Chapter 7 Substance Abuse and Victimization

Abstract

The use and/or abuse of alcohol and other drugs are correlating factors in the commission of some crimes. In addition, some victims use substances as a negative coping mechanism to deal with the short- and long-term trauma of victimization. Collaborative efforts among professionals who serve victims-including victim service providers, criminal and juvenile justice professionals, child protection agencies, mental health professionals, and substance abuse treatment providers-are necessary to promote early identification, prevention, and intervention efforts relevant to victimization and substance abuse.

Learning Objectives

Upon completion of this section, students will understand the following concepts:

• Clinical definitions of substance-related disorders, including use, abuse, and dependence.



• Current research findings relevant to the abuse of alcohol and other drugs and victimization as applied to specific victim populations, including victims of domestic violence and sexual assault, and child and adolescent victims.



• The correlation between victimization, posttraumatic stress disorder, and substance abuse.



• Responses for victim interventions and assistance.



• Promising practices in preventing and responding to substance abuse among victims of crime.

Introduction

Traditionally, the topic of substance abuse within the context of criminal justice has focused primarily on offenders, and the correlation between substance use/abuse and the commission of crimes. In the 1990s, a different and critical emphasis focused on substance abuse among victims, primarily those who are victims of or witnesses to domestic violence and child abuse.

Current research suggests the need for greater attention to the issues of substance abuse among crime victims and those who serve them. The use, abuse, or dependency of victims on legal (alcohol and prescription drugs) or illegal (illicit drugs) substances may precede the criminal activity, occur during the commission of a crime, or develop after the crime has occurred, most often as a delayed reaction associated with trauma. Increased understanding of the linkages between substance abuse and victimization can lead to more effective prevention efforts and improved responses by victim assistanceand justice professionals, mental health providers, and substance abuse treatment professionals to help individuals cope with the trauma of victimization.

These are sensitive concerns that people are aware exist but are hesitant to discuss or address in a meaningful way. Both victimization and substance abuse carry weighty societal stigmas, and when the stigma of victimization is combined with the stigma of substance abuse, victims can fall prey to a "double-edged sword." Moreover, substance use or abuse by victims may be viewed as a "reason" for their victimization, which is an erroneous and potentially harmful assessment within the contexts of both criminal/juvenile justice and mental health services.

While victim service providers should not be expected to be experts in substance abuse assessment and treatment, they should be familiar with professionals and agencies that possess such knowledge and skills. Collaboration is key to preventing and responding to victims who develop dependencies or abuse alcohol and other drugs as a means of coping with the trauma of victimization.

Research that specifically addresses substance abuse and victimization is limited at the present time. This chapter raises issues relevant to substance abuse and victimization in a predominantly exploratory fashion, with emphasis upon collaborative strategies for victim service providers in conjunction with allied victim-serving professionals.

The Need for Research and Services Evaluation

The interface between substance abuse, mental health, and victimization was first addressed in 1985 by a colloquium convened by the National Institute of Mental Health (NIMH) and the National Organization for Victim Assistance (NOVA). The Final Statement of the Assessment Panel from a Services Research and Evaluation Colloquium specifically addressed substance abuse as "an area in victim services in need of further research and services evaluation":

Research is needed that can assist in the development of more effective means of treating substance abuse by crime victims. Such research may show that treatment strategies need to differ according to whether victim involvement in substance abuse preceded the crime event, developed soon after the crime event, or emerged as a delayed reaction to stresses induced by the crime event. On the question of the role of substance abuse in the development of posttraumatic stress disorder, there appears to be little research on the relationship between substance abuse and the development or treatment of PTSD prior to the decision to seek treatment.

There are a number of research implications which require investigation. The major issues include, but are not limited to, the role of substance abuse in both the victim, as well as the victimizer. National data indicate that a large percentage of persons who commit crimes have drug or alcohol problems.

Another issue is the use, either appropriate or inappropriate, of drugs or alcohol in self-medication to reduce stress and anxiety. Additionally, for those individuals who do develop PTSD, a careful review of the past and current substance use/abuse patterns needs to be undertaken. . . .

. . . With regard to children, racial groups, ethnic groups and other minority groups, specific research is required which examines the role of substance use/abuse with victims in general and PTSD specifically.

The NIMH/NOVA recommendation has been addressed, particularly in the past decade, with research, model policies, and training programs that address substance abuse and victimization. Some are highlighted in this chapter.

Serving Victims with Drug and Alcohol Abuse

Crime victims should not be "labeled" with mental disorders by victim service professionals and allied professionals. Victims and their advocates will not accept a psychiatric diagnosis as a substitute for their private struggle against a crime that brought horror and helplessness to their lives. Crime victims may be neglected by our culture-and stigmatized by those who are insensitive to or unaware of their vulnerability to be "retraumatized." Their responses need to be respected as adaptive and protective-not as pathologic.

There are, however, psychiatric disorders that are clearly reactive to the trauma of the crime to which anyone would be vulnerable. These are not primarily genetic or neurochemical "disorders" as is the case with some major psychiatric disorders. Instead, the horror and helplessness of being victimized have somehow "triggered" a persistent pattern of distress which may be viewed as an exaggerated adaptive and protective response. It is important to recognize that these reactive disorders to the trauma of being victimized would occur in many people if they were not able to release themselves from the chaos, trauma, and potential vicious cycle of maladaptive responses caused by the victimization. People can become "disordered" if forced to live in chaos. That is the experience of some crime victims-their minds cannot rest from the chaos created by the crime.

There are several psychiatric disorders (major depression, anxiety, posttraumatic stress disorder [PTSD], and substance abuse) that commonly occur in combination after a severe stress, including the stress of a crime. PTSD refers to a characteristic set of symptoms that develop after exposure to a traumatic event or an extreme stressor, including: persistent re-experiencing of the events; persistent avoidance of things associated with the traumatic event or reduced ability to be close to other people and have loving feelings; and persistent symptoms of increased arousal such as sleep difficulties, outbursts of anger, difficulty concentrating, constantly being on guard, and extreme startle response. (For a more complete discussion of mental health issues and crime victims, see Chapter 6.1, Trauma Assessment and Intervention.)

Recent studies have shown a particularly potent and maladaptive combination of PTSD and substance abuse in some crime victims. To understand the problem of substance abuse in crime victims, one must begin by understanding how it is related to trauma and PTSD. To lay the groundwork for understanding this relationship, a brief overview of (1) clinical definitions pertaining to substance abuse, and (2) research relevant to substance abuse and victimization, is in order.

Clinical Definitions

There are important and significant differences between substance "abuse," "dependence," and "use" that should be understood in the context of both research and practical applications in victim assistance:

DEFINITIONS FOR SUBSTANCE-RELATED DISORDERS

In the Diagnostic and Statistical Manual-IV (DSM-IV) published by the American Psychological Association (1994), "substance-related disorders" include disorders related to the taking of a drug of abuse (including alcohol), as well as disorders related to the side effects of a medication and to toxin exposure. The substances discussed in this section are grouped into eleven classes: alcohol; amphetamine or similarly acting sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opioids; phencyclidine (PCP) or similarly acting arylcyclohexylamines; and sedatives, hypnotics, or anxiolytics.

DSM-IV CRITERIA FOR SUBSTANCE DEPENDENCE

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same twelve-month period:

• Tolerance, as defined by either of the following:
  • A need for markedly increased amounts of the substance to achieve intoxication or desired effect.

  • Markedly diminished effect with continued use of the same amount of the substance.

• Withdrawal, as manifested by either of the following:
  • The characteristic withdrawal syndrome for the substance.

  • The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

• The substance is often taken in larger amounts or over a longer period than was intended.
• There is a persistent desire or unsuccessful efforts to cut down or control substance use.
• A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), to use the substance (e.g., chain smoking), or to recover from the effects of the substance.
• Important social, occupational, or recreational activities are reduced or given up because of substance use.
• The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

DSM-IV CRITERIA FOR SUBSTANCE ABUSE

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a twelve-month period:

• Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).



• Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use).



• Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct).



• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights).

DEFINITIONS FOR ALCOHOL USE

• Current use. At least one drink in the past month (includes binge and heavy use).



• Binge use. Five or more drinks on the same occasion at least once in the past month (includes heavy use).



• Heavy use. Five or more drinks on the same occasion on at least five different days in the past month (SAMHSA 1998)



• Moderate Drinking. Two drinks a day for men, and only one drink a day for women and anyone age 65 and over (NIAAA 1992).

Research Findings Relevant to the Abuse of Alcohol and Other Drugs and Victimization

GENERAL SUBSTANCE ABUSE

A substantial number of adults and youth in America are dependent upon or abuse alcohol and other drugs. The cost of alcohol and drug abuse to society in terms of public and mental health, as well as economic costs, is staggering:

• At least 4.5 million women are alcohol abusers or alcoholics; 3.1 million regularly use illicit drugs; 3.5 million misuse prescription drugs; and 21.5 million smoke cigarettes (Reid 1996).



• Of the 23.1 million persons who used an illicit drug in the past year, 1.9 million reported some health problem due to their illicit drug use; 3.5 million reported an emotional or psychological problem due to their drug use; and 4.1 million were dependent on an illicitdrug. An estimated 963,000 had received treatment or counseling for their drug use (SAMHSA 1998).



• 9.7 million people were estimated to be dependent on alcohol, including 915,000 youths ages twelve to seventeen. An estimated 1.7 million people (including 148,000 youths) reported receiving treatment or counseling (Ibid.).



• In 1995, the estimated annual cost of alcohol abuse in the U.S. was $166.5 billion, and drug abuse is estimated to have cost $109.8 billion. Alcohol use disorders cost $56.7 billion more than the estimated annual economic cost of illegal drug use (Harwood et al. 1998).



• Alcohol abuse was involved in over 70 percent of substance abuse treatment admissions in 1997, and about half of people entering treatment reported alcohol as their primary drug of abuse (SAMHSA 1999b).



• The 1997 National Treatment Improvement Evaluation Study of addiction treatment effectiveness found a 70 percent reduction in the number of clients reporting problems with alcohol in the year following treatment (SAMHSA 1997a).

DOMESTIC VIOLENCE AND SUBSTANCE ABUSE

Research indicates a significant correlation between substance abuse and domestic violence victims. The presence of alcohol or other drugs in domestic violence incidents raises important concerns about victims' safety and their capacity to respond to threats or acts of violence. It does not mean, however, that the presence of such substances caused the abuse to occur. Moreover, substance abuse is sometimes wrongly considered by law enforcement, justice professionals, substance abuse treatment professionals, and batterers intervention professionals to be a causal, as opposed to correlating, factor in domestic violence within the framework of both the abuser and the victim.

The following facts represent several findings about the correlation between substance abuse and domestic violence:

• Being a victim of domestic violence is associated with an increased incidence of substance abuse (Miller, Downs, Testa, and Panek 1990, as cited by Goldberg 1995).



• Approximately 50 percent of all female alcoholics have been victims of domestic violence (Miller and Downs 1993).



• In a research study conducted by medical personnel and researchers who accompanied police in Memphis as they responded to nighttime calls for assistance, 42 percent of victims of domestic violence used alcohol or drugs on the day of the assault according to their own reports or reports of family members. Fifteen percent had used cocaine, and about half of those using cocaine said their batterers had forced them to use it (Brookhoff 1997).



• In a study of murder in families, half of the victims in spouse murders had consumed alcohol before the crime (Dawson and Langan 1994).



• Having a partner who abuses chemicals is more likely to generate substance abuse in women (Wilsnack and Wilsnack 1991, as cited by Goldberg 1995).
• A batterer may also be the victim's drug supplier, which complicates the situation (SAMHSA 1997b).



• Drug- or alcohol-involved victims of partner abuse may not be taken as seriously by professionals (Stark and Flitcraft 1991). Substance abuse may be viewed as a reason for the abuse, and this is often an inaccurate assessment (Kurz and Stark 1988).



• 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 (SAMHSA 1997b).

SEXUAL ASSAULT AND SUBSTANCE ABUSE

Alcohol and other drugs are often present in both victims and offenders of sexual assault. Similar to crimes of domestic violence, this can wrongly be construed as a causal rather than a correlating factor to the offense. There is overwhelming evidence that victims of sexual assault and rape are much more likely to use alcohol and other drugs to cope with the trauma of victimization than nonvictims:

• Rape victims were 5.3 times more likely than nonvictims to have used prescription drugs nonmedically (Kilpatrick, Edmunds, and Seymour 1992).



• Rape victims were 3.4 times more likely to have used marijuana than nonvictims (Ibid.).



• Victims of rape were six times more likely to have used cocaine than their counterparts who were not raped (Ibid.).



• Compared to women who had not been raped, rape victims were 10.1 times more likely to have used "hard drugs" other than cocaine (Ibid.).



• Drinking by the victim, the assailant, or both is involved in over half of sexual assaults (BJS 1998).

SUBSTANCE ABUSE, ADOLESCENTS, AND ADOLESCENT VICTIMS

Research reveals that adolescents who use and abuse substances are more prone to serious psychological and behavioral problems. Youth who are victimized by physical or sexual abuse are much more likely to develop chemical dependencies:

• In a nationally representative sample, youth who experienced either physical or sexual abuse or assault were twice as likely as their nonvictimized peers to report past-year alcohol or other drug abuse or dependence (Kilpatrick et al. 2000).



• This same national study found that youth who witnessed violence (including domestic violence and violence among their peers) were three times as likely to experience substance use disorders (Ibid.).



• Among 12-to-17-year-old current drinkers, 31 percent had extreme levels of psychological distress, and 39 percent exhibited serious behavioral problems (SAMHSA 1999a).

In 1995, the National Crime Victims Research and Treatment Center at the Medical University of South Carolina conducted the first-ever National Study of Adolescents (NSA) that examined victimization, mental health, and substance abuse issues among teenagers. A telephonic survey of 4,023 adolescents ages twelve to seventeen determined that, based on U.S. Census 1995 estimates of the U.S. population of adolescents of 22.3 million: 1.8 million adolescents have been sexually assaulted; 3.9 million have been physically assaulted; 2.1 million have been subjected to physically abusive punishment; and 8.8 million have witnessed violence. Significantly, over one half of adolescent victims said that their first use of substances occurred after the year they were first assaulted (53.8% for alcohol, 47.8% for marijuana, and 63.5% for hard drugs).

Much of the knowledge gained from the NSA raises crucial issues that cross over lines of research, policy, and practice. As such, collaborative efforts to address these concerns should be encouraged among professionals in the fields of victim assistance, criminal and juvenile justice, mental health, and substance abuse. Among the many NSA recommendations for public policymakers are three that are specific to youth victimization and substance abuse:

1. The NSA found that many violence victims had comorbid PTSD and substance use/abuse/dependence problems, and that victimization is an important pathway to substance abuse and delinquency. These findings imply that effective mental health treatment for adolescent victims is important not only to relieve post-victimization mental health problems, but also to prevent future substance use and delinquent or criminal behavior. Therefore, mechanisms should be developed to ensure that funding is available to provide mental health counseling to adolescent victims who need it, irrespective of their ability to pay or whether they qualify for crime victim compensation.
2. Policies should promote the primary and secondary prevention of child victimization as part of a comprehensive plan for preventing youth substance use and delinquency. Effective and efficient prevention begins as early as possible in the risk factor chain. Results of this study suggest that victimization and its effects are strong and primary correlates with youth substance abuse and delinquency, even when controlling for other risk factors. Therefore, prevention of these early primary experiences will contribute to preventing these secondary problems.
3. Policies should encourage early identification of and intervention with victimized children (secondary and tertiary prevention). All child victimizations cannot be prevented. However, if more can be recognized and effective interventions provided to child victims, it is likely that at least some of the long-term negative effects leading to substance use and delinquency can be mitigated. Therefore, policies should encourage proactive-rather than reactive-approaches to identifying victimized youth, and should promote effective and rapid intervention for victimization-related problems that are related to the development of substance use and delinquency.

The NSA's emphasis on collaborative initiatives to respond to substance use and abuse among adolescent victims extended to practitioners as well, with three important recommendations:

1. Mental health professionals who work with children and adolescents should be informed about the high rates of victimization that occur among children and adolescents, and about the extent to which victimization serves as a risk factor for PTSD, substance use/abuse/dependence, and delinquency. In addition, they should be encouraged to screen for victimization experiences among child and adolescent clients. Substance abuse treatment programs for adolescents should do likewise.
2. Victim assistance professionals in the criminal and juvenile justice systems should establish relationships with mental health professionals who are knowledgeable about crime victims' mental health issues. Criminal and juvenile justice practitioners and victim service providers should establish or enhance professional relationships with substance abuse professionals in order to effectively address issues of substance use, abuse, and dependency among adolescents and children who have been victimized.
3. Mental health programs dealing with child victims should incorporate substance abuse and delinquency prevention components into their protocols. While mental health programs designed to reduce common psychological problems associated with child victimization are common, few include specific interventions for reducing substance use onset, substance abuse, or conduct and delinquency problems. Given the findings of the NSA, mental health programs should incorporate these prevention components as a regular part of their victimization treatment protocols (Kilpatrick et al. 1998).

SUBSTANCE ABUSE AND CHILD VICTIMS

Research reveals that when alcohol and other drugs are present in family environments, the likelihood of child victimization increases. A significant proportion of substance abusing mothers who are involved in child abuse and neglect cases reports childhood victimization:

• According to the National Committee to Prevent Child Abuse (NCPCA), 81 percent of all states in 1995 listed substance abuse as one of the primary problems characterizing child protective service cases (NCPCA 1996).
• In a recent study of substance-abusing women who were admitted for services sponsored by the New York City Administration for Child Services-the public agency responsible for responding to reports of child abuse or neglect-24 percent of the women reported having been sexually abused and 45 percent reported having been physically abused in their childhoods. Of those who reported experiencing childhood sexual or physical abuse, 82 percent were victimized by relatives; 16 percent were victimized by someone they knew; and 2 percent were victimized by strangers (Kang et al. 1999).
• Risk factors associated with substance abuse disorders include histories of childhood abuse and neglect (Carlson 1997). In fact, a recent study found that adults with histories of child abuse have an increased likelihood of heart disease, cancer, and chronic lung disease and greater risk for alcoholism, drug abuse, depression, and attempted suicide (Felitti et al. 1998). These findings emphasize the importance of comprehensive screening and assessment for individuals with substance abuse disorders and client access to adequate health care (CSAT and SAMHSA 2000).

SUBSTANCE ABUSE AND HOMICIDE

Research reveals that the sudden and violent loss of a loved one can increase one's propensity to use or abuse substances in order to cope with the trauma resulting from an unexpected and emotionally devastating victimization.

In "Bereavement After Homicide: A Comparison of Treatment Seekers and Refusers" (1995), Dr. E. K. (Ted) Rynearson, Director of Separation and Loss Services of the Virginia Mason Medical Center in Seattle, cites several recent well-controlled studies that have demonstrated the co-occurrence of trauma and bereavement responses with substance abuse (15-20%). The explanation for this co-occurrence is presumably due to multiple factors, including: (1) a number of symptom criteria overlap and (2) an increased risk of the development of psychiatric disorders pursuant to the occurrence of a traumatic event, such as homicide. It is critical for victim advocates and allied professionals to be aware of the high incidence of coexistent psychiatric disorders following trauma or loss. It is particularly important for advocates to be aware of symptoms that indicate the need for appropriate mental health, substance abuse, or other treatment referral.

Victimization, PTSD, and Substance Abuse: A Strong Correlation

SUBSTANCE ABUSE AS A PRE-VICTIMIZATION FACTOR

There is considerable empirical evidence that use of alcohol and other illicit drugs increases one's likelihood of being victimized:

• Women's use of drugs nearly doubled the likelihood they would experience an assault when compared with those who did not use drugs. The greatest risk was to women who used drugs and had experienced an assault previously (Kilpatrick et al. 1997).



• The odds of being assaulted for hard drug users and marijuana users were 5.06 and 1.46 times those of nonusers, respectively (Cottler et al. 1992).



• In a study of an urban population of young adults, the odds of experiencing traumatic events in individuals with alcohol or drug use problems were 1.47 and 1.79 times those of individuals without such substance use problems, respectively (Breslau et al. 1991).



• Alcohol and drug abusers are about 1.5 times as likely to experience traumatic events as nonusers (Kessler et al. 1995).



• A 1993 study of emergency room trauma found that patients with violence-related injuries were at least twice as likely to have been drinking than patients with injuries from other causes (Ibid.).

There is clearly a significant body of research that shows alcohol and other drugs present in the systems of perpetrators and some victims during the commission of many crimes. As noted earlier, for victims of crime, this creates a "double-edged sword" in which the stigma of victimization is exacerbated by the stigma of being under the influence of some type of chemical. This double stigma can often affect the provision of treatment and the response of the criminal justice system.

It is critical to note that the research cited above supports substance abuse among some victims at the time of the crime as a correlating, and not a causal, factor. (This distinction is discussed in detail from a research standpoint in Chapter 17, Research and Evaluation.) In environments where alcohol or other substance abuse is occurring, the likelihood of criminal activity may be greater. However, a person's use or abuse of substances in no way equates to a basis for blaming that person for his or her victimization by another. Rather, substance use or abuse impairs an individual's perception, judgment, and mental faculties, and often may then have a detrimental effect on his or her ability to maintain personal safety. Because of the devastating effects of societal blaming of victims and substance abusers, this problem needs to be acknowledged and thoroughly addressed by victim advocates.

Stigma against chemically-dependent women. Societal and individual attitudes about and stigma against women who are chemically dependent detrimentally affect the access to and provision of all types of supportive services. Furthermore, most treatment modalities have been based on the needs of male substance abusers whose histories and recovery-related issues are likely to be significantly different from women. The stigma against chemically dependent women can be seen in the following issues (Goldberg 1995):

• Cultural stereotypes of women perpetuate the idea that it is worse for a woman to get drunk (or use drugs) than for a man, with the implication that she may be less deserving of help.



• Most substance abuse treatment approaches are based on models developed for men. Women needing treatment often also have the responsibility of caring for children, making participation in treatment programs (especially residential programs) more difficult.



• Substance abusing women tend to have fewer economic resources for obtaining treatment. Also, they are more likely to have complicating health needs, including pregnancy.



• Generally, women take a shorter period of time than men to go from occasional substance use to abuse, and thus begin to suffer social and physical consequences.



• The criminalization of substance abuse during pregnancy has made many pregnant substance abusing women reluctant to seek treatment.



• Having a substance abuse problem may exclude victims from domestic violence services.



• Women in recovery are likely to have a history of violent trauma and are at high risk of being diagnosed with PTSD (SAMHSA 1997b).

The stigma against chemically dependent women is much worse when they are also the victims of domestic violence; as noted above, this is true for 50 percent of all chemically dependent women. Despite this significant correlation between domestic violence and chemical dependency, hardly any research has been conducted and little has been written about the need to develop intervention strategies that simultaneously address both the batterer's substance abuse and domestic violence. Even though there is often substance abuse group treatment for men indomestic violence programs, most of it is traditional substance abuse treatment with little focus on the domestic violence issues. Similarly, little has been done to assist battered women with chemical dependency problems in order to meet their needs for both safety and sobriety. Neither system is currently equipped to provide the range of services needed by battered women and batterers who are chemically dependent. The issue of cross-training and integrated assessment will be discussed below in "Responses for Victim Interventions and Assessment."

In the addictions treatment system, misinformation often leads counselors to understand and respond to domestic violence through the use of an addiction's "hard love" framework, an approach that has particularly harmful consequences for battered women. Such an approach identifies battering either as a symptom of abuse or addiction-or as an addiction itself. The interventions that follow are based on the erroneous belief that correlation equals causation. The significant correlation between substance abuse and domestic violence denotes some connection between the two, but gives no clear picture of causation; it is entirely possible that some third factor is causing this relationship. Much research is needed in this area before conclusions can be drawn about this relationship. Even if there is shown to be some type of causation, this would indicate that a new paradigm of treatment is necessary to effectively treat both issues simultaneously.

This erroneous belief of causation often leads to interventions based on a number of harmful, false assumptions by substance abuse counselors:

• Alcohol use or alcoholism causes men to batter. It may predispose a person to violence, but the causes of any crime are always multiple and complex. The presence of two problems simply means both need to be treated-not excused.



• Alcoholism treatment alone will adequately address the domestic violence issue. Traditional treatment almost never addresses this issue directly; only in the discussion of taking full responsibility for "the wreckage of the past" is it generally addressed.



• Battered women are "co-dependent" and thus contribute to the continuation of the abuse. This mixes and corrupts concepts. In traditional alcohol treatment, a battered woman may be "co-dependent" regarding the substance abuse. This concept has nothing to do with domestic violence, and it was never meant to be used to remove the responsibility for the substance abuse (or any other problem, such as battering) from the substance abuser.



• Addicted battered women must get sober before they can begin to address their victimization. Both issues must be treated simultaneously. (Note the National Institute of Drug Abuse Principle #3 on page 20.)

SUBSTANCE ABUSE AS A POST-VICTIMIZATION FACTOR

Research reveals that the trauma of victimization leads a considerable number of victims to use alcohol and other drugs as a means of coping with the trauma:

• Nearly nine in ten alcoholic women were physically or sexually abused as children (Miller and Downs 1993).



• Exposure to sexual or physical abuse often contributes to the development of a variety of short- and long-term psychological disturbances, for example, PTSD, depression, anxiety, anger, self-destructiveness, suicidal behavior, low self-esteem, and difficulties with interpersonal relationships (Gil-Rivas, Fiorentine, and Anglin 1996).



• Women who have been assaulted are twice as likely as nonassaulted women to use or abuse substances (Kilpatrick et al. 1997).



• Of the adult women receiving substance abuse treatment in the 1999 National Treatment Improvement Evaluation Study, 43 percent reported having been sexually abused. Significantly more of these sexually abused women also reported physical abuse, mental health problems, suicide attempts, and poor general health-all of which could be potential obstacles to successful substance abuse treatment. In spite of these additional problems, sexually abused women did as well in treatment as nonabused women (CSAT October 1999).



• When a highly specific diagnostic instrument was employed to assess victimization history among substance abusers, 65 percent of the women and 16 percent of the men reported a history of sexual assault (Grice, Dustan, and Brady 1992).

There are several comprehensive and well designed community surveys that have documented the strong prevalence of PTSD in crime victims. The most recent (Breslau et al. 1998) surveyed over 2,000 young adults in metropolitan Detroit to measure the frequency and recovery rate of PTSD responses after all kinds of trauma. The analysis confirmed the findings of another large community survey (Resnik et al. 1993).

Findings indicated the following:

• Crime victims who suffered more brutal trauma showed higher frequencies of PTSD: rape (49%), torture (54%), badly beaten (32%), and sexual assault (24%).



• Overall, assaultive violence of all kinds had the highest risk of PTSD (21%) compared with other traumas (9%).



• Women's risk of PTSD following exposure to any trauma was twice as high as men's.



• Twenty-six percent of PTSD cases had improved by six months, 40 percent by one year, and 50 percent by two years. In more than one-third of the cases, PTSD persisted for more than five years.



• Women who had been directly exposed to trauma were a highest risk for nonrecovery.

Drug and alcohol abuse is strongly associated with PTSD. A recent article (Stewart 1996) presents a critical review of over 300 clinical studies that demonstrate a highly positive correlation between trauma, PTSD, and alcohol abuse.

• Alcohol and drug abuse is the most prevalent of all psychiatric disorders in the United States-16 percent of the population.



• Alcohol abusers report three times as much trauma as nondrinkers.
• Studies show a much stronger association with PTSD and alcohol abuse than with trauma exposure alone.



• PTSD signs and symptoms precede the development of alcohol abuse, suggesting that PTSD somehow promotes abuse.



• Studies show a high degree of coexistence between PTSD and alcohol abuse-40 to 70 percent of subjects with PTSD will also have a diagnosis of alcohol abuse.

Victimization, PTSD, and Substance Abuse: A Preliminary Conceptual Model

Because of their exposure to trauma, crime victims are at high risk of developing PTSD (20% or one of every five victims-a conservative average) and at additional risk of abusing drugs and alcohol (three or four times the normal prevalence) if the PTSD persists-as it will for over one-third of the cases. Extrapolating from these frequencies brings the stark realization that many thousands of crime victims are at high risk for presenting with the comorbid disorders of PTSD and alcohol abuse. If they remain untreated, these absolute numbers would be accumulative.

Research from the National Center for PTSD (1999) clearly demonstrates that PTSD and alcohol abuse is potentially a very serious problem for crime victims and their families:

1. PTSD and alcohol problems often occur together. People with PTSD are more likely than others of similar background to have alcohol use disorders both before and after being diagnosed with PTSD, and people with alcohol use disorders often also have PTSD.
• 25 to 75 percent of survivors of abusive or violent trauma report problematic alcohol use.
• 10 to 33 percent of survivors of accidental, illness, or disaster trauma report problematic alcohol use, especially if troubled by persistent health problems or pain.
• Being diagnosed with PTSD increases the risk of developing an alcohol use disorder.

2. Alcohol problems often lead to trauma and also disrupt relationships. Persons with alcohol use disorders are more likely than others of similar background to experience psychological trauma and to have problems with conflict and intimacy in relationships.
• Women exposed to trauma show an increased risk for an alcohol use disorder even if they are not experiencing PTSD.
• Women with problematic alcohol use are more likely than other women to have been sexually abused at some point in their life.
• Men and women reporting sexual abuse have higher rates of alcohol and drug use disorders than other men and women.
• Problematic alcohol use is associated with a chaotic lifestyle, which reduces family emotional closeness, increases family conflict, and reduces parenting abilities.
3. PTSD symptoms often are worsened by alcohol use. Although alcohol can provide a feeling of distraction and relief, it also reduces the ability to concentrate, to enjoy life and beproductive, to sleep restfully, and to cope with trauma memories and stress. Alcohol use and intoxication also increase emotional numbing, social isolation, anger and irritability, depression, and the feeling of needing to be on guard (hypervigilance).



• Alcohol use disorders reduce the effectiveness of PTSD treatment.
• Many individuals with PTSD experience sleep disturbances (trouble falling asleep or waking up after they fall asleep). When a person with PTSD experiences sleep disturbances, using alcohol as a way to "self medicate" becomes a "two edged sword": it may help with one sleep-related problem but exacerbate another.

• Alcohol use may decrease the severity and the number of frightening nightmares commonly experienced in PTSD, but may continue the cycle of avoidance found in PTSD. When a person withdraws from alcohol, nightmares often increase.