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Health and Domestic Violence - Good Practice Guidelines

Principles of Good Practice for working with women experiencing
domestic violence

Guidance for those working in the Drug and Alcohol sectors

What is domestic violence?

Domestic violence is physical, psychological, sexual or financial abuse that takes place within an intimate or family-type relationship and forms a pattern of coercive and controlling behaviour. Crime statistics and research both show that domestic violence is gender specific - usually the perpetrator of a pattern of repeated assaults is a man. Women experience the most serious physical and repeated assaults.(i)

Any woman can experience domestic violence regardless of race, ethnic or religious group, class, sexuality, disability or lifestyle. It is estimated that one in four women will experience domestic violence at some time in their lives.

In this document, we will refer to survivors of abuse as female and perpetrators as male.

Aims of the Good Practice Guidelines:

To increase safety for those experiencing domestic violence
To raise service standards for users of drug and alcohol services
To raise awareness of domestic violence among those working in drug and alcohol services
To increase safe choices for women and children experiencing domestic violence where substance misuse is also an issue
To encourage liaison between domestic violence and substance misuse sectors
To hold abusers accountable

Some information on substance use and domestic violence

There are many women for whom domestic violence and substance misuse are a simultaneous concern. Here we are following the Stella Project in defining substance misuse as: "the use of substances (such as illegal drugs, prescription medication or alcohol) in such a way that results in harm to the individual user or to the wider community…". (ii) Many women use substances as a response to and a way of dealing with abuse.(iii) Many women who access drug and alcohol services will have current or past experience of domestic violence.

Despite this co-existence there is no evidence to suggest a direct causal link between substance misuse and domestic violence: women's substance use should never be used to justify or "explain" their experiences of violence; nor should drug or alcohol use by either partner be accepted as an excuse for violent and abusive behaviour.

Substance misuse professionals tend to underestimate the proportion of their clients who experience domestic violence, and to have only limited contact with domestic violence services.(iv)

Women experiencing domestic violence are up to fifteen times more likely to misuse alcohol and nine times more likely to misuse other drugs than women generally.(v)
40% of Asian women who seek treatment for alcohol misuse are experiencing domestic violence.(vi)
Some women are introduced to substances by their abusive partners as a way of increasing control over them (vii); and when a woman's partner is also her supplier, it will be particularly difficult for her to end the relationship.
When a woman seeks support, information or treatment for her substance misuse, her partner may become even more abusive, or may actively prevent or discourage her attendance at a substance misuse service.(viii)
Women whose partners misuse substances may minimise or excuse their violence on those grounds; it is important to emphasis that even if substance use ceases, the violence and abuse usually continues.(ix)

Women with problematic substance use who also experience domestic violence are particularly likely to feel isolated and doubly stigmatised. They may find it even harder than other women to report or even to name their experience as domestic violence; and when they do, are in a particularly vulnerable position, and may be unable to access any suitable sources of support.

Suggested Guidelines for Drug and Alcohol Services

Some of these recommendations are addressed to management or to the organisation as a whole. Others are aimed more specifically at front line workers. For several reasons, however, it did not prove practicable to separate the points on that basis.

Any response must ensure that the safety of women and children is the first priority. In this context, "safety" means safe from further abuse and violence.
Do not blame women for the abuse they experience from their partners or other family members. Responsibility(1) for the abuse lies with the perpetrators.
Always believe a woman who discloses abuse(2). The perpetrator may have told her that no-one would believe her - your belief in her story is vital.
All substance misuse services need to develop specific domestic violence policies, together with appropriate protocols and guidelines for responding to clients who have experienced domestic
violence(3)
We recommend that all substance misuse services should appoint a member of staff with designated responsibility for domestic violence issues, in order to promote and implement these policies and guidelines, and to work in partnership with local domestic violence organisations to take this agenda forward.
All those working in substance misuse services should be given regular training on domestic violence awareness issues. Your local Women's Aid organisation or Domestic Violence Forum should be able to help with accessing appropriate training.
Ensure that your service is accessible to women of all races, ethnicities, cultures, ages, sexualities and abilities. Culturally appropriate services should be developed for those from minority ethnic groups, in consultation with them. Interpreters should be available to call on when necessary(4): the use of partners or children or other relatives is inappropriate, and may prevent any disclosure of abuse.
Organisations should work towards introducing routine questioning about domestic violence (experienced or perpetrated) during their initial assessment of all new clients, provided that this can be done safely, and never in the presence of a partner or other family member. Such questions should not, however, be introduced without appropriate training so that staff feel confident and able to respond appropriately to disclosures of abuse.
When domestic violence is disclosed, it should be documented carefully. Evidence can be important when the perpetrator has been charged with an assault, in helping an abused woman obtain protection through the civil courts, or - when a woman is subject to immigration restrictions - in assisting with an application for leave to remain in the UK under Part 8 (Domestic Violence) of the Immigration Rules.
Safety planning must be treated as a priority, whenever a client discloses abuse.
Risk assessments should include consideration of the risk to the client from others, including partners, former partners, family members, and others within the household. There should also be an assessment of the risks to other vulnerable people within the household - e.g. children, or older people. Assessments need to include the risks involved when domestic violence and substances are both present.
When a service user is identified as a perpetrator of domestic violence, substance misuse workers need to be aware that his use of violence will not necessarily decrease as a result of addressing his alcohol or drug use, and may increase as a result of treatment. This is particularly likely during stages of withdrawal or rapid reduction of drug or alcohol use. The physical and emotional safety of those experiencing the violence must always be treated as the first priority. In such circumstances, workers should ensure that the partner receives support and information about options and services, provided this can be done without further endangering her or her children(5).
Women living with domestic violence will not necessarily want to end their relationships, or may decide to return to an abusive partner. They should be offered a choice of options, time to talk these through and non-judgmental support in making their own choices.
Women who want to reduce or stop using substances may not necessarily want to end an abusive relationship at the same time. Nor will ending the relationship necessarily stop the abuse: many women experience the most severe violence after separating from their abusers.(x)
Substance misuse treatment services should not insist on "sobriety first" but respond to the issues of domestic violence and substance misuse simultaneously: this applies when working with either survivors or perpetrators of domestic violence.
All staff working in substance misuse services should be aware of local and national domestic violence services, and how they can be contacted when needed; and they should ensure that this information is easily available to women service users(6). In most areas, specialist refuge provision for women with drug or alcohol issues is not available; but all refuge organisations will offer support and information, and will assist women who have been abused in accessing appropriate service provision.
Service providers may need to be particularly aware of confidentiality and safety if both partners are in treatment, or if they are considering involving partners in discussions over treatment. This may be of particular concern if a woman enters residential treatment; or if her partner is caring for her children while she is in residential treatment.
Confidentiality needs to be balanced with safe information-sharing: organisations should develop information-sharing protocols for use when referring clients to other services, such as refuge organisations or other domestic violence services.(xi)
Women clients should be offered the choice of a female key worker or counsellor, or women-only group work, as appropriate. Women-only services are particularly important when both partners are receiving treatment; or when women services users do not wish their partners to know they are accessing services.
Child protection policies and procedures should be fully explained to clients, to enable their fears (for example, that their children might be taken away) to be addressed. When child protection concerns are raised, appropriate support should be given to women to enable children to stay with their mothers whenever possible. Those investigating child protection concerns should take care to avoid increasing the danger for women and children.(xii)
When women have to leave home because of domestic violence, they should be able to transfer easily and quickly to relevant treatment in their new area.
Treatment should always include exploration of the links between a woman's use of substances and past and current abuse she has experienced. The impact of domestic violence on a woman's health, well-being and use of alcohol and/or other drugs needs to be acknowledged explicitly.
Posters, leaflets and other information about domestic violence services should be displayed within all substance misuse settings.
Substance misuse services should develop partnership working with other organisations, including domestic violence organisations. Representatives should attend local domestic violence forums, Crime and Disorder Reduction Partnerships, and other appropriate inter-agency organisations.
Service users should be involved in planning and development of services.

Above all, the ongoing safety of women and children must be paramount.

For further information:

- Women's Aid website: www.womensaid.org.uk
- The Stella Project has produced a Toolkit for working with domestic violence, drugs and alcohol: Domestic Violence, Drugs and Alcohol: Good Practice Guidelines (2004); contact Michelle Newcomb, The Stella Project Co-ordinator, The Greater London Domestic Violence Project, Third Floor, City Hall, The Queen's Walk, London, SE1 2AA; tel: 020 7983 4510; email: Michelle.Newcomb@london.gov.uk
- See also Department of Health (2000) Domestic Violence: A Resource Manual for Health Care Professionals.
- Freephone 24 hour National Domestic Violence Helpline run in partnership between Women's Aid and Refuge: 0808 2000 247
- Respect phoneline for perpetrators: 0845 122 8609

These Principles of Good Practice are a product of the Women's Aid Mental Health, Substance Misuse and Domestic Violence Project, a three year initiative funded by the Department of Health. The first part of this project was a national survey to gather information on existing services. The Report of that survey, Struggle to survive, is available from Women's Aid, price £10 (£8-50 for Women's Aid members).

In developing these Principles of Good Practice, I have had helpful comments from a number of people, and am particularly grateful to Michelle Newcomb from the Stella Project, and to Jane Lewis, Domestic Violence Policy Officer, Nottingham City Council.

Please send any comments on this Guidance to:

Jackie Barron
Health Project Worker
Women's Aid National Office,
Bristol,
BS99 7WS
Telephone: 0117 915 7451
Email: j.barron@womensaid.org.uk

Final draft 24/1/05

Footnotes:
1. We acknowledge that a small minority of domestic violence perpetrators may - because of severe mental illness, dissociative disorder, or mental incapacity - not be held fully responsible in law for their abusive behaviour; nonetheless it is important to acknowledge that their actions (rather than those of the victim) led to the resultant outcome. Use of alcohol or drugs - by either party - should never be accepted as a justification for violence.
2. It is particularly crucial to take seriously any allegations of abuse by those who are most vulnerable and most likely to be disbelieved; for example, women with learning disabilities or who suffer from psychotic disorders. In only a small minority of such cases will allegations be completely misfounded.
3. Some organisations will have Adult Protection procedures or Vulnerable Adult policies, based on the Department of Health's No secrets guidance (2001). These policies are complementary to, but not a substitute for, specific domestic violence policies and procedures.
4. All interpreters should be accredited and should sign binding confidentiality agreements.
5. See Further Information at the end of this Guidance: perpetrators should only be referred to programmes which comply with Respect minimum standards.
6. See Further Information at the end of this Guidance.

References:
(i) Findings from the British Crime Survey self-completion module on interpersonal violence show that whereas 45% women and 26% men had experienced at least one incident of inter-personal violence in their lifetimes, women are much more likely than men to be the victim of multiple incidents of abuse, and of sexual violence, and are more likely to be injured as a result. Walby, Sylvia and Allen, Jonathan (2004) Domestic violence, sexual assault and stalking: Findings from the British Crime Survey (London: Home Office Research, Development and Statistics Directorate. In this Guidance we will for convenience refer to the victim/survivor as female and the perpetrator as male. However, we expect the same principles to apply regardless of the gender of either party.
(ii) The Stella Project (2004) Domestic violence, drugs and alcohol: Good Practice Guidelines (London: The Stella Project), p.43.
(iii) Raine, Pamela (2001) Women's perspectives on drugs and alcohol: The vicious circle (Aldershot: Ashgate)
op.cit.; Stark, E. and Flitcraft, A. (1996) Women at risk: Domestic violence & women's health (Thousand Oaks, California: Sage); Jacobs, John (December 1998) The links between substance misuse and domestic violence: Current knowledge and debates ed. by Mary-Ann McKibben and Fran Walker (Alcohol Concern and Institute for Study of Drug Dependence (ISDD); Ettorre, Elizabeth (1997) Women and alcohol: A private pleasure or a public problem? (London: The Women's Press.)
(iv) This became apparent when undertaking the Women's Aid survey of drug and alcohol services. See Barron, J. (2004) Struggle to survive: Challenges for delivering services on mental health, substance misuse and domestic violence (Bristol: Women's Aid Federation of England).
(v) Stark, E. and Flitcraft, A. (1996) op.cit.; Maryland Department of Health, Journal of American Medical Association 2001, quoted in Lewis, Gwynneth, Drife, James, et al. (2001) Why mothers die 1997-1999: Report from the Confidential Enquiries into Maternal Deaths in the United Kingdom (London: RCOG Press).
(vi) Shaikh, Zaibby and Nez, Farah (2000) A cultural cocktail: Asian women and alcohol misuse (Hounslow: EACH).
(vii) Swan, Suzanne, Farber, Stephanie, Campbell, Donna (2000) Violence in the lives of women in substance Abuse treatment: Service and policy implications Available from www.womensconsortium.org; the Stella Project (2004) op. cit. p.71.
(viii) Taylor, Holly (2003) Domestic violence and substance misuse: Making the links: An evaluation of the service provision in Tower Hamlets (London Borough of Tower Hamlets: Tower Hamlets Partnership and Learning Design Ltd.); the Stella Project (2004) op. cit. p.71 and passim.
(ix) Taylor, H. (2003) op.cit.
(x) Humphreys, C. and Thiara, R. (2002) Routes to Safety: Protection issues facing abused women and children and the role of outreach services. (Bristol: Women's Aid Federation of England); Lees, S. (2000). "Marital rape and marital murder" In Hanmer, J. and Itzin, C. (ed.). Home Truths about Domestic Violence: Feminist Influences on Policy and Practice: A Reader. (London: Routledge.)
(xi) See Douglas, Nicola, Lilley, Sarah-Jane, Kooper, Liz, and Diamond, Alana (2004) Safety and justice: Sharing personal information in the context of domestic violence - An overview (London: Home Office Development and Practice Report 30). This is a useful guide to the issues.
(xii) Useful publications include: Advisory Council on Misuse of Drugs (2003) Hidden harm: Responding to the needs of children of problem drug users (ed. by Dr. Laurence Gruer); Carr, Deborah (2003) Pilot project for the provision of childcare to enhance attendance at the Iceni Project treatment Services (Suffolk Drug Action Team). The Stars project in Nottingham, supported by the Children's Society, is a potential model for a child-centred service for children of drug-using parents. (Reported in The Guardian , 31/03/04.) See also www.usingwomen.org.uk; and www.the-childrens-society.org/.