Substance Abuse Treatment- Batterer Intervention Integration Project. Background

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1 Substance Abuse Treatment- Batterer Intervention Integration Project Background The eventual goal of the Substance Abuse-Batterer Intervention project is to ensure that individuals who have substance use disorders and use violence in relationships will be identified and receive services that address both of these issues appropriately in a coordinated way. As a preliminary step, it was decided to conduct focus groups with substance abuse treatment providers in order to collect information on 1) their current understanding of intimate partner violence and its intersection with substance use disorders 2) their current knowledge and experience of certified batterer intervention programs in Massachusetts 3) the obstacles they perceive to assessing for perpetration of intimate partner violence in substance abuse treatment and referring to certified Batterer Intervention Programs and 4) what they would need in order to be able to implement identifying appropriate clients and referring them to Batterer Intervention programs. A secondary goal was to begin a dialogue between the Division of Violence and Injury Prevention Batterer Intervention Programs and providers of substance abuse treatment. Funding from the Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment was awarded in July 2011 with a requirement that the focus groups be conducted by August 26, 2011 and a report written by September 2, Focus Group Plan The plan for the focus groups was developed with input from staff from the Massachusetts Department of Public Health/Bureau of Substance Abuse Services (BSAS), the Institute for Health and Recovery (IHR), and Robert Haynor of the Division of Violence and Injury Prevention Batterer Intervention Programs (DVIP/BIP). BSAS agreed to invite the participants, schedule the meeting rooms and provide refreshments. IHR agreed to conduct the focus groups, document the focus groups, and develop a report. DVIP/BIP agreed to develop and conduct a brief informational presentation on Batterer Intervention and its relevance for substance abuse providers. The content of the focus groups was as follows: Welcome and Introduction- BSAS or IHR (10 minutes) Exploration of participant beliefs/opinions using anonymous polling technology- IHR (30 minutes) Informational presentation-dvip/bip (20 minutes) Overlap of substance use disorders with perpetration of intimate partner violence 1

2 Principles and content of Batterer Intervention Effectiveness of Batterer Intervention Victim safety and Batterer Intervention Focus group questions-ihr (60 minutes) Have any of you ever referred a client to Batterer Intervention? How did it go? What might have made it better? Have any of you ever collaborated with Batterer Intervention providers in any way? What was that like? What would have made it better? What do you think the barriers or obstacles would be to assessing for use of violence in relationships within substance use disorder treatment programs? What do you think you would do now if a client told you he or she was using violence in an intimate relationship? What would you need to be comfortable assessing for the perpetration of violence in our programs? (probe for specifics) What would you need to be more comfortable referring clients to Batterer Intervention? (Probe for specifics). Focus Group Implementation Although it was originally hoped that there would be a focus group in each of the 5 Public Health Regions of the state, due to scheduling difficulties only four focus groups were conducted. They were: August 22, :00-4:00 Central Massachusetts Region West Boylston, MA August 23, :00-12:00 Metro Boston and Southeast Regions Canton, MA August 24, :00-12:00 Northeast Region Tewksbury, MA August 25, :00-4:00 Western Massachusetts Region Northampton, MA In spite of relatively short notice, there was good attendance. Programs were asked to send a supervisor or a program director if possible, but direct care workers were welcome if a supervisor was not available. The Central Massachusetts focus group had 22 participants, all of whom were supervisors or program directors. The Metro Boston and Southeast focus group was attended by 33 supervisors, 8 direct care workers, and 1 individual who did not indicate a title. The Northeast focus group was attended by 23 supervisors, 3 direct care workers, and 1 individual who did not indicate a title. The 2

3 Western Massachusetts focus group consisted of 13 supervisors and 5 direct care workers. A total of 109 treatment providers attended focus groups. Anonymous Polling Focus Group Findings Participants were able to respond to each statement on a 7 Point Likert Scale ranging from to. The percentage of participants who chose each response was then posted on a PowerPoint slide. (A table depicting the percentage of participants who chose each response by region appears at the end of this report.) Participants were then asked to discuss the reasoning behind their choices. Statement 1- People who have substance use disorders and also use violence in relationships will stop using violence if they stop using substances. Overall, 71% of participants responded on the side (, or, 22% on the side (,, or ) and 8% were Neutral. Those on the side argued that these were separate problems and that violence was a learned behavior with its own history that had to be addressed separately. Those on the side sometimes mentioned observing individuals who did stop being violent once they stopped using, and sometimes argued that it would depend on the individual and the cause of the violent behavior. Answers appeared to be influenced by whether participants believed the question referred specifically to violence that was based on power and control, or whether they believed that the question did not include enough information to separate out power and control in a relationship from a person being violent in general. Some participants indicated that the violence might get worse in early recovery, while others believed that abstinence would reduce the violence but would not stop it. One participant pointed out that if a person were truly in recovery they would be examining all of their behavior, including the use of violence. Statement 2-If I were to speak with my clients about their use of violence in intimate relationships it would have a negative effect on our relationship Overall, 85% of participants answered this question on the side, 6% were Neutral, and 9% answered on the side. The discussion centered around the relationship between the person asking and the client and on the way the questions were asked. That is, if trust was already established and the questions were asked in a nonjudgmental way, most providers felt this would not be a problem. Some felt that even in an initial intake, it could be done without a problem if done in a sensitive way. Those who agreed with the statement were concerned about questions being asked before trust was established or those clients who had not acknowledged the problem to themselves. They suggested that it might be more appropriate to provide psycho-education about intimate partner violence for all clients, rather than identifying those who were using violence in relationships. However, some on the 3

4 side argued that it was a good idea to ask the questions as a way to indicate to clients that it would be safe to talk about, even if clients do not necessarily disclose. Statement 3- Using violence in an intimate relationship might be a trigger for relapse in some clients Overall, 89% of participants responded on the side to this statement, while 6% were Neutral and 6% were on the side. Discussion on the side centered around the fact that many clients use substances to deal with strong feelings so that either the feelings that fuel the violence or the feelings that follow the violence could be triggers for relapse. Others wondered whether the violence could, in fact, be an early warning sign of relapse;, that is, violence might be one of the behaviors that a client would revert to when his recovery was slipping. No participants argued that violent behavior would not be somehow connected to a client s substance use. Statement 4- Addressing intimate partner violence with clients who use violence in relationships and are in substance abuse treatment might put victims at risk About half (51%) of the responses to this statement were on the side, while 15% were Neutral and 33% were on the side. There was much controversy about this issue. Those on the side expressed concern that the client might blame the victim for the issue coming up, and/or might become more controlling as the problem was addressed. Others suggested that the level of care might be an important variable, for example, whether the client went home to or had contact with the victim. Another concern was that information might be revealed that had to be reported, such as child abuse or something that activated duty to warn and that could escalate violence. It was also suggested that contacting the victim and ensuring his or her safety and offering resources might be important. Participants believed it was important for the client to be told why the questions were being asked, and for there to be clear guidelines in place for responding to disclosure. Participants on the side argued that the risk already existed for the victim and would not be changed by addressing it, especially if it were done skillfully. Some believed that the more people knew about the violence, the safer the victim might be. Statement 5-Not addressing intimate partner violence with clients in substance abuse treatment who use violence in relationships might put victims at risk Overall, 75% of participants responded to this statement on the side, 17% were Neutral and 11% were on the side. Those on the side often stated that by not asking about this providers were being a silent witness and giving tacit permission for the behavior, and that it was a missed opportunity to work with the whole person, using clinical skills, which is what treatment providers are expected to do. Those on the side argued that it depended on the modality of treatment and the resources available, and that not addressing something would not make it worse, so again the risk to the partner was considered to be pre-existing. One participant expressed concern that addressing it within substance abuse treatment might not communicate to clients that these are separate issues. 4

5 Statement 6- It would be a good idea for substance abuse treatment providers to assess for use of violence in intimate relationships and refer to Batterer Intervention Overall, 84% of participants responded on the side, 5% were Neutral and 6% d. Those on the side argued that it was a recovery issue that needed to be addressed. Most providers seemed to agree that assessing for violence was a good idea, and that raising the issue was a good idea from a motivational interviewing perspective. However, one participant was concerned that the issue not be raised in a way that made the violence seem acceptable. Many providers were not certain that Batterer Intervention should be the only option in terms of addressing violence. Some providers believed that there were many causes for the use of violence and that there should be different interventions for different individuals. Many objected to the name Batterer Intervention, believing it was too stigmatizing. Some wanted to refer to Batterer Intervention because they are the experts, but others wanted to consider ways to address the issue within substance abuse treatment. Current s to Disclosed or Observed Intimate Partner Violence Within Treatment Of 109 participants, approximately 19 had made referrals to Batterer Intervention. Most of those that had made referrals felt that the outcome had been positive. One participant specifically mentioned the cultural competence of the programs as a positive factor. Some participants reported mixed results, depending on the readiness of the client. Providers who reported negative outcomes stated a variety of concerns. One participant reported that the program refused the referral because it was not a court or Division of Children and Families referral. One participant referred a woman to a men s program and reported that the woman was re-traumatized by the experience. Another participant stated that the client was uncomfortable and did not identify with the other clients in the Batterer Intervention Program because they were glorifying violence. A number of participants felt that the outcome of referrals would be improved if there were more communication in both directions between the Batterer Intervention Program and the substance abuse treatment program. Other than referral to Batterer Intervention, programs reported a variety of responses when clients disclosed or were observed engaging in intimate partner violence. A number of participants discussed exploring and addressing the violence in individual counseling sessions or referring to outpatient therapy. One participant talked about referring to Batterer Intervention, but if the client refused the referral, continuing to work on engagement and/or working with probation/parole and asking them to mandate the intervention or asking the outpatient therapist to make the referral. Another participant mentioned the use of multidisciplinary teams and supervision to support clinicians working with these particularly complicated clients. Obstacles to Assessing for Perpetration of Violence in Treatment for Substance Use Disorders Some of the obstacles to assessing for perpetration of violence within treatment for substance use disorders are issues that providers are struggling with as an attempt is made to create a comprehensive, integrated system of care. Many clients are struggling with multiple issues and have highly complex needs. As these needs are identified, providers are concerned about how to prioritize these needs. 5

6 Some participants stated that Clients could only participate in a limited number of multiple services at one time, and these services must be coordinated and include mutual communication or clients could become confused or overwhelmed. A client has only so much time and money (or insurance) and multiple needs. Clients often live with families that also have multiple needs and time and money must be spent on them as well. How do providers help a client decide on the most appropriate services to access at a given point in time? Of course, providers have their limits as well. As providers are asked to assess for more and more problems and client needs, the length of intake interviews increases, which increases the burden on staff time with no additional funding. Funding is usually not available for service coordination or for following up to ensure that clients follow through on referrals that are made. These pressures may decrease the quality of the assessment and referral process. It follows that staff are more likely to assess for the issues they themselves have been trained to address or that they believe can be effectively addressed in some way. Some recovering staff may be uncomfortable addressing issues of violence. Some providers believe that it is unlikely that a client will disclose their use of intimate partner violence. Others do not know whether services that address perpetrator violence are accessible or effective. Providers would have to be convinced of the utility of assessment for it to be effectively implemented. Providers were clear that the most important support for implementing assessment for perpetration of intimate partner violence would be a very carefully thought out and developed evidence-based protocol for assessment and referral. The protocol would need to address the following questions in terms of likelihood of disclosure, availability of appropriate intervention, and impact on victim safety. In what levels of care is assessment appropriate? What is the best timing for assessment? What tool should be used for assessment? What are the qualifications and competencies of the person conducting the assessment? What to say to clients about the reasons for asking the questions and what will be done with the information? What are the limits of confidentiality in these circumstances? How should the provider respond when perpetration of violence is identified? Obstacles to Referral to Batterer Intervention Some providers uncertainty about whether or not a batterer intervention program was an appropriate referral for their clients was an obstacle.. Providers believe that there are many reasons why an individual client may be using violence in an intimate relationship. They would prefer to have a variety of interventions (i.e., Batterer Intervention, Anger Management, Outpatient therapy, psychoeducation 6

7 within a substance abuse treatment program, a peer-run group, a safe coping skill-building group) of different lengths and intensities to meet the needs of different clients, and an assessment that helps identify which clients will benefit from each intervention. Providers understand Batterer Intervention to serve only clients who are mandated to participate by the courts. Its length, the requirement for self-pay, even its name were developed in that context. Evidence of its effectiveness comes from research done primarily with court-mandated clients. Some wonder whether this is the appropriate intervention for voluntary clients. The name Batterer Intervention itself is stigmatizing. The 80 hour length of the intervention and the cost are barriers to clients following through on referrals. Providers wonder whether a more flexible intervention, in which clients sign on for periods of several weeks and then can choose to continue or not, would be more likely to attract voluntary clients. An intervention that could be considered medically necessary and billed to insurance would be ideal. In addition, providers wonder about whether there is a philosophical disconnect between batterer intervention and current evidence-based approaches such as motivational interviewing and person-centered care. Perhaps an intervention more in line with that philosophy would be more appropriate for voluntary clients. Providers lack of analysis of power and control as being the framework for understanding domestic violence impacted their identification of obstacles to refer to a batterer intervention program. Providers did seem to believe that certain clients are appropriate for Batterer Intervention. When those clients are identified, an additional obstacle to referral is their lack of knowledge about Batterer Intervention and their lack of relationship with Batterer Intervention providers. The need for a searchable database of services or very good resource lists was frequently mentioned. Those providers who had collaborated with Batterer Intervention providers in the past were quite satisfied with those experiences and more likely to make referrals. Those collaborations included meetings of local providers to discuss responding to violence in the community, on-site training for staff or clients, the availability of telephone consultation, or providing educational materials. It was suggested that Batterer Intervention providers attend substance abuse provider meetings and describe their programs and how referrals can be made. It was also suggested that re-instituting collaborative projects would be another way to build relationships among providers. What Is Needed The main thing that providers felt they needed to implement assessment and referral for perpetration of violence was a good protocol. This would include a good assessment tool, clear guidelines for implementation, and clear guidelines as to how to respond. One suggestion was something like Screening, Brief Intervention and Referral to Treatment, which is used by primary care providers for referral to substance abuse treatment. The protocol includes screening, education for those who are seen as at risk, and referral to treatment for those with more serious problems. A similar protocol, with Batterer Intervention for those with serious problems that did not respond to briefer intervention, is being developed. 7

8 The second identified need was for training for staff that is available in an ongoing way, preferably onsite. It should include: How to introduce the assessment How to explain limits of confidentiality What are the criteria for mandated reporting and duty to warn What to do if a client discloses a crime Potential risks of assessing and how to address them How to identify a perpetrator if both partners use physical violence How to identify all forms of power and control behavior Information about Batterer Intervention including who is an appropriate client for referral Effectiveness of Batterer Intervention Client rights How to address power and control behavior within a substance abuse treatment program Providers also suggested some tools that would be helpful to them; a psycho-educational curriculum about intimate partner violence to use with clients, a self-assessment tool that clients could use to consider whether they have a problem, a means of knowing if a referral is successful, two-way communication with Batterer Intervention providers, and to develop relationships with local Batterer Intervention Programs. Next Steps There was not sufficient time between conducting the focus groups and the writing of this report for the Advisory Council for the Substance Abuse Treatment-Batterer Intervention Integration Project to meet to consider the information that was collected in the focus groups. That meeting will likely take place within the next few months. Possible next steps include: Circulating a report of the focus group findings to substance abuse treatment providers Developing a white paper to distribute to providers in both fields that includes the rationale for integration along with shared language, vision and values Convening a group of providers from both fields to develop draft protocols for assessment, referral and service coordination Developing cross-training for providers based on the findings of this report, the white paper mentioned above, and the draft protocols Piloting the training and the protocol 8

9 age of to Focus Group Poll Statements People who have SUDs and also use violence in intimate relationships will stop using violence if they stop using substances 3% 1% 18% Neutral 8% 10% 37% 24% If I were to speak with my clients about their use of violence in intimate relationships it would have a negative effect on our relationship 1% 1% 7% Neutral 6% 14% 48% 23% Using violence in an intimate relationship might be a trigger for relapse in some clients 26% 53% 10% Neutral 6% 2% 2% 2% 9

10 Addressing intimate partner violence with clients who use violence in relationships and are in substance abuse treatment might put victims at risk 4% 15% 14% Neutral 15% 27% 20% 4% Not addressing violence in intimate relationships with clients in substance abuse treatment who use violence in relationships might put victims at risk 15% 44% 16% Neutral 17% 4% 5% 2% It would be a good idea for substance abuse treatment providers to assess for use of violence in intimate relationships and refer to Batterer Intervention 39% 33% 12% Neutral 5% 5% 0% 1% 10

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