An alcohol and drug clinician’s  guide to addressing family  and domestic violence Professor Ann M Roche Director National Centre for Education and Training on Addiction (NCETA) Flinders University www.nceta.flinders.edu.au

Winter School, Brisbane 23 ‐24 July 2015

Increasing Attention Directed to FDV Ice crisis taskforce: Indigenous women take  drug to withstand abuse

The relationship between alcohol and drug use and domestic violence is  complex but pervasive.  Until recently relatively little attention had been directed to the issue of  DFV among AOD services clientele.  This presentation outlines best practice practical strategies that can be  applied in various service settings with clients and/or family members.

NCETA’s Roles Research  Generation

Research  synthesis

Research  translation

Facilitating  research‐ policy/ practice  transition

Our Activities original  research  (quantitative  and  qualitative)

Strategy  development

research  dissemination  (resource  production,  policy advice,  professional  development)

evaluation Evidence based  practice and  policy secondary  data  analysis systematic  and  descriptive  reviews 

Background • Impetus   need for comprehensive approach to understanding and  addressing the causes, prevention and treatment of  family and domestic violence (FDV) across broader  welfare system

• Increased focus on the interrelationship between  sectors such as: – alcohol and other drugs (AOD),  – child and family welfare, child protection  – FDV

• Reflected in national policies related to protection  and wellbeing of children and family support

AOD and FDV Research Findings International Violence Against Women Survey (IVAWS)  showed:  alcohol consumption played a significant role in violence against  women (Mouzos & Makkai, 2004)   women whose partners were intoxicated 2+ times per month  experienced higher rates of DV than women whose partners drank  less, or not at all.   35% of women indicated partner was drinking at the time of the  most recent violent incident   4% indicated that their partner was using other drugs  (Mouzos & Makkai, 2004). 

AOD and FDV Research Findings It is estimated that alcohol contributes to 50.3% of all  partner violence, and 73.0% of physical partner assaults  (Laslett et al., 2010)  Previous research has indicated that abusive males who  have a substance problem, including alcohol:  inflict more frequent violence  cause more serious injury   are more likely to inflict sexual violence on their intimate partner than those without a substance  use problem  (Browne, 1997 cited in Mouzos & Makkai, 2004).  9

AOD Sector Responses • Long awareness of FDV and AOD association • Growing awareness of FDV factors that impact on client wellbeing and may impede their progress with AOD issues • Addressing FDV is a measure services can implement to: – improve clients treatment outcomes – support child and family sensitive practice – contribute to the wellbeing of clients’ children

• However can be a challenging to address !

Impact on Children • For every adult seeking AOD treatment, there is generally one child impacted by problematic parental AOD use (Advisory Council on the Misuse of Drugs, 2003)

• Witnessing or experiencing violence can lead to trauma causing long term, devastating impacts on children including: – developmental delay – relationship, physical health, behavioural and educational difficulties – serious lifelong mental health issues including problematic AOD use.

• Triggers mandatory report

Association with parenting Victorian study found of parents involved in substantiated cases of child neglect: – – – –

approximately 1/3 had problems with alcohol 1/3 had other drug problems more than 50% had experienced family violence nearly 20% had a psychiatric disability (Community Care Division, 2002)

Definition The term “family and domestic violence” (FDV) captures  a wide range of abusive behaviours that occur in the  context of intimate and family relationships.  It may involve: • spouses/de‐facto partners • ex‐partners • children • siblings • parents/caregivers • same sex relationships.

Defining Violent Behaviours Violence has many forms. It can be verbal, physical, social,  financial or psychological. It may be a crime. • Violence may include: – slapping, pushing, hair pulling, punching, kicking,  choking, holding someone down – threats, yelling, swearing, bullying or starting fights – name calling, criticising or put downs – financial or social control – forcing someone to do anything against their will – using weapons, breaking things – threatening or harming children, pets or others.

Forms of family and domestic violence Form of violence

Tactics of violence

Emotional

Manipulation, humiliation, lying, ridicule, withdrawal, shaming, punishment, blame. All forms of violence are  implicitly emotionally violent.

Physical

Sexual

Any actual or threatened attack on another person's physical safety and bodily integrity; also physical  intimidation such as threatening gestures or destroying property, and harming or threatening to harm pets or  possessions. Any actual or threatened sexual contact without consent. Note that some forms of sexual violence are criminal  acts, for example, sexual assault and rape, many other forms—such as using degrading language—are not.

Social

Any behaviour that limits, controls or interferes with a person’s social activities or relationships with others.  Includes controlling a person’s movements and denying access to family and friends, excessive questioning,  monitoring movements and social communications (including phone use, emails, texts or social networking), and  being aggressive toward others (e.g., men who are viewed as “competition”).

Financial

Any behaviour that limits access to a fair share of the family's resources. Includes incurring debts in the victim’s  name, spending money without their knowledge or consent, monitoring their spending, and expecting them to  manage the household on an impossibly low amount of money and/or criticising and blaming when they are  unable to.

Spiritual

Any behaviour that denigrates a person’s religious or spiritual beliefs, or prevents them from attending religious  gatherings or practising their faith. Includes forcing them to participate in religious activities against their will.

(adapted from NSW Department of Attorney General and Justice, 2012)

Factors incorrectly attributed as causes of FDV Factor

The perpetrator’s psychological  profile

False Attribution

While various attempts have been made to identify a particular set of personality traits and develop psychological profiles of  perpetrators, these have been unsuccessful. Perpetrators of FDV are identifiable only by their use of power and controlling behaviours.

The victim’s psychological profile

That some people allow themselves to be abused, or have psychological problems that lead them to choose partners who perpetrate  violence. However, there is no evidence that it is a particular “type” of person who is likely to experience FDV.

Alcohol and drugs

Perpetrators of FDV can be more dangerous when they are under the influence of alcohol or other drugs. However, not all people who  abuse alcohol are violent, and many people are violent whether they are drunk or sober. While alcohol and other substances might  exacerbate violence in some men, their underlying attitudes and values are the starting point for violence.

Family history

Often people seek to explain FDV by suggesting that men who perpetrate violence had traumatic childhoods, or that they repeat the  violence they witnessed in their own family backgrounds. While this may be true for some, this belief cannot account for the very large  number of men and women  who have been exposed to family violence as a child and are not violent in adulthood. Nor does it explain  how a significant number of people who report happy and non‐violent childhoods perpetrate violence in an adult relationship.

Perpetrators and the broader community commonly attribute violence to a failure to manage anger or frustration. However,  perpetrators of violence often experience a number of other emotions—such as anxiety, distress, impatience, agitation, possessive  jealousy and frustration—before and during violent acts, instead of or in addition to anger. Failure to manage emotions (such as  Most people can manage anger and other feelings without resorting to violence. Indeed, most perpetrators of FDV successfully manage  a range of feelings (including anger and distress) outside of their domestic environment. People who are violent towards family  anger or frustration) members usually do not perpetrate violence against their work colleagues, bosses or friends. This suggests that failure to manage  emotions is not at the core of FDV – but rather, a deliberate choice about how to behave in particular situations.

Mental illness

There is no evidence that those who are violent have higher rates of psychiatric disorders than others. Given that FDV affects a significant proportion of the population, it cannot be explained in terms of “abnormal” personality characteristics. Those who  perpetrate family and domestic violence look and act like “ordinary” members of society.

All communities ‐ including Anglo Australian ones ‐ have violence‐condoning and violence‐supporting values, systems and practices. In  all communities, there are women and children resisting family and domestic violence while still upholding their cultural or religious  Cultural or religious customs used to  texts, beliefs and customs. excuse control over women

(adapted from NSW Department of Attorney General and Justice, 2012)

The cycle of violence Thebuild‐up phase

May begin with normal relations between the people in the relationship, but involves escalating tension marked by increased verbal, emotional or financial abuse.In non‐ violent relationships these issues would normally be resolved between the people in the relationship.

Thestandover phase

Can be extremely frightening for people affected by FDV.The person subjected to violence may fear that anything they do will cause the situation to deteriorate further and feel that they have to “walk on egg shells”. The  behaviour of  the person who uses violence in relationships escalates to the point that  a release of tension is inevitable.

Explosion

This stage marks the peak of violence in the relationship and can involve physical assault, terrorising, threats to bodily integrity, reputation, or financial status, and propertydamage.

Remorse

In this phase, the person who uses violence in their relationships feels ashamed of their behaviour and/or they may be afraid of the consequences. They may retreat and/or become withdrawn from the relationship. They may try to justify or minimise their actions to themselves and to others.

Pursuit

In this phase, the person who uses FDV promises never to be violent again and may go through a dramatic personality change. The person who uses domestic violence may try to make up for their past behaviour during this period, and blame other factors for their violence (e.g., work stress, drugs, or alcohol). They may try to win back  their partner with gifts and promises and attention, or they may  act  helpless, saying such things as “I can’t live without you” or “I’ll kill myself”. The person affected by the violence will feel hurt, but possibly relieved that the violence is over. If these tactics do not work, the person who usesviolencein theirintimaterelationships mayusemorethreatsandviolence.

The honeymoon

During this phase both people in the relationship may be in denial about the severity of the abuse and violence. Both people do not want the relationship to end, so ignore the possibility that the violence could occur again.

(Walker, 1984)

Why some people use violence • There is no such thing as a ‘typical’ person who uses  violence.  • People who use violence may: – use it to control others – sometimes believe they have the right to get their own way  despite harming others – use it to inappropriately express frustration or stress – not take responsibility for and make excuses about their violence:  e.g., blaming alcohol or stress – claim to ‘lose control’ when angry around their families, but  control their anger around others – minimise, blame others for, justify or deny their use of violence,  or the impact it has on others.

Who Experiences FDV? Women • between 41-80% in AOD treatment experienced violence (US) • 4-40% in FDV programs report AOD problems (US) • FDV likely to feature in background of majority in AOD programs Men • % of male AOD clients who use or suffer from FDV is unknown • based on current indicators likely to be substantial • approximately 2/3 seeking AOD help are male • important opportunity to engage men and help break the cycle Aboriginal and Torres Strait Islander people • substantially over-represented in AOD treatment, FDV and child abuse and neglect data Children • affected by experiencing, witnessing and exposure

Important Caveats • Not all alcohol and other drugs users become violent. • Some of the violent behaviour would occur without the use of alcohol or  other drugs but the use of  AOD can exacerbate or escalate the violence. • Some alcohol or other drug users exhibit violent behaviour where there  has previously been no such behaviour. • Some substances are more likely to trigger violent behaviour – stimulants  or alcohol more likely than depressants. • Mental health issues can also be a key factor in AOD‐related violence  cycles. • Some violent episodes are ‘one offs’ and don’t develop into long term D.V.

Alcohol and other drug use and violence  • May affect the way someone understands and  reacts to situations or people. • May increase the risk of violent behaviour. • However, violence is never acceptable.  • Important to support clients – not addressing  violence can be seen to condone it. • Don’t allow clients to take responsibility for  someone else’s use of violence, help them take  responsibility for their safety and seek help.

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Family and Workforce Support • Alcohol and other drug use and family violence often occur together. • Families coping with a family member with AOD problems can also be exposed to violent behaviours. • Living with a family member who uses alcohol or other drugs and who is violent can be frightening. It can feel like walking a tightrope. Specialist support and medical attention may be helpful. • NCETA has developed a range of resources designed to provide workers and clients with the support.

WFD Implications  • policy implementation • training for clinicians/staff • universal application (all clients) • targeted  • families (where violence is present or there  is a risk of violence).

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AOD Strategies to address FDV May include: 1. Evidence-based policy and practice responses 2. Organisational awareness of family issues 3. Prioritising safety 4. Coordination of services 5. Policies and systems 6. Standardised response frameworks 7. Broad-based rather than single issue focused interventions 8. Access to highly skilled practitioners as required 9. Targeted workforce development 10.Monitoring, accountability and evaluation.

New Resources

NCETA and Odyssey House (Vic) developed  two publications: • that address the need for a  comprehensive approach to addressing  family and domestic violence (FDV)  across the broader welfare system • support the implementation of National  and AOD sector policies

NCETA and FDS produced a resource for  families to address FDV.

www.nceta.flinders.edu.au

Figure: Responses to FDV (based on Nicholas, 2012)

Practitioner skill sets Few AOD staff have received appropriate FDV training or support. Suggested skill sets are: All AOD workers 

Frontline/counselling staff

• provide enhanced  • provide basic level  response to FDV issues responses • have an awareness of  • skills in:  FDV issues • raising FDV issues  sensitively  • knowledge of  • screening,  organisation’s FDV policy  assessment and procedures • respond sensitively and  • risk assessment  appropriately to FDV  • safety planning;  issues and immediate  • referral concerns • non‐collusive  engagement

Specialist AOD/FDV staff • provide intensive  response to FDV issues  where they co‐occur  with AOD issues • work collaboratively  with FDV, family and  child welfare and  protection services.

Pyramid of Family Care/Needs

Source: Gruenert, S & Tsantefski, M. Responding to the needs of children and parents in families experiencing alcohol and other drug problems. Prevention Research Quarterly. 2012; 17.

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Responding to Violence

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Common responses to violence •

Dealing with a family member’s AOD problems and violence can lead to feelings of: powerlessness, self-blame, shame, guilt, embarrassment, anger, fear, hopelessness, confusion, exhaustion and a lack of control.

•

AOD clinicians can help clients understand that these are common feelings and offer support and identify ways to cope and/or overcome them.

•

Support can be beneficial for drug treatment outcomes.

Skilling clients to communicate  • Support your client to develop their skills to communicate appropriately with a family member who uses alcohol, drugs and violence. • Key skills include: – timing conversations carefully, not discussing issues when they have been drinking or using drugs – avoiding an argument if their family member is already angry – talk when everyone is calm – emphasise the importance of: • listening and trying to understand what is going on for everyone • avoiding criticising, judging, moralising and blaming • focusing on the behaviour not the person. 32

“I” or “We” statements “YOU” statements: “You come in high on drugs, throwing your weight around and threatening everybody. You need to wake up to yourself.” versus “I” or “We” statements :

“I get worried when drugs have been used because I feel threatened and afraid and I don’t want drugs used in our house.”

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I statement excercise I statements have thee parts: 1. When X happens…  • When there is a lot of drinking and arguing in the  house

2. I feel ... • Scared about my safety

3. … and what I would like to happen is… • that I don’t have to talk about things that make us  angry if there has been drinking. 34

Dealing with violent behaviours Provide clients with clear guidelines about dealing with violence. This may include: • never confronting someone who is intoxicated • being aware that alcohol and other drugs can affect the way people think and interpret situations • avoiding heated arguments and trying to stay calm • staying physically safe: – avoid arguments in areas of the house (kitchen, bathroom, garage) where there may be things used as weapons – exit awareness – don’t block exits or corner yourself or them – leave if situation no longer safe and you can go safely – try to keep everyone safe, especially children. 35

Involving the police • The client is generally considered to have a right to privacy - involving police would be their decision. • Discuss the pros and cons of involving the police. • Respect the clients right to self determination. • Exceptions: – Mandatory reporting requirements (children witness or experience FDV) – Duty of care (risk of harm, criminal act) – As determined by organisational policy.

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Intervention orders • Important to develop an understanding of IOs in your  jurisdiction: – issued by either police or court  – can help to stop a person behaving in ways which may harass,  threaten or abuse others and which may be violent – not a criminal charge, but a criminal offence to disobey one – police can provide advice about intervention orders and assist  clients to obtain one  – an intervention order is made specifically for a person and  their situation  – in some circumstances can include a clause which removes  the other person from the family home.

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Family members with a mental illness • Provide clients with information about comorbidity: – Most people with a mental illness are not violent. – Some people with a mental illness who use alcohol or other drugs may be more likely to be violent, especially if they are not getting good mental health care. – Alcohol, other drugs and mental health issues are complex and can take time, commitment and patience to resolve. – Prepare the client for a long process and some setbacks. – Getting support from professionals, family and friends is crucial. It can help people to get better, stay well, and remain safe. 38

Safety Plans A safety plan can include: • A list of important phone numbers • Keep this list somewhere private but where you can get to it easily. Include: – – – – – – –

police, emergency housing and domestic violence services solicitors or legal aid local mental health crisis team, emergency medical centre or hospital someone living nearby who can help quickly people to help care for children and/or animals. identifying where you can go to make a phone call for help without being overheard – identifying somewhere safe you and your children can go such as a family member or friend’s place – keeping important documents, bank details/cards, mobile phone where you can get to them easily. – a safety plan does not prevent a crisis but it may help in responding to crises, helping you get to safety faster. 39

Pre‐planning  You may need to help a client plan to leave.  What does a client need to need to take with them? – cards – ATM card/bank book, driving licence, Medicare & Centrelink cards – other documents – birth, marriage & divorce certificates, passport, family  court orders, rental agreement or mortgage documentation, utility bills, car  registration – medication and toiletries – keys to house/car/work – money – mobile phone & charger (consider changing your number, redirecting bills) – telephone numbers for family & friends – change of clothes and basic food.

Have them consider: – – – –

who they can safely tell about the violence and your plan to leave. where they will go and plan how to get there. how to avoid leaving indications about where a partner can find them pre‐packing essential items in a safe place in case theyneed to leave in a hurry 40

Challenges

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Potential Barriers to Change • Political environment – ideology • Social environment – disadvantaged  groups • Service system – resources, policies • Educational environment ‐ curricula • Practice environment – time, resources,  organisational structure • Practitioner – knowledge, beliefs,  attitudes • Patient/client – demands, perceptions

Role definition Role definition Core role only

Practice implication “It’s not my concern” No engagement with child and family  sensitive practice

Core role plus assessment of ‘other  needs’

“It’s a concern but someone else’s job” Minimal engagement leading to referral

‘Other needs’ incidental but unavoidable

“Not my core role but I have to do it” Willing to address issues where they  impact on client needs

‘Other needs’ intrinsic part of core role

“It’s part and parcel of my job” Engaged with  child and family sensitive  practice 

Adapted from: Scott, D. 'Think Child, Think Family': How Adult Specialist Services Can Support Children at Risk of Abuse and Neglect. Family Matters. 2009: 37-42.

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Challenges – Ethical Dilemma of Deservingness What are the social justice implications of providing care to individuals  with stigmatised conditions?   Provision of health care (for example) represents a dilemma of social  justice (equitable access to high quality care) and distributive justice  (high quality care is a scarce resource).   Judgements of deservingness relate to the justice or fairness of an  outcome: • a just and deserved outcome likely to be viewed with satisfaction  and approval • an unjust and underserved outcome will be met with disapproval  and displeasure (Skinner, Freeman, Feather and Roche, 2007)

Challenges – Systems Issues Relationships between adult specialist services  (e.g., AOD) and health, education and social  services have been described as inadequate in  many child protection and child death reviews. Adult services that could address parental problems  have traditionally not: – been aware of whether adult clients are parents – considered their clients’ parental role and the needs  of children – legitimised workers engagement with family and  children 45

Challenges ‐ Silos Program and practice silos create barriers: • Ethical (information sharing, disclosure,  notification) • Conceptual (client, patient, victim, risk) • Professional (values)  • Organisational e.g. • Client? = child, adult, family, community • Single input services based on categorical funding

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Challenges – Client Complexity Common co‐presenting problems of parents  involved with alcohol and other drug services are: – mental health issues – family violence – homelessness – child abuse and neglect Many present with more than one problem and so  have more than one worker/service.  47

Organisational barriers Organisational barriers include:  • inadequate access to relevant resources, strategies,  education and training • lack of appropriate intake and assessment questions  • insufficient intra‐agency linkages  • limited information exchange • undefined treatment plans/goals  • competing priorities. 

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System Redesign Universal Prevention for all Children/Families Alcohol and other drug treatment

Mental Health Services

Domestic Violence Services

Children  /family in  need of  support

Homelessness Services

Disability Services

Correctional Services

Child Protection Intervention

(Based on Scott, D., 2009)

Targeted Prevention and Intervention for Vulnerable Families

Better integration of AOD/FDV services Is not simple and requires systemic changes including: • Ongoing policy changes at all levels • Improved collaboration between organisations • A skilled workforce of service professionals who practice in a range of disciplines, and have the: – skills to identify where support is needed and – ability to work with other professionals to support the provision of effective and responsive services to their clients in the context of their family situation.

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AOD Sector May Require: • expanded education and training aimed at building AOD workforce capacity re FDV • develop organisational checklist(s) to ensure child and family sensitive policies and procedures are in place (including explicit questions on FDV) • regularly review organisational procedures • include parenting roles/responsibilities in assessment tools • ensure clinical supervision captures the needs of clients as parents and the needs of their children. 51

Conclusion 1. FDV will affect a significant proportion of  AOD clients. AOD issues may be inextricably linked to  FDV.  2. Substantial capacity for the AOD sector to enhance its ability  to detect and respond to FDV problems as: • Families could benefit from AOD services making the links  between AOD use and FDV explicit. Potential to:

– increase the client’s capacity and motivation to  change AOD use – mimimise harms from FDV  – improve outcomes for their children • Requires a whole of system response and improvements to  intersectoral collaboration.

1800 RESPECT

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