Motivation to change substance use among offenders of domestic violence

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1 Journal of Substance Abuse Treatment 19 (2000) 1 5 Article Motivation to change substance use among offenders of domestic violence Caroline Easton, Ph.D.*, Suzanne Swan, Ph.D., Rajita Sinha, Ph.D. Department of Psychiatry, Yale University School of Medicine, SATU, Box 18, 1 Long Wharf, New Haven, CT 06511, USA Received 17 September 1999; accepted 10 November 1999 Abstract Substance use alone leads to increased rates of violence, reduction in adherence to treatment regimes, and other negative psychiatric sequelae. Given the high rates of co-occurring substance use and family violence-related problems, substance use was assessed among offenders of domestic violence who were mandated by court to attend anger management classes. Rates of substance dependence diagnoses ranged from 33 to 50%, while rates of substance abuse diagnoses ranged from 60 to 75%. This study evaluated the effectiveness of a motivational enhancement intervention on readiness to change substance use. Two anger management groups were targeted to assess substance use, violence, and motivation to change substance use behaviors. One group was randomly chosen to partake in a motivational enhancement intervention session. The comparison group was offered standard anger management classes. Forty-one clients were evaluated for substance abuse and dependence diagnosis using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. A brief motivation to change survey, adapted from the Readiness to Change subscale of the Stages of Change Readiness and Treatment Eagerness Scale was administered pre- and postsession. Results indicate that a motivational enhancement intervention is feasible and effective in increasing readiness to change substance use among domestic violence offenders. The results illustrate the importance of assessing and treating substance use among offenders of domestic violence, as this may be an important indicator for higher dropout rates and reoffenses among this population Elsevier Science Inc. All rights reserved. Keywords: Substance use; Motivation; Family violence; Treatment; Offenders 1. Introduction Rates of co-occurring substance use and domestic violence are high, ranging from 40 to 92%. Brookoff et al. (1997) showed that 92% of assailants used alcohol or drugs on the day of the domestic violence assault, 44% had prior arrests for charges related to violence, and 72% had arrests related to substance use. Other researchers have tried to assess the variables that place individuals at risk of being a perpetrator of family violence. The common risk factor for family violence is substance use. In fact, one of the correlates of domestic abuse is early onset of drug- and alcohol-related problems (Bennett et al., 1994). Substance use is also related to severity of violence. For example, Holtzworth-Munroe and Stuart (1994) found that alcohol and drug use was highest among a moderate to highly violent group of batterers. Rivera et al. (1997) found alcohol and illicit drug abuse to be related to an increased risk of violent death in the home. Despite these high rates of co-occurring substance use and domestic violence, treatment for these problems is often * Corresponding author. Tel.: ; fax: address: caroline.easton@yale.edu (C. Easton). ordered separately. Domestic violence arrests will most likely lead to standard anger management or domestic violence treatments. It is only when the batterers incur repeated offenses and show glaring evidence of substance use that courts refer patients to substance abuse treatment (Collins et al., 1997). There is some initial evidence that when substance use and domestic violence are addressed in an integrated way, there are better treatment outcomes (Goldkamp et al., 1996.) For example, Goldkamp et al. (1996) examined treatment outcomes and same-victim reoffending in clients who attended an integrated substance use-domestic violence treatment program versus clients who did not participate in this hybrid approach. The findings showed that the integrated treatment approach was more successful at getting offendees and probationers to attend treatment (43% of the control group were no-shows, as compared to 13% of the integrated treatment group). The integrated treatment approach had a greater success in keeping participants in treatment as well as having lower rates of same-victim reoffending. Alternatively, studies with alcohol-dependent patients in the VA system designed to target alcohol-related problems in the context of couples therapy yielded results that showed lower levels of marital violence (O Farrell & Murphy, 1995). Additionally, after this treatment, there was a de /00/$ see front matter 2000 Elsevier Science Inc. All rights reserved. PII: S (99)

2 2 C. Easton et al. / Journal of Substance Abuse Treatment 19 (2000) 1 5 crease in drug use, longer periods of abstinence, and fewer drug-related arrests (Fals-Stewart et al., 1996). Although these studies show some promising results, the data involve a population of subjects that may be different than domestic violence offenders referred to a family violence program. There is very little information on substance use behavior change in a population of individuals referred to these psychoeducational programs. With this in mind and knowing that substance use alone leads to increased rates of violence, reduction in adherence to treatment regimes, and other negative psychiatric sequelae, a preliminary study was designed to further assess substance-related treatment needs among batterers. A study was designed to evaluate the effectiveness of a motivational enhancement intervention on readiness to change substance use within this population. The population evaluated was a heterogenous group of male batterers referred by court because of a recent domestic violence charge. 2. Methods 2.1. Subjects Forty-one male subjects, aged years, mean age 36 (SD 13.4) participated in the study. The sample was 100% male and consisted of the following racial composition: 58% African American, 29% Caucasian, and 7% Hispanic. Refer to Table 1 for demographic characteristics. The participants were 41 male offenders of domestic violence who were referred by court to attend 10 weeks of psychoeducational classes on anger management. Clients were specifically referred by the Family Relations Division of the Superior Court after they received a domestic violence arrest. The classes were performed on an outpatient basis. This program is designed to prevent violence and if clients successfully complete 9 out of the 10 of the classes, their sentence is likely to be suspended. This Family Violence Education Program (Scott, 1990) consists of psychoeducational classes that focus specifically on the following topics per week: Understanding Anger (wk. 1); Controlling Anger (wk. 2); Effective Communication (wk. 3); What We ve Learned From Our Families (wk. 4); Effects of Violence on Children (wk. 5); What We ve Learned From Our Culture (wk. 6); The Dynamics of Power and Control (wk. 7); Learning to Live With Stress (wk. 8); Substance Use and Violence (wk. 9); and Effects of Violence on Women (wk. 10). In general, clients entering this program are not assessed for substance use or any other co-occurring mental health problems. Hence, clients may be participating in classes under the influence of alcohol, a psychoactive substance. Two anger management groups were targeted at session 9, the session that focuses on standard anger management and substance use. The groups were targeted to assess substance use, violence, and motivation to change substance use behaviors. One group was randomly chosen to partake in a motivational enhancement intervention session. The comparison group was offered the standard class, which discusses the relationship between substance use and violence. The motivational enhancement used a style that was empathic, avoided confrontation, rolled with resistance, used double-sided reflections, pointed out discrepancies in what clients were disclosing, elicited positive self-statements for change, and promoted self-efficacy. This style was designed to elicit discussion/disclosure of substance-related problems and steps to change these problems. The motivational enhancement procedure was modeled from Project Match NIDA Motivational Enhancement Treatment Manual (Miller et al., 1995) Assessments Forty-one clients were evaluated for substance abuse and dependence diagnoses using a self-reported version of the Schedules for Clinical Assessment of Neuropsychiatry (SCAN) (American Psychiatric Association, 1994) instrument. This diagnostic interview assessed only substance-related disorders. The criteria are based on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV; American Psychiatric Association, 1994). This instrument is a reliable and valid diagnostic tool and has been widely used (Dawson et al., 1994; Chou et al., 1994; Easton et al., 1997; Room et al., 1996). The substance use and demographic self-reports were administered at the onset of the sessions. A brief motivation to change survey, adapted from the Readiness to Change subscale of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES; Miller & Tonigan, 1996), was administered pre- and postsession. This subscale was chosen based on preliminary studies showing its positive relationship to engagement and retention in treatment. Additionally, at postsession, both groups were given a sign-up sheet with an address and appointment time for a follow-up to a confidential substance use evaluation Statistical analyses Prevalence of substance abuse and dependence diagnoses was calculated via each clients endorsement of DSM- IV criteria (the diagnoses included a lifetime diagnosis). A percentage was calculated via a frequency of tally counts per subject (three of seven criteria for substance dependence diagnosis; and one of four criteria for substance abuse diagnosis). Group differences in demographic, legal, violence, and substance use variables were analyzed using a one-way analysis of variance (ANOVA) for continuous variables and the 2 test for nominal/categorical variables. Significant differences in demographic and substance use characteristics were analyzed using separate one-way analyses of covariance (ANCOVAs). Significant differences were further evaluated by Tukey post-hoc comparisons. Significance was assumed at p.05.

3 C. Easton et al. / Journal of Substance Abuse Treatment 19 (2000) Table 1 Demographic and legal characteristics Demographic Total N p n Age [M (SD)] 36.2 (13.4) 38.9 (14.6) 33.2 (11.05) F 8.25, p.007 Age range Race (%) 2.67 Caucasian African American Hispanic Other Marital status (%) 2.48 Married/cohabitating Divorced Parent/child/relative Other Living arrangements (%) 2.60 Same household Separate residence Other Primary legal charge(s) (%) 2.67 Arrest Assault Threatening Breach of peace Disorderly conduct Harrassment Unknown Nature of the violence (%) 2.41 Verbal conflict Physical violence Verbal conflict w/physical violence Verbal conflict, physical, property, etc FVMET Family Violence Motivational Enhancement. 3. Results Demographics, and legal and substance use characteristics are summarized in Table 1. It should be noted that the two groups; Family Violence Motivational Enhancement and Family Violence Motivational Enhancement ( and, respectively) were statistically equivalent in age, gender, racial composition, marital status, living arrangements, legal charges, nature of violence, and substance use characteristics. Results indicated that 80% of male offenders of domestic violence are married/cohabiting, 44% are still residing together in the same home, 44% were arrested for assault, and 51% of the violence was verbal aggression and physical violence. In general, 41% of the total population endorsed substance dependency criteria and 67% reported that they abused substances. There were no statistically significant differences between group in rates of substance abuse or dependence diagnoses. A paired t-test indicated that the group had a significant difference from pre- to posttesting in motivation to take steps to change their substance use scores, t(1, 18) 3.26, p.004. Their motivation scores increased from pre to post. However, the comparison group was not calculated due to an insufficient sample size. From the total sample of 19, only 9 subjects were motivated to fill out the self-reports. There was a significant difference between groups ( vs. ) in the amount of missing data. The group had 53% data missing (lack of filling out substance use criteria and motivation to change substance use scores). Further, the subgroup of 9 subjects represents a population that may not accurately represent the comparison group as a whole, since the majority of individuals in this group did not complete the self-reports. Additionally, a sign-up sheet with preset appointment times for a substance use evaluation and treatment were administered. However, neither group had any individual signup regardless of their motivation scores (Tables 1, 2, and 3). 4. Discussion In a sample of male offenders of domestic violence entering anger management classes, a total of 67% met criteria for substance abuse, and 41% endorsed criteria for substance dependence diagnoses. Of the two family violence groups, there was no significant difference in rates of abuse or dependence diagnoses. Fifty percent of the group met criteria for substance dependence and 75% met criteria for substance abuse. The group included 33% who reported that they were substance-dependent and 60% abused substances.

4 4 C. Easton et al. / Journal of Substance Abuse Treatment 19 (2000) 1 5 Table 2 vs. group: Self-reported substance use diagnoses Variables Total (N 41) (n 18) (n 9) p Substance use (%) Abuse diagnosis Dependence diagnosis FVMET Family Violence Motivational Enhancement. In this sample of 41 male offenders of domestic violence, 80% reported being married, 44% still resided with their partners, and 51% were arrested for physical violence and verbal aggression. Forty-four percent were charged with assault. There was no significant difference between the and groups across demographic legal, or substance use characteristics. However, there was a significant difference in the amount of missing data on self-reported alcohol and drug use. Additionally, there was a significant difference between groups in the amount of missing data on the SOCRATES (motivation to change substance use scores). The group had greater than 50% of the self-reports incompleted. An ANOVA could not be performed because the nature of the dependent variable was motivation. The discrepancy between the sample size and amount missing data was too large to adequately perform this analysis. Although the prevalence rates for co-occurring substance use among this group were calculated, they should be considered preliminary, as this may represent a subsample that has a different level of motivation within this group. When assessing the difference in SOCRATES scores (motivation to change substance use) among offenders of domestic violence in the group from pre- to postsession, there was a significant difference from pre to post. At postsession, individuals reported an increase in their motivation to take steps to change their substance use. However, no individuals signed up for an additional appointment, in which they would be evaluated for substance use treatment. There were a number of limitations that may have affected the outcome of this preliminary study. For example, due to an Table 3 vs. on SOCRATES (self-reported motivation to take steps to change substance abuse scores) and percent missing data per group Motivation to take steps (n 18) (n 9) a SOCRATES (13.1) 3.1 (2.0) SOCRATES (10.4) 21.0 (13.2) Sample size n 22 n Missing data (%) FVMET Family Violence Motivational Enhancement; SOCRATES Stage of Change Readiness and Treatment Eagerness Scale. a Due to an insufficient sample size on SOCRATES data for the group, an ANOVA was not performed. insufficient sample size, it was difficult to separate out specific substances of abuse and dependence. Another possible limitation of this study was that the substance use diagnoses included lifetime and within the past year. All diagnoses were obtained via self-report and not a clinical interview. Additionally, this sample included individuals with court cases pending, and therefore, subjects may have been underreporting. However, all individuals were counseled regarding the strict confidentiality of this study and their names were not written on any of the self-reports. Although the substance use data was obtained via self- reports, objective indicators of use (e.g., breathalysers and urine toxicology screens) were not used to verify under- or overreporting due. Another possible limitation of this study was that co-occurring psychiatric disorders were not assessed. It is known that substance use disorders often have co-occurring psychopathology, such as depression, anxiety, and personality disorders. These additional mental health problems can further complicate and predispose individuals to family violence. Keller (1996) found that alcohol and drug abuse, antisocial personality disorder, and depression are associated with increased risk of male violence in the home. Easton, Swan, and Sinha (2000) found that clients in substance abuse treatment with a history of physical violence had significantly more cocaine and alcohol-related problems and had reported significantly more depressive symptoms. If co-occurring mental health problems existed, they could have contributed to differences in motivation to change substance use. Another explanation for the current findings is that the facilitator of the intervention group had a Motivational Enhancement Therapy (MET) style, which may have increased the likelihood of individuals in this group to complete all forms regardless of pre- and postintervention. The comparison group did not have any facilitators trained in MET, hence the lack of motivation to complete the self-reports at pre- and postsession. However, this only underscores the importance of including MET as a form of treatment among offenders of domestic violence with co-occurring substance-related problems. This group is in need of motivation to change current domestic violence and substance-related problems. In sum, the results indicate that a motivational enhancement intervention is feasible and effective in increasing readiness to change substance use among domestic violence offenders. However, one session of MET in context to anger management appears to be insufficient in bringing about actual behavioral change (e.g., signing-up for further substance abuse evaluation and treatment). The results illustrate the importance of assessing and treating substance use among offenders of domestic violence, as this may be an important indicator for higher dropout rates and reoffenses among this population. Additionally, from a risk management perspective, a group of male offenders of domestic violence still residing with their partners, arrested for physical and verbal assault have high rates of substance abuse and dependence diagnoses. Given that the court refers these individuals to stan-

5 C. Easton et al. / Journal of Substance Abuse Treatment 19 (2000) dard anger management classes without assessing substance use, suggests the dire need for a policy change. Hence, a comprehensive assessment of substance use treatment needs should occur among this population. Acknowledgments Support for this research was provided, in part, by P50- DA We would like to especially thank Tiffany Fuse and Lisa Aubin for their assistance. References American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Bennett, L. W., Tolman, R. M., Rogalski, C. J., & Srinivasaraghavan, J. (1994). Domestic abuse by male alcohol and drug addicts. Violence and Victims 9, Brookoff, D., O Brien, K. K., Cook, C. S., Thompson, T. D., & Williams, C. (1997). Characteristics of participants in domestic violence. Assessment at the scene of domestic assault. Journal of the American Medical Association 277, Chou, S. P., Grant, B. F., Dawson, D. A., & Towle, L. H. (1994). A Cross Cultural Comparison of the Diagnosis and Classification of Drug Abuse and Dependence: Results of the WHO/NIH CAR Project-SARS Substudy. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. Collins, J. J., Kroutil, L. A., Roland, E. J., & Moore-Gurrera, M. (1997). Issues in the linkage of alcohol and domestic violence services. Recent Developments in Alcoholism 13, Dawson, D. A., Grant, B. F., & Towle, L. H. (1994). A Cross Cultural Comparison of the Diagnosis and Classification of Alcohol Abuse and Dependence: Results of the WHO/NIH CAR Project-SARS Substudy. Geneva, Switzerland: World Health Organization. Easton, C., Meza, E., Mager, D., Ulug, B., Kilic, C., Gogus, A., & Babor, T. (1997). Test-Retest reliability of the alcohol and drug use disorder sections of the schedules for clinical assessment in neuropsychiatry (SCAN). Drug and Alcohol Dependence 47, Easton, C., Swan, S., & Sinha, R. (2000). Prevalence of family violence in clients entering substance abuse treatment. Journal of Substance Abuse Treatment 18, Fals-Stewart, W., Bichler, G. R., & O Farrell, T. J. (1996). Behavioral couples therapy for male substance-abusing patients: Effects on relationship adjustment and drug-using behavior. Journal of Consulting and Clinical Psychology 64, Goldkamp, J. S., Weiland, D., Collins, M., & White, M. (1996). The Role of Drug and Alcohol Abuse in Domestic Violence and Its Treatment: Dade County s Domestic Violence Court Experiment. From the Executive Summary of a Crime and Justice Research Institute study funded by the National Institute of Justice. Holtzworth-Munroe, A., & Stuart, G. L. (1994). Typologies of male batterers: Three subtypes and the differences among them. Psychological Bulletin 116, Keller, L. E. (1996). Invisible victims: battered women in psychiatric and medical emergency rooms. Bulletin of the Menniger Clinic 60, Miller, W. R., & Tonigan, S. J. (1996). Assessing drinkers motivation for change: the stages of change: the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors 10(2), Miller, W., Zweben, A., DiClemente, C., & Rychtarik, R. (1995). Motivational Enhancement Therapy Manual. A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence. National Institute on Alcohol Abuse and Alcoholism (Vol. 2). Washington, DC: Project MATCH. O Farrell, T. J., & Murphy, C. M. (1995). Marital violence before and after alcoholism treatment. Journal of Consulting and Clinical Psychology 63, Rivera, F. P., Mueller, B. A., Somes, G., Mendoza, C. T., Rushforth, N. B., & Kellermann, A. L. (1997). Alcohol and illicit drug abuse and the risk of violent death in the home. Journal of the American Medical Association 278, Room, R., Janca, A., Bennett, L. A., Schmidt, L., & Sartorious, N. (1996). WHO cross-cultural applicability research on diagnosis and assessment on substance use disorders: an overview of methods and selected results. Addiction 91, Scott, D. (1990). Family Violence Education Program for the State of Connecticut Superior Court Family Division: 10 Session Program Guide. The Consultation Center, 389 Whitney Avenue, New Haven, CT