“She doesn’t think there is a problem.”
“He said he can handle it.”
“She just hasn’t reached her ‘bottom’ yet.”
“You have to change people, places and things.”
“It’s not going to change until she wants it to change.”
“Why doesn’t he just stop?”
These statements may sound familiar. What may surprise you is that here, they are not about addiction. They are about domestic violence, which has come to be known as Intimate Partner Violence (IPV).
IPV is an enormous public health issue. According to the National Intimate Partner and Sexual Violence Survey (2010), more than one in three women and more than one in four men in the United States have experienced IPV in their lifetime. Twenty people per minute are victims of IPV every day in America.
IPV is deeply connected to addiction and substance use, although the connections are complicated and not always clear.
What is IPV?
IPV can be any single or combination of the following behaviors: physical violence, sexual violence, stalking, or psychological aggression. An “intimate partner” could be a current/former spouse, dating partner, or sexual partner. Sexual intimacy does not have to have occurred for someone to be considered an intimate partner.
What many of us may not realize is that the definition of IPV has evolved over the years.
Since the CDC first created its IPV definition in 1999, it has grown to include stalking behaviors, sexual violence in more ambiguous social contexts, and unwanted behavior over the internet and mobile technology.
Trauma, Substance Use, and IPV
What has not changed over the course of the years is the co-occurrence of substance use/substance use disorders and IPV.
SAMHSA’s Treatment Improvement Protocol (TIP) Series 25, published in 1997, noted studies as far back as the 1970s that indicated alcohol or drugs contribute to, facilitate, precipitate, or exacerbate IPV in some way. Those studies looked at the perpetrators of abuse as well as those who were assaulted or witnessed the IPV. What many studies failed to uncover is why such a strong connection exists.
Addiction can lead individuals to circumstances that involve high risk behaviors, including IPV, either as a perpetrator or a victim. For example, victims of IPV are 70% more likely to drink alcohol heavily than those who have not experienced IPV, although we don’t understand which one causes the other.
More than one in three women and more than one in four men in the U.S. have experienced IPV in their lifetime.
And trauma is intertwined with both IPV substance use disorders. The TIP 25 says that those who witness or experience trauma in early childhood in the form of physical violence are more likely to be involved in IPV situations as adults, either as victims or perpetrators. Trauma can sometimes lead to substance use disorders, but not all individuals who experience trauma become addicted. SAMHSA’s TIP 57 explains that the use of substances as a coping mechanism when dealing with trauma can be attributed to a variety of factors, including the symptoms the person is trying to suppress as well as his ability to gain access to the particular substance. Likewise, not all individuals who become addicted are involved in IPV.
What is clear is that the coexistence of IPV and substance use is a complex and multifaceted dynamic that does not receive the research funding it deserves. Many of the studies that are performed focus on one or the other. Not surprisingly, most conclude that more research is needed.
Screening for At-Risk Substance Use and IPV
Many of us have been screening for IPV since the late 1990s. The U.S. Preventive Services Task Force recommends screening all women of childbearing age (defined as ages 14-46) for IPV. They note a lack of clinical evidence to support screening women over age 46. The Institute of Medicine (2011) identified screening for IPV and subsequent interventions as one of eight services imperative to the health and well-being of women.
Several IPV screening tools do exist, including the HITS, WAST, and PVS. Currently, there is a need for validation of existing screening tools and interventions for IPV co-occurring with substance use disorders.
What Can We Do To Help?
I challenge you, in your practice, to evaluate your own concepts about IPV and substance use.
– Be non-judgmental.
– Educate yourself about the prevention of IPV.
– Screen all of your clients for IPV. Many people don’t know how to talk about it (This is true for perpetrators as well as those who are assaulted or witness the assaults). Additionally, for some clients, reaching a substance-free state is necessary before they can even start to think or talk about it.
– Offer educational resources on IPV prevention, warning signs and local services.
– Facilitate an open dialogue about IPV with your clients, your co-workers, and your friends.
– Remember that help is available! Links to some local, state and national resources are listed below:
Center for Victims | Crisis Center North | Domestic Violence Services of Southwestern Pennsylvania | National Coalition Against Domestic Violence | Pennsylvania Coalition Against Domestic Violence | Women’s Center and Shelter of Greater Pittsburgh
April Chaney, DNP, RN is a psychiatric registered nurse who has worked in various inpatient, outpatient, and residential facilities since the turn of the twenty-first century. She is a nurse educator and consultant with an eye toward the future of interprofessional education and the application of innovative technologies in behavioral healthcare. She can be reached at GreenbrierDNP@gmail.com.