Chapter 6 -- Linkages: A Coordinated Community Response

Community Assessment

Before linkages can be developed, it is necessary to know what resources exist within the community. Each entity has its own organization and its own culture that must be understood for collaboration to be successful. Every State has a unique infrastructure for housing the health care, legal, social, and other services related to substance abuse treatment and domestic violence services. Communities themselves also vary in government structure, available resources, and funding streams. Some combine alcohol treatment with treatment for other substance abuse, whereas others separate the two. Some locate services for victims of domestic violence in the criminal justice system, which affects the tone and procedures used to deliver services, while others locate such services in a hospital system linked to the emergency department. A program within a nonprofit entity in the private sector has far different restraints than one housed in a government agency.

Disciplines also differ dramatically in structure and orientation. Some substance abuse treatment programs, for example, are staffed by nurses, and others are staffed by certified addiction counselors. Many existing programs, such as Minnesota's Turning Point and African American Services, have incorporated family violence issues into substance abuse treatment, and communities throughout the United States are increasingly integrating the two areas (Clark et al., 1996). A single treatment approach would be enhanced by making programs accountable to the local community, strengthening the linkages between the two fields and the court system, and improving evaluation procedures.

The Argument for Case Management

In the current early state of development of linkages between the fields of substance abuse treatment and domestic violence services, it has been suggested that "the linkage mechanism that seems most appropriate is case management" (Collins et al., 1997, p. 400). Increasingly, the substance abuse treatment field has recognized that case management may be a key contributor to successful treatment (Ridgely and Willenbring, 1992). In the case management approach, a specially trained single practitioner or case management team is responsible for coordinating linkages to the wide variety of services -- including domestic violence support -- needed by many if not most clients in substance abuse treatment (Sullivan, 1994).

Although locating and gaining initial access to these services can be challenging, many programs have found that use of case management is well worth the effort, since it helps clients work through problems that may trigger use of alcohol and other drugs or that interfere with progress in treatment. Such problems may include homelessness, mental illness, HIV infection, lack of vocational skills, and unemployment (Willenbring, 1994). An additional advantage is that the case manager serves as a client advocate, representing the client's interests in both accessing other agencies and ensuring that their services are used effectively (Rapp et al., 1994).

Linking Substance Abuse Treatment and Domestic Violence Services

Several locales have attempted to develop model programs integrating substance abuse and domestic violence services. These include the Amend Program in several Colorado communities (Rogan, 1985-1986), the Intercede Program of Longford Health Sources in Ohio (Burkins, 1995), and the Pittsburgh Veterans Affairs Medical Center (Gondolf, 1995). A study of linkage efforts in Illinois found that staff cross-training is inadequate to meet the goals of these efforts (Bennett and Lawson, 1994).

This TIP takes some of the first steps in formalizing linkages between the two fields. Chapters 2 and 3 present substance abuse treatment providers, who may lack knowledge about this population, with psychosocial profiles of survivors and batterers and their needs for specialized care. Such training is a key ingredient in bringing the two fields closer. Chapter 4 stresses the need for screening for domestic violence early in the substance abuse treatment process and the importance of timely referral of clients affected by domestic violence to the appropriate agencies. Routine screening for cross-problems by both types of programs is a major step toward linkage.

Linkages With the Criminal Justice System

One of the first linkages that must be identified by a substance abuse treatment program that is working with domestic violence survivors is with the legal system (see Chapter 5). A legal professional or legal service is the best resource for resolving problems that pertain to individual clients' involvement in the justice system and may be the best resource for information and guidance regarding the Violence Against Women Act (VAWA). Many of the Act's provisions -- such as those relevant to immigrants -- are complex and detailed. In addition, other Federal and State statutes may include provisions that appear to contradict those of the VAWA.

To treat substance abuse clients who are either survivors or batterers, treatment providers must be knowledgeable about policies and laws related to domestic violence; they must understand the roles of police, judges, probation staff, and other representatives of the justice system and be able to interact effectively with these individuals when necessary. As one field reviewer noted, "Integrating the criminal justice system's efforts should be the first step in forming linkages. If a provider wants assistance protecting a woman or getting a batterer to attend treatment, it is the criminal justice system that can get this done."

Specialized courts to process domestic violence cases, which combine intensive survivor services, treatment for batterers, and an active judicial role in the social contexts of the community, have been established. The Dade County, Florida, Domestic Violence Court, which commenced in late 1992, is a noteworthy example, and outcomes are still being evaluated (Fagan, 1996). However, some early data indicate that recidivism rates among treated batterers processed through these courts are high and comparable to rates found in studies of the deterrent effects of protective orders and arrests. Failure rates are strongly correlated with lengthy prior records and a history of abuse in the batterer's family of origin (Fagan, 1996).

In pursuing victim protection goals, criminal justice agencies have been required to expand their traditional focus on the detection and punishment of crimes. Placing these expectations on police and prosecutors may require tasks and roles for which they are not well trained. Such role and policy ambiguities can affect the performance of agencies with respect to their missions. As Fagan notes:

There is no doubt that linkages between legal institutions and services for domestic violence victims are critical to stopping violence. However, these linkages may best be accomplished through a strategic division of roles among institutions that tap the strengths of each organization. . . . Although legal systems should be open and accessible to battered women, these institutions should not take on the role of managing the coordination of services that involve social service, shelter, and other interventions. (Fagan, 1996, pp. 39-40)

Collaborative Treatment Planning For Survivors and Batterers

Treatment plans for substance abuse clients who are survivors or batterers must incorporate all the issues surrounding both sets of problems and ideally will be coordinated by a case manager. Treatment planning for matters such as time sequencing (e.g., when to start support for a domestic violence survivor in substance abuse treatment) and goals of treatment is not effective without consideration of all the factors that have a bearing on the client's best interests. Substance abuse treatment providers, domestic violence experts, and legal or other relevant professionals should plan treatment collaboratively.

Because treatment plans for domestic violence survivors are built around the premise that safety must always be the first priority, substance abuse treatment may initially take a back seat. For example, a client who lives with a violent partner may report being pressured or coerced by him to use alcohol or other drugs. In these instances, some degree of relapse may need to be tolerated in light of the threat to the client's safety. A survivor's frequent reporting of such a situation, however, signals the need for substance abuse treatment and domestic violence staff to jointly reconsider treatment priorities.

A batterer entering treatment for substance abuse can be required to sign a contract agreeing, among other stipulations, to refrain from using violence (see Chapter 4). Such "no-violence contracts" are most effective when linkages are made with other agencies involved with his case, and violations should be reported to all involved agencies, especially the criminal justice system.

Treatment providers can help persuade the courts to consider alternative sanctions that take the victim's circumstances into account. Incarcerating batterers can actually harm their victims by taking away the family income. On the other hand, not incarcerating the batterer may give him the false message that his behavior is not that bad and thus tacitly give him "permission" to continue his violence. Courts may order the batterer to receive counseling, perform public service, or a variety of other sanctions.

Airing and Addressing Grievances

In collaborative relationships, difficulties can arise if one entity feels taken advantage of, perceives that the other is deriving more benefits from the association, receives more credit, or believes that power is unequal between the two groups. Balance is central to an effective collaboration that satisfies the expectations and needs of all involved. When a collaborative domestic violence effort, for example, used the letterhead of one participating organization, the other partners were displeased because their participation was not acknowledged. To give equal recognition to all partners, a new project-specific letterhead reflecting all the collaborators was designed. Not all solutions will be so simple, but this example demonstrates the importance of frank communication, responding to the concerns of all the partners in the network, and moving quickly to resolve problems.

Readiness for Collaboration: Program Evaluation

Many programs have in place a system for periodic internal evaluation of their success in meeting their goals. Decisionmakers may find it useful to reexamine a program or organization specifically in terms of its readiness to take advantage of and maintain a collaborative association.

Understanding the True Costs of Collaboration

Even if an organization takes all the steps above, the path to collaboration is still paved with unforeseen difficulties. The importance of differences in perspectives between the two fields, as discussed in Chapter 1, should not be underestimated. One survey of staff in both types of program found that more than half of all staff cited "conflicting beliefs about personal responsibility" as a reason for noncooperation between programs (Bennett and Lawson, 1994). Service delivery structure and funding also can block collaboration.

Furthermore, confidentiality and informed-consent practices vary among fields (see Appendix B). Large programs may have trouble linking with small programs, especially if documentation and tracking procedures are incompatible. Conversely, small grassroots programs may have problems following the formal procedures required by larger organizations or may lack staff to ensure that paperwork is completed in a timely fashion. Professionally led and staffed organizations may doubt the competence of paraprofessional staff members who are in recovery and may discount their suggestions in the course of treatment planning. Similarly, untrained staff may fail to recognize the validity of the insights and suggestions proffered by professional social work and mental health care givers.

Other issues affecting the costs of collaboration include the number of approvals and layers of bureaucracy that must be negotiated to obtain services from a linked agency, requirements for research and evaluation that may be attached to participation in a network, and the amount of staff time required to maintain linkages and resolve problems.

Funding Sources and Reimbursement

Funding sources for domestic violence support include the criminal justice system through Federal block grants, State money, or fines levied against perpetrators. Private and community organizations also represent funding sources. Employee assistance programs (EAPs) can serve as both allies and access points to solicit and obtain corporate funding. Third party reimbursement for domestic violence services is slowly gaining some acceptance. At one time, insurers might have refused to pay for these services for a woman who was covered under the batterer's policy, reasoning that the woman's injury was self-inflicted because she chose to stay with the batterer. In some cases, the batterer must authorize payment for treatment for the survivor if medical, health, or disability coverage is in his name.

One reason domestic violence has not been incorporated into concepts of managed care is that, as discussed in Chapter 1, some advocates for domestic violence survivors have rejected the use of a medical model to define the problem. In addition, most managed care companies have specific requirements about who can deliver services; if no program staff meet those requirements, it is not likely that the program will be reimbursed. Domestic violence support encompasses services such as housing and job training that are outside the realm of health care and that have outcomes difficult to measure in terms of health improvement, which are the outcomes of interest to health maintenance organizations (HMOs). However, many managed care organizations are investing funds to help their enrollees deal with issues that are not traditionally medical; many HMOs offer strss management and exercise programs. All health systems are increasingly recognizing the cost-effectiveness of early detection and prevention in general in their covered populations, and some have set up routine screening for substance abuse. Furthermore, increased interest in outcomes measurement and consumer satisfaction has broadened the spectrum of behaviors monitored and outcomes measured by health care providers.

Reimbursement from managed care organizations and other third parties relies on diagnostic classifications and treatment categories. Advocates for reforms in health care and social welfare must find ways to classify joint substance abuse-domestic violence problems to ensure reimbursement. Although some domestic violence programs use the classification "trauma" and receive reimbursement for treatment, services are frequently provided as nonreimbursable advocacy or coaching. Victims who are thought to have underlying problems are typically referred to other programs (e.g., for psychological or substance abuse treatment). Research indicates that there are no psychological risk markers for becoming a victim of adult domestic violence (Hotaling and Sugarman, 1990). However, certain characteristic symptoms are seen in many people following highly traumatic life events. Some battered women experience these symptoms as a result of violence-associated trauma, and they are normal psychological responses to stressful life events. Often, these symptoms dissipate as women achieve greater safety from the abuse. Other women may require more intensive therapeutic interventions to heal from the effects of violence. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994), offers some diagnoses that may be helpful in classifying survivors' symptoms and helping programs receive reimbursement for treatment. Some survivors may meet criteria for posttraumatic stress disorder (see Chapter 2) or for depressive and anxiety disorders.

Licensing, Credentialing, And Certification

Credentialing processes for substance abuse treatment providers must assess their ability to screen for violence and create a safety plan, as well as their knowledge of legal issues related to domestic violence. They should demonstrate a knowledge of child abuse and neglect, child sexual abuse, partner violence, elder abuse, extended family violence, and violence as an issue in relationships other than marital or partner relationships.

Examples in Health Care Settings

Many of the linkages between domestic violence support services and other service organizations that have been most effective have occurred in health care settings, especially in hospitals. Linkages of the type described here might benefit from involvement of staff from substance abuse treatment programs. At the Dekalb Medical Center in Atlanta, emergency room nurses who suspect that a woman has been battered call a patient representative with specialized knowledge to interview the patient after medical treatment is provided (Dekalb Medical Center, 1993). The representative, who is able to spend more time with the patient than the nurses, refers the patient to a community shelter or makes other referrals and also provides feedback to the emergency room staff.

Other examples of hospital-based service linkages come from Boston, Minneapolis, and Seattle (Loring and Smith, 1994). At Children's Hospital in Boston, staff from AWAKE, an advocacy program for battered women and their children, are called in to provide safety planning and support for patients who are violence survivors. In Minneapolis at the Hennepin County Medical Center, an advocate from a battered women's shelter makes rounds in all services -- not just the emergency room -- to speak directly with medical staff and interview violence survivors. In this way the hospital administration and medical staff are assured that in addition to receiving appropriate medical care, survivors are assisted in other areas, such as locating the batterer, obtaining legal protection, and proceeding with assault charges when appropriate. Harborview Hospital in Seattle employs an "adult abuse protocol" with components of various systems to ensure comprehensive services to the battered woman patient. Finally, health maintenance organizations, many of which maintain detailed databases to track service utilization and outcomes, may find it easier than general hospital systems to identify and reach out to survivors of domestic violence.

Promising Activities and Future Directions

In 1994 the Board on Children and Families, the National Research Council, and the Institute of Medicine sponsored a 3-day workshop, Violence and the American Family (Chalk, 1994). Although the focus was a broad one and included child and elder abuse as well as other forms of family violence, many of the participants suggested action ideas for linkages among agencies involved in the treatment of domestic violence survivors and batterers. As can be readily seen, no single agency or system can successfully undertake the broad tasks and initiatives outlined below that were suggested by workshop participants. Rather these projects invite broad collaboration and cooperation.

In the area of social services, tasks to be undertaken included (Chalk, 1994)

• Developing a set of principles for designing violence interventions that would ensure client empowerment, build on family strengths, and be based on effectiveness evaluations
• Creating violence intervention and prevention systems at the community level that build on formal and informal social networks in diverse neighborhoods
• Requiring schools to make violence prevention education mandatory
• Exploring new methods of cash payments to families to deter violence resulting from economic stress.

In the area of health, the workshop participants identified three specific initiatives (Chalk, 1994):

• A national campaign against violence to focus on health aspects and costs of family violence to society
• Improvement of screening and diagnosis among health and mental health professionals of risks and injuries associated with family violence
• Consensus-building about what is known about family violence, leading to the formation of a constituency to serve as an advocacy group to educate public officials.

In the area of criminal justice, three issues were raised as fruitful areas for activities (Chalk, 1994):

• Effectiveness research on the use and enforcement of restraining orders to deal with domestic violence; new methods of offender control, such as electronic monitoring may be effective
• Research on the availability and effectiveness of court-ordered treatment and on returning abusers to their families
• Consideration of new proposals that experiment with the development of a one-family, one-judge court system.

In addition to these recommendations, the workshop participants outlined three broad steps necessary to establish a much-needed basis for future research and program plans (Chalk, 1994):

• Develop a broad-based public education campaign to foster understanding of family violence
• Bridge the gap between research resources and policy needs, especially by developing rigorous evaluations of public sector programs to reduce domestic violence
• Integrate preventive measures for domestic violence into a comprehensive, community-based program of family support services across a spectrum of developmental milestones. The goal goes beyond information sharing and seeks to simplify access to services.

A Public Health Approach

A public health approach has been effective in reducing morbidity and mortality by modifying behavior in many areas (e.g., campaigns to reduce smoking, to reduce alcohol abuse among pregnant women, and to prevent head injuries by wearing helmets). A public health approach to violence has been suggested (Koop and Lundberg, 1992) in response to the surge in morbidity and mortality due to violence (Prothrow-Stith, 1991). As the epidemiological evidence mounts that society's rising mortality figures are due in large part to violence, public health professionals acknowledge the destruction of "quality years of life" as well as the expensive healing process and now study the problem in terms of understanding and changing unhealthy outcomes (Koop and Lundberg, 1992).

Public health officials, generally solution-driven rather than theory-driven, view domestic violence as the result of a complex array of causal factors. By focusing on "risk factors," they can identify structural, cultural, and situational conditions that accompany, precede, and follow events of interpersonal violence (Moore, 1995). They also monitor public health, identify at-risk groups, and implement programs with evaluation components.

Education is a critical component of a public health campaign. In Houston, for example, the March of Dimes targeted both health care professionals and the public with educational interventions and brochures about battering during pregnancy; public service announcements were developed for the media.