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WHAT TODAY IS, WHAT TODAY ISN’T

WHAT TODAY IS, WHAT TODAY ISN’T. Dual Emphasis on Research and Practice Emphasis on Content, Not Practicing Skills Emphasis on Videotaped Examples, Not “Live Examples”. INTIMATE PARTNER VIOLENCE (IPV): CAVEATS AND CONTROVERSIES. IPV Research and Practice are Fragmented

nigel-holcomb
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WHAT TODAY IS, WHAT TODAY ISN’T

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  1. WHAT TODAY IS, WHAT TODAY ISN’T • Dual Emphasis on Research and Practice • Emphasis on Content, Not Practicing Skills • Emphasis on Videotaped Examples, Not “Live Examples”

  2. INTIMATE PARTNER VIOLENCE (IPV): CAVEATS AND CONTROVERSIES • IPV Research and Practice are Fragmented • Many “Stakeholders” with Competing Agendas • Many Claim to Have “The Answer” and Claim to be “Right” • Pre-Paradigmatic Area • People in Glass Houses… • History of Alcoholism Treatment • Everyone Is Right, Everyone Is Wrong

  3. SUBSTANCE USE &INTIMATE RELATIONSHIPS • Is It All Bad? • How Do They Influence Each Other? • Are Intimate Partner Violence (IPV) and Substance Use Related? • Can We Manipulate Aspects of Each to Influence the Other?

  4. SUBSTANCE USE AND RELATIONSHIPS:It Is Not All Bad…

  5. BUT WHEN IT GETS BAD:IT’S A FAMILY AFFAIR Thinking About Drinking and Drug Use Systemically

  6. Vicious Spiral Denial, Poor Problem Solving, Cognitive Distortions, “Checking Out” Substance UseFamily Problems Nagging, Fighting, “4 O’Clock Happy Hour” Inadvertent Reinforcement of Use

  7. THEMES: EASY AND HARD • Easy (or at Least Easier) • Drug Use • Relationship Adjustment • Hard (or at Least Harder) • Psychiatric Problems • Violence • Sex • Children

  8. IPV & SUBSTANCE ABUSE Controversies and Questions

  9. IPV AND SUBSTANCE ABUSE • Part of a Family Picture • Co-Exists and Interacts with Other Elements of the Bio-Psycho-Social Context • Genetics • Family & Friends • Neighborhood • Cultural • Much That We Do Not Know

  10. “Unfortunately, Being Stupid Can Make You Powerful Because You Just Don’t Know Any Better.” John Stuart Mill Philosopher

  11. EXAMPLE:FIRST SURVEY OF IPV IN DRUG ABUSE TREATMENT • Conducted Survey of Drug-Abusing Couples (N = 140) Regarding Prevalence of Intimate Partner Violence (IPV) • 60% Reported 1 or More Episodes • Protocol Stopped by Agency!!!

  12. COMMON STANCE:DON’T ASK, DON’T TELL • Most Substance Abuse Treatment Programs Assess IPV Poorly or Not At All • Most Marital Therapists Don’t Systematically Ask About IPV • 40%-60% of Partners Entering Marital Therapy Report Episodes of IPV • Most Batterers Programs Assess Substance Use Poorly or Not at All

  13. WHY DON’T WE WANT TO KNOW? • Clinical Concerns • Can We Treat This Effectively? • Is It Acceptable To Ignore It? • Legal/Economic/Political Concerns • Do We Have the Expertise To Treat This? • If We Refer, Will We Lose the Patients? • For Marital Therapists, Should We Use Couple Therapy with Partner Violent Dyads?

  14. CONVENTIONAL WISDOM AND ARMCHAIR SPECULATION

  15. SUBSTANCE USE AND VIOLENCE:FOUR “WORKING” ASSUMPTIONS • Intoxication is an Excuse, Not a Cause • Alcoholics and Drug Abusers Are Very Violent • Substance-Abusing Men in Violent Couples Should Be Referred to Batterers Treatment • Couples Treatment is “Never Appropriate” for Partner-Violent Couples, Including Those with Alcohol or Drug Problems

  16. ARE THESE ASSUMPTIONS ACCURATE? Available Evidence That Speaks to These Assumptions

  17. IS INTOXICATION CAUSALLY CONNECTED TO IPV? • No Randomized Clinical Trial Evidence • Research Ethics Barrier • Hill’s Evidence of Causality in Observational Studies • Consistency of Association • Strength of Association • Dose-Response • Theoretical Coherence • Temporal Precedence • Experimental Evidence • Elimination of Plausible Alternative Explanations

  18. EXPLAINING THE CAUSAL LINK:MULTIPLE THRESHOLD MODEL • We Have a Threshold for Aggression That is Influenced by Levels of Provocation • Various Factors Influence This Threshold • Intoxication May Lower the Threshold

  19. ASPD Sober Threshold Agressive Motivation IntoxicationThreshold Low Moderate High Provocation

  20. INTOXICATION AS A CAUSAL FACTOR IN IPV • Certainly “Looks” Like a Causal Factor • Not the Only Causal Factor—One of Many • Cannot Fully Escape the “Homunculus Explanation” • Yet, We Should All Agree Intoxication Is, At Very Least, A Marker for Increased Likelihood of IPV

  21. ARE SUBSTANCE ABUSERS VERY VIOLENT IN THEIR RELATIONSHIPS? • How Frequent is IPV in These Relationships? • What Does This Violence Look Like? • Is it All Male-to-Female? • Is it All Severe Violence?

  22. CHARACTERISTICS OF VIOLENCE IN SUBSTANCE-ABUSING COUPLES • Vast Majority is Low-Level, Bi-Directional • 75% Report This Kind of Violence • Some Report Uni-Directional Low-Level Violence • 20% Report This Kind of Violence • Female-to-Male Violence Common Here • Some Report Severe Uni-Directional Violence • 5% Report This; Mostly Male-to-Female Violence

  23. FEMALE-TO-MALE VIOLENCE • Very Common • In Our Samples, Slightly More Frequent Than Male-to-Female Violence! • Calendar Interview Reveals It Is Not All Defensive Responding • Often See It When Male Partner Drinks, Usually Before He Hits Her

  24. VIOLENCE TYPOLOGY • ”Battery” is a Unitary Phenomenon, With Differences Occurring on a Single Continuum VERSUS • Distinct Sub-Groupings of IPV • Common Couple (Situational) Violence • Most common among substance abusers • “Patriarchal” Terrorism • Non-Physical Aggression

  25. CLINICAL IMPLICATIONS • Implicitly, Many Providers Treat All IPV as Patriarchal Terrorism • Assumes IPV Arises Out of Power and Control • Yet, Among Substance Abusers, Common Couple Violence Is Far More Typical • Also True in DV Treatment Programs • Is There a Treatment-Problem Mismatch?

  26. INTERVENTION STANCE: TREAT ALL IPV AS PATRIARCHAL TERRORISM • ASSUMPTION: If It Works For Patriarchal Terrorism, It Will Work For Less Severe Variants of IPV • Assumption Is Correct IF IPV Consists of One Type of Behavior That Lies on a Single Continuum • Assumption Is Not Correct IF the Heterogeneity Reflects Different Types of Violence

  27. WHAT IS THE EVIDENCE REGARDING THE EFFECTIVENESS OF DV TREATMENT?

  28. TREATMENT FOR DOMESTIC VIOLENCE:DOES IT WORK? • Studies Are Riddled With Problems • Drop-Outs Are Sometimes Not Included • Brief Follow-Ups (or Only Follow-Up During Treatment) • Contact Often Not Considered • Use of a Single Informant • Comprehensive Reviews Indicate Effects of Treatment for DV Are Very Small

  29. IMPLICATIONS • Should We Refer Substance-Abusing Patients to Standard DV Treatment? • Does the “Chicken Soup” Philosophy Apply Here (i.e., It Couldn’t Hurt?) • Is DV Treatment Harmful if Ineffective? • What Else Can We Do?

  30. TREATING IPV AMONG SUBSTANCE-ABUSING PATIENTS: OPTIONS • Treat the Substance Abuser Only • Treatment-As-Usual (TAU) • Treat the Partners Together • Couples Therapy + TAU • Treat the Partners Separately • “Separate-But-Equal” + TAU

  31. TREAT THE SUBSTANCE ABUSER ONLY (TAU) • Relatively Effective if Substance Abuse Treatment is Effective • Relies Almost Exclusively on Abstinence as the Curative Mechanism

  32. REDUCING VIOLENCE EVEN IN THE FACE OF INTOXICATION • Treatment-As-Usual Is An Ineffective Treatment for IPV When Relapse Occurs • Given High Rate of Relapse After Treatment for Substance Abuse, Methods for Reducing IPV, Even When Substance Use Occurs, Are Necessary

  33. COUPLES THERAPY WITH PARTNER VIOLENT COUPLES • Highly Controversial • Advantages • Systemic View of Violence • Can Provide Nonsubstance-Abusing Partners with Strategies to Avoid Violence • Safety plan • No arguments when someone is intoxicated • No ‘Angry Touching’

  34. COUPLES THERAPY WITH SUBSTANCE USERS WHO ENGAGE IN IPV:WHAT SHOULD WE EXPECT? • Compared to Individual Treatment Approaches for Drug Use, We Should Expect: • Comparable Likelihood of IPV on Days of No Substance Use • Smaller Likelihood of IPV on Days of Substance Use • Wives have strategies to avoid violence on days of husbands’ substance use

  35. WHAT DO WE FIND? • Fewer Days of IPV Among Couples Who Receive Couples Therapy Compared to Individual Tx • Due to Less Substance Use Among Those Who Receive Couples Therapy • Comparable Likelihoods of Violence For Both Groups on Days of No Substance Use, BUT • Lower Likelihood of IPV on Days of Male Partner’s Substance Use for Those Who Receive Couples Therapy

  36. PROBLEMS • Requires Complex and Subtle Decision-Making • “Should I Resolve Conflict or Should I Avoid it” • Miscalculation Can Contribute To Violence • Assumes Sobriety on the Part of the Nonsubstance-Abusing Partner

  37. “SEPARATE-BUT-EQUAL” • Treat Both Partners, But Not in a Couples Format • Address Violent Partners’ Drinking and Drug Use • Provide Nonviolent Partner With Coping Strategies to Reduce Likelihood of Violence

  38. COMPARISON OF STRATEGIES:INITIAL PILOT DATA • TAU vs Referral vs Couples Therapy vs Separate-But-Equal • 80 Partner-Violent Couples (Male-to-Female Violence) • Couples Therapy and Separate-But-Equal Are Doing Better Than TAU and Referral

  39. ASSESSMENT: Theoretical and Practical Considerations One Size Does Not Fit All…

  40. ASSESSING SUBSTANCE USE AND RELATIONSHIP PROBLEMS(INCLUDING IPV) • Severity of Relationship Problems • Severity of Violence (Explore Safety) • Severity of Substance Use • Evaluation of Implicit and Explicit Violence • Type of Violence (Uni- Versus Bi-Directional) • The Interrelationship of Relationship Problems /Violence & Substance Use

  41. METHODS OF ASSESSMENT:“TRIANGULATING IN ON THE TRUTH” • Communication Samples -Partner Interaction Often Hidden in the Context of Conjoint Delivery Approach • Clinical Interview -Highly Structured to Unstructured -With Partners Together and Separately • Questionnaires -Assess Substance Use, Relationship Adjustment, Psychological Adjustment, and Violence

  42. COMMUNICATION SAMPLE • Have Couple Identify a Topic of Conflict Between Them • Observe a 10-min Discussion of Topic • Debrief

  43. CLINICAL INTERVIEW:UNSTRUCTURED • The Seven “Cs”: A Helpful Heuristic • Commitment • Caring • Communication • Conflict Resolution • Character Features • Cultural & Ethnic Factors • Contract Features

  44. UNDERSTANDING THE ROLE OF SUBSTANCE USE IN EPISODES OF IPV

  45. MEETING WITH PARTNERS SEPARATELY • Often Done as Part of a Violence Assessment • Obtain Each Partners’ View Without the Other Person in the Room • DISCUSS ISSUES RELATED TO CONFIDENTIALITY

  46. CONFIDENTIALITY MODELS • No Confidentiality in Individual Sessions • All Things Said in Individual Sessions Can be Revisited in Conjoint Sessions at the Discretion of the Therapist • Limited Confidentiality • Material is Treated as Confidential Unless, in the Opinion of the Therapist, it has Significant Implications for the Couple

  47. SEMI-STRUCTURED CLINICAL INTERVIEWING • Calendar Interviewing • Timeline Followback Method • Substance Use Version • Spousal Violence Version • Other Behaviors • Provides a Temporal Sequence of Behaviors • Visual • Reveals Patterns

  48.   Key:    h->w husband to wife non severe violence H->W husband to wife severe violence Key:Yellow- Wife report of non severe husband to wife violence Red- Wife report of severe husband to wife violence Green X - Substance use by husband 22 Days of No Substance Use 8 Days of Husband Substance Use 20 Days of No Violence 7 episodes of Non- Severe Violence 3 episodes of Severe Violence

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