SUDPs and IPV perpetration
Generally, substance use disorder treatment programs were not addressing co-occurring violence in a formal and comprehensive way when we considered the in-program practices of client intake, treatment, and monitoring. Few SUDPs (only 39 of 241 surveyed; 16%) had a policy requiring potential clients to be assessed for violence perpetration, although most (68%) assessed potential clients’ violence perpetration at least sometimes. Almost one-quarter of SUDPs did not admit potential clients who perpetrated IPV, and only about one-half followed up on referrals to determine that help was obtained. Anecdotal evidence suggested that non-admission of IPV perpetrators was due to staff perceptions that these clients needed mental health services beyond the scope of the SUDP. Only 20% of SUDPs had a specific component or track to address violence, and only about one-quarter offered individual or group counseling for IPV perpetration.
The most common reasons SUDPs did not provide IPV services were that violence prevention was not part of the program’s mission, and staff members lacked training in violence prevention and management. Services outside SUDPs’ focus are often prohibited by reimbursement policies . That is, SUDPs are often not allowed to bill for IPV perpetration services and so do not provide them . However, such policies, as well as lack of staff training, are both remediable barriers . For example, regarding staff training, SUDPs could adopt an IPV prevention toolkit comprised of a DVD to illustrate clinical tools, a laminated counselor guide, and worksheets and wallet cards for clients to retain key points .
In SUDPs, monitoring violence among admitted clients appeared to be emphasized more than assessing violence among potential clients. Specifically, almost twice as many programs (N=75; 31%) had a policy requiring monitoring clients for violence. Still, only 48% of programs monitored violence at least sometimes. About one-third of SUDPs suspended or terminated clients known to engage in violence, and only 43% followed up on referrals to determine if terminated clients obtained help.
BIPs and substance abuse
In contrast, BIPs appeared to be addressing substance abuse in a relatively formal and comprehensive way. One-half (117 of 235 BIPs surveyed) had a policy requiring potential clients to be assessed for substance abuse, and 94% assessed potential clients’ substance abuse at least sometimes. Similar to SUDPs, one-quarter of BIPs did not admit potential clients with the cross problem, but a higher proportion (61%) followed up on referrals to determine if potential clients obtained help. In addition, 56% of BIPs offered group, and 29% offered individual, counseling related to substance abuse, and almost one-half of BIPs had a specific component or track to address substance abuse. SUD services were not provided in BIPs most often because they were not part of the program’s mission, and were not required for licensing, certification, or accreditation. Criteria for approving programs could be extended to include substance abuse assessment, treatment, and/or ongoing monitoring [43, 46].
Supporting the idea that BIPs were more fully addressing substance abuse than SUDPs were addressing violence, we also found that 64% of BIPs (N=151) had a policy requiring monitoring of substance abuse among clients, and 83% monitored substance abuse at least sometimes. However, 40% suspended or terminated clients known to abuse substances, and similar to SUDPs, only 42% followed up on referrals to determine if terminated clients obtained help. BIPs may focus more on substance abuse because of widespread recognition by BIP directors that substance abuse among their clients is a predictor of program dropout [47, 48].
It is possible that SUDPs placed less emphasis on addressing violence because their clients had fewer resources (marriage, job, income, housing) and more severe and numerous problems needing attention (both alcohol and drug use disorders, dual substance use and other mental health disorders, HIV + status). The difficulties of treating clients with multiple, complex problems may have competed with and dissuaded consideration of violence perpetration. Supplementary analyses (not yet presented) supported this hypothesis in that programs with higher proportions of clients who were unmarried, unemployed, and low-income, with both alcohol and drug use disorders, and both substance use and mental health disorders, were less likely to assess for and monitor the cross problem. On the other hand, SUDPs had a higher staff-patient ratio to address these challenges of the client population. Higher staff-patient ratios are indicative of higher quality care , but the larger number of staff members in SUDPs may make requiring all staff to be trained in violence prevention and management less practical; smaller staff sizes in BIPs may make cross training in substance abuse more feasible, despite possible higher costs of training per staff member should a trainer be brought in to the program. Notably, almost one-third of SUDPs did not have even one staff member with formal or informal training in IPV. More broadly, the NTCS identified large training gaps among addiction counselors that raise concerns about the integrity with which care is delivered , particularly to clients with co-occurring disorders and problems . Shortages of trained staff may be more severe in rural areas  where some SUDPs and BIPs were located. The provision of toolkits mentioned previously, in combination with web-based resources, may ease the difficulties of staff training in the cross-problem when programs have large staff numbers or rural locations.
Returning to the finding that SUDPs had clients with fewer resources and more severe problems, SUDPs may complete more frequent and thorough assessments of these problems than BIPs do, because SUDPs are administered by health agencies, and BIPs are administered within the criminal justice system. That is, SUDPs have the primary goal of service provision, whereas BIPs, as justice-related organizations, have the primary goal of public safety . Policy researchers have urged both the addiction treatment and criminal justice systems to move toward a more even balance between public health and public safety through systems integration . To achieve more integration between the SUDP and BIP systems, one step is to define and develop reliable and valid tools to measure such integration, and to institute policies to support integration. In addition, program directors could become experts on cross-problem evidence-based practices that they disseminate effectively to staff, and establish working relationships with cross agencies that encourage staff to collaborate and coordinate efforts [10, 53, 54]. Other suggestions are to use change teams within programs (e.g., a SUDP would select a change leader, who would gather ideas for addressing violence, focus on clients with a history of IPV perpetration to understand and consider their needs, and evaluate improvements to address violence), and to partner government agencies with multiple programs to support greater access to and implementation of cross services . For example, county probation departments that oversee BIPs could partner with SUDPs within their county to achieve better integration of services for substance abusing individuals who perpetrate IPV.
Service centralization and treatment integration
We found relatively little evidence that services are centralized for individuals with both substance abuse and violence-related problems. Roughly one-half of SUDPs and BIPs combined were able to help dual-problem clients via a call to only one phone number; SUDPs were more likely than BIPs to offer this aspect of centralization. However, about three-quarters of SUDPs and BIPs required clients with both problems to complete multiple sets of intake procedures. In addition, about three-quarters of SUDPs, and one-half of BIPs, did not provide help for both problems at a single location, despite findings that health care consumers prefer “one stop shopping” for co-occurring needs . Furthermore, about 80% of SUDPs did not share client records with any BIP, and about the same proportion of BIPs did not share client records with any SUDP. Although it is quite common for individuals to need help with both substance abuse and violence perpetration, these results show that services for these two interrelated problems are not centralized to facilitate client access and utilization.
As reviewed by Bennett , in practice, substance abuse and IPV perpetration have often been viewed as independent - separate problems with different interventions. Our data suggest that this view is held within the majority of both SUDPs and BIPs in that most directors endorsed the statement that help for both substance abuse and violence should be obtained at the same time, but in separate treatment programs. This is known as parallel treatment. There is some evidence that parallel treatment has positive effects on reducing substance abuse and domestic violence . The disadvantage of parallel substance abuse and batterer programs is that the time and financial commitments may become a burden, engender resistance in clients and their family members, and increase perceived hardship in an already-difficult situation . In addition, without explicit integration of treatment, clients may have difficulty managing the cognitive and affective components of battering intervention treatment during early abstinence. Specifically, individuals in early abstinence often experience memory loss, emotional dysregulation, and poor impulse control [57, 58].
Research also suggests that integrated substance abuse and family relationship treatment reduces both substance abuse and family violence for some couples. Our results show that a sizeable minority within both SUDPs and BIPs – about 30% -- endorse having help for both substance abuse and IPV perpetration integrated into one treatment program. In this regard, Behavioral Couples Therapy enhances both abstinence and relationship functioning to promote recovery and reduce violent behavior [59, 60]. Similarly, Brannen and Rubin found that for court-ordered men with alcohol problems, participation in a couples group produced greater reductions in physical abuse than did participation in a men’s group . Importantly, that study included components to protect victims’ safety . Couples counseling may be detrimental for victims experiencing the form of IPV known as intimate terrorism (the violence is embedded in a general pattern of the perpetrator attempting to exert control over the partner) rather than situational couple violence, in which specific arguments escalate to violence . In this regard, to ensure victim safety, couples counseling should be considered only after providers have had time to gain confidence that situational couple violence, rather than intimate terrorism, is occurring . Studies support conclusions that for some couples improvements in relationship functioning and substance use outcomes jointly account for reductions in IPV perpetration associated with substance abuse treatment .
In keeping with having clients with fewer resources and more psychological and medical difficulties, SUDPs had higher attrition rates than BIPs did . Average drop-out rates were 40% in SUDPs, and 32% in BIPs. In both types of programs, about 25%-30% were using substances at program discharge, and under 10% were engaging in partner violence. Increasing client retention rates may serve to improve outcomes [32–35]. One suggestion is to discuss possible barriers to retention with clients, so that they can be addressed. Common barriers are unmet social services needs (help with employment, housing, court hearings, child care) and lack of flexibility in scheduling around work and family requirements . In addition to improving retention rates, we need programs to collect more systematic follow-up information on SUDP, and especially BIP, clients.
This study had strengths and weaknesses. In terms of strengths, we achieved high response rates for this type of survey in samples of SUDPs and BIPs. We collected a substantial amount of useful information from both types of programs. Weaknesses are that we studied programs in only one state using a cross-sectional design with program-level outcomes, to the exclusion of client-level data. We did not independently audit each program; thus, the accuracy of data presented is based on reports by program directors, who may have slightly different responses in some cases than other staff members, such as clinicians . Even so, this dataset provides a useful benchmark against which to assess future efforts to link services addressing substance abuse and violence. In this regard, our survey showed that the great majority of SUDP and BIP directors agreed that more linkages and cooperation between the two communities would benefit clients.