauma and depression and stayed in treatment while maintaining sobriety. They observe there are several other programs that have been shown to be effective, including Seeking Safety.

According to Najavits (2009) Seeking Safety is a present focused coping skills model designed to address trauma and substance abuse at the same time. Navjavits claims that “[a]t this point, it is the only model for trauma and substance abuse that meets criteria as an effective treatment” (p. 292). She observes that Beyond Trauma awaits a published outcome study. She also questions Covington’s conclusions that there is need for specificity with regard to women, based upon a lack of research. The treatment offers 25 topics and covers four content areas – cognitive, behavioral, interpersonal, and case management. Typically the number of sessions is 25 over some three months. As with WIT, these include written course work which is facilitated by trained paraprofessionals. As with WIT, it holds considerable promise.

Conclusion

The treatment of women who have suffered interpersonal violence and substance abuse is a major public policy matter, especially because of implications for the collateral impacts upon children. Traditional PTSD exposure based therapies may not be best suited to domestic violence victims generally, and particularly for those with dual diagnoses of PTSD and SD. Many domestic violence shelters are not trained to deal with substance abuse issues or have available a meaningful program of treatment for such persons or sufficient funding resources, and so refuse to treat women who are practicing addicts. Research suggests that before women can be effectively treated for PTSD, they must first be stabilized from their substance abuse; and vice versa. In a large percentage of the intimate partner abuse population there is an established comorbidity of PTSD and SD. This is likewise true of many women within the criminal justice system. Ignoring these issues risks the tail wagging the dog, and potential failure in the successful treatment of a large percentage of these victims.

Whether or not gender responsiveness is critical to effective treatment of PTSD, this huge population of victims has it unique attributes and problems. Shelters are the front line defense, and sometimes the last line defense, for many of them. Further inquiry is necessary to determine whether a refusal to recognize and treat these comorbid tendencies is a failure in the developing struggle to stop the cycle of victimization for women. However, without recognition of the importance of treating dual diagnosis victims of domestic violence on the part of governmental and community agencies, there will continue to be a dearth of financial resources available for this expansion of appropriate and needed treatment.

References

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Footnotes:

In 1832, the Belgian mathematician and sociologist Adolphe Quetelet coined the phrase "the dark figure of crime." By this he meant the true crime rate as opposed to the number of governmentally recorded crimes. The dark figure, he suggested, would inevitably be much higher than the official figure – people who commit crimes take pains to ensure that their endeavors do not come to the attention of the government. All of our reasoning about crime, Quetelet suggested – about its scope, nature, and impact – would be defective were we to rely upon official statistics.

This also appears to be true of men. (Najavits, Schmitz, Gotthardt, & Weiss, 2005).

At least one study has questioned whether the literature establishes that women are really worse off remaining in certain abusive relationships, at least in the short-term, given that “many victims encounter tremendous difficulties in securing employment, finding housing, and accomplishing other tasks related to establishing a life apart from their mates.” (Bell, Goodman, & Dutton, 2007, p.414).