Sanctuary for the Abused
Tuesday, March 11, 2008
The Hidden Face of Addiction
When is Domestic Violence a Hidden Face of Addiction?
by Richard Irons, M.D., FASAM*, and Jennifer P. Schneider, M.D., Ph.D.**
Journal of Psychoactive Drugs, Vol 29, pages 337-344, 1997.
This article reviews studies pertaining to comorbidity of domestic violence, addictive disorders, and sexual abuse, and presents a model in which domestic violence parallels the chief features of chemical dependency. Domestic violence and addictive disorders have a number of common characteristics, including loss of control, continuation of behavior despite adverse consequences, preoccupation or obsession, development of tolerance, and family involvement. Domestic violence predisposes the next generation to both domestic violence and addictive disorders. Sexual abuse within the family of origin and/or the couple relationship are common features of both domestic violence and addictive disorders, and predispose to both in the next generation. Clinicians encountering patients who are perpetrators or victims of domestic violence or sexual trauma, or have addictive disorders, must assess for the presence of either of the other problems.
"I first experienced the effects of alcohol at age four. My father came home from work late one night, staggering and intoxicated. He and my mother got into a terrible fight. They were hitting each other. My mother drew a kitchen knife out of a drawer and held it up to defend herself. She asked me to go across the street to my grandmother's house to get her. She was the only person who could control my father once he had begun drinking."Introduction
-- Comments at an AA meeting
Domestic violence may be defined as one or more types of physical, sexual, mental, emotional, psychological or verbal assault perpetuated by one relational partner upon another, typically a spouse or partner in a committed relationship. Domestic violence and addictive disease will be seen to have a number of common features. However it is defined, domestic violence involves an effort to control another person by force, coercion and /or intimidation.
Domestic violence, spouse abuse, and battering all refer to the victimization of a person with whom the abuser has had an intimate relationship. It is generally repeated, and often escalates within relationships (AMA Council on Ethical and Judicial Affairs, 1992). Investigation and research on domestic violence and its impact on domestic partners, families, children, as well as its association with violence expressed in our society, has accelerated greatly over the past two decades. Violence of all types is graphically presented to us as both news and entertainment by the media every day.
Statistics on the prevalence of domestic violence alone in North America are staggering and difficult to fully appreciate. Nearly one fourth of women in the United States will be abused by a current or former domestic partner within their lifetime (AMA, 1992; Warshaw, 1993). A Bureau of Justice report on emergency care in 1994 indicated that about 17% of the 1.3 million people treated for nonfatal violence related injuries in emergency care facilities in 1994, or 243,000, sustained their injuries from someone with whom they had an intimate relationship. More than a third of these women ( 38.6%) were hurt by a current or former spouse or domestic partner. "Domestic violence is seriously underreported to law enforcement authorities, said a Justice Department official (AMA News, 1997). When 491 women presenting to a Denver, CO, emergency department for any reason were asked three brief screening questions for detecting partner violence, 29.5% admitted to having been battered within the previous year ; overall, 13.7% of the visits were the result of acute episodes of partner violence (Feldhaus et al, 1997). Similar results were obtained in an inner-city emergency department, where among 516 patients appearing for any reason, 28% of men and 33% of women had experienced past physical violence (Ernst et al., 1997). Battery is the single most significant cause of injury to women in the United States. However, only about one in 20 (5%) who enter the healthcare system have the etiology of their trauma correctly identified as spousal abuse (Rodriguez, 1994).
Batterers come from all socioeconomic groups, cultural backgrounds, and sexual orientations; in one study, 63 percent of abusers reported having seen their mothers abused when they were children themselves (AMA, 1992). In the United States, battered women comprise 22Ð35 percent of women seeking care in emergency rooms, 14Ð28 percent of female ambulatory care patients, 23 percent of women who are seeking prenatal care, 25 percent of women presenting for psychiatric emergency care, and 64 percent of female patients admitted to an inpatient psychiatric service, according to articles reviewed by Warshaw (1993).
The Canadian statistics are no better: One woman in six is physically or sexually abused by her husband, ex-husband, or live-in partner (Lawson, 1992). For 70 percent of all pregnant wife assault victims, the violence begins or increases during pregnancy (Bain, 1989). Family violence accounts for 60 percent of all murders of women in Canada (MacLeod, 1987). Several Canadian studies have shown that more than 50 percent of batterers suffer from alcoholism, antisocial personality, or recurrent depression (Bland & Orn, 1986; Hoffman & Toner, 1988; Stark et al., 1981; and Van Hasselt, Morrison, & Bellack, 1985).
Domestic violence is far more than a single episode of trauma. On average, a woman will be assaulted 35 times before contacting the police (Bain, 1989). Approximately 47 percent of husbands who beat their wives do so three or more times a year (AMA, 1992).
In a recent study of 62 assault victims seen in a Tennessee emergency room, 89% reported previous assaults by their current assailants, 35% on a daily basis (Brookoff et al, 1997.) Rape is a significant or major form of abuse in 54 percent of violent marriages (AMA, 1992). Among battered women who are first identified in a medical setting, 75 percent will go on to suffer repeated abuse (Warshaw, 1993). Of women over the age of 30 who have been raped, 58 percent were raped within the context of an abusive relationship (AMA, 1992; Warshaw, 1993).
Domestic violence can, and in many cases does, lead to permanent physical and emotional injury and even mortality. An FBI report for 1990 noted that 30 percent of women murdered that year alone were killed by their husbands or boyfriends (AMA, 1992). It is currently estimated that approximately two million domestic partners will be physically assaulted by their spouses or live-in partners in any single year (AMA Council on Scientific Affairs, 1992), and that 2,000Ð4,000 of them will die as a result of battering (Eichelman, 1994). This represents a mortality rate of 0.1 percent.
Increasing attention is now being focused on the problem of male victims of domestic violence. As stated above, a recent study of 233 men appearing for any reason in an inner-city emergency department found (Ernst, 1997 that 28& of the men (compared with 33% of 283 women) had experienced recent physical violence. The authors pointed out that some experts in this field believe that attention directed at domestic violence against men will detract from the significance of domestic violence in women and the more limited choices this group has in responding to this problem. They conclude by saying "Recognition of the global nature of violence may be more realistic than assuming that only women are victims" (pg. 195-6). . Men who stay with abusive wives describe the disbelief they receive from family, friends, and law enforcement officials to whom they turn for help, and express their fear of losing custody of their children should they choose to leave the abusive relationship (ABC's "20/20" news show, September 19, 1997); in fact, none of the men interviewed who had left their wives were able to obtain custody of their children.
Parallels between domestic violence and addictive disease
A number of common features can be found between domestic violence and substance related disorders. They often intersect with each other to compound the challenge of effective intervention, complicate treatment of each disorder, and predispose to relapse of either behavior. This paper will review the interrelationship of these two related social and family behavioral disorders. Addressing their many manifestations is crucial to the success of treatment of addictive disorders, and the prevention of domestic violence.
In the early days of alcohol treatment, it was believed that attaining and maintaining sobriety was fundamentally a matter of attending Alcoholics Anonymous meetings and "keeping the plug in the jug." Multiple studies, however, attest to the need to address other aspects of the addict's life in order to attain a good quality of recovery and prevent relapse to substance use. Primary exacerbating factors include (1) the role of violence in the family and (2) the frequent presence of multiple addictions. The interrelationship between these factors commonly serve to keep the patient and family stuck in active addictive disease.
One way to illustrate the behavioral parallels between violence and chemical dependency is to review the DSM-IV criteria for substance dependency [DSMIV, p. 181] and consider their application to domestic violence. The DSM lists seven criteria, which can be summarized as:
(1) loss of control [criteria (3) and (4)]
(2) continuation of behavior despite adverse consequences [criteria (6) and (7)]
(3) preoccupation or obsession [criterion (5)]
(4) tolerance [criterion (1)]
(5) withdrawal [criterion (2)]
Domestic violence also involves a loss of control-but in this case it is a loss over the control of anger rather than substance use. The loss of control seems to progress, with less provocation and increasing amounts and severity of violence over time. There are characteristically periods of contrition, when the abuser promises to reform and refrain from ever using violence again. The time between the thought or impulse to act upon anger and the behavior seems to diminish, much like the tendency of substance dependency to progress to impulsive as well as compulsive substance use.
In both these disorders, the behavior continues despite adverse consequences. Domestic violence continues despite knowledge that physical injuries have been sustained by the partner and symptoms of traumatic stress, intimidation and emotional pain are present. The source of problems is characteristically blamed on others, particularly the spouse or partner, or external causes, even the use of mood altering substances. " If I hadn't been drinking I would never have hurt you." In relationships where domestic violence is present, important social, occupational, family, and recreational activities are frequently given up or very restricted and controlled by the abuser.
Over time both the abuser and battered partner become preoccupied with the behavior, even when violence is not presently occurring or being threatened. A great deal of time is spent either anticipating or fearing violence, recovering from past consequences or associated physical or emotional sequelae, or engaging in efforts to avoid setting off any further episodes of violence.
Tolerance develops to not only the threshold for defining uncontrolled anger and unacceptable behavior, but also the ability to endure physical, emotional, and sexual trauma and pain. In addition the abuser often believes that increasing threats, control and more severe violent behavior is necessary to adequately control the victim as the relationship progresses. Exchange of pain and antagonistic action is not uncommon as the battering relationship progresses. Withdrawal is often experienced in these relationships as a period of anxiety or tension that follows episodes of violence. Over time the periods of contrition described in the classic cycle of violence seem to diminish, and the periods of tension in anticipation of further violence increase in duration and intensity.
The parallels between domestic violence and substance dependency are graphically outlined in Table 2.
Table 2: Characteristics of Domestic Violence
Parallels with DSM-IV
(1) loss of control: The abuser is contrite after the abuse, promises not to do it again, but inevitably does so.
(2) continuation despite adverse consequences: The victim experiences emotional, sexual, and physical damage and loss of self-esteem; abuser experiences remorse and guilt at times, but the abuse continues.
(3) preoccupation or obsession: Abuser is preoccupied with controlling the victim and
(when sexual violence is involved) maintaining access to sexual gratification.
(4) tolerance: Initially a testing of violence; the victim gets desensitized and tolerates increasing levels; the violence escalates in frequency and/or intensity and/or diversity.
There are many other parallels between chemical dependency and domestic violence. Some of the items outlined in Table 3 are self-evident, while others merit additional comment. The addictive cycle (Carnes, 1983), which is applicable to all addictive disorders, consists of preoccupation with the addictive behavior, rituals associated with the behavior, acting out, and remorse or guilt and shame. The remorse is relieved by preoccupation, and the cycle continues. The battering cycle (Walker, 1979) consists of the tension-building phase, the explosion or acute battering incident, and the calm, loving respite which is based on the batterer¹s remorse.
For both addictive disorders and domestic violence, involvement of the workplace is a late manifestation. Intoxication at work, or sexual exploitation within the professional setting, is indicative of severe progression of an addiction; similarly, irritability and rage in the workplace is more typical of a late-stage batterer, who for a long time is able to restrict his outbursts to the home environment.
Both victims of domestic violence and partners of addicts often have difficulty leaving. In addition to realistic fears of escalation of violence and consideration of financial and parenting constraints, both types of domestic partners often get caught up in a cycle of codependency, where they blame themselves for the current situation and feel that if they are only able to do particular things better, the situation will improve. Attendance at Al-Anon and similar 12-step programs can help both types of partners to improve their self-esteem and place themselves in a situation where they are able to make appropriate choices for themselves (DellaCorte, 1985).
Table 3: Other parallels between Domestic Violence and Addictions
Domestic violence and addictive disorders have the following common features:
1. They adversely affect intimacy and sexuality.
2. Constitute family disorders, and adversely affect all family members across generational lines.
3. Involve ritualization of behavior: The cycle of violence and cycle of addiction both include periods of escalation of behavior often followed by a time of contrition and promises to change and give up the behavior, followed by a time of increasing tension and then a return to behavioral acting out.
4. Involve the use and abuse of power for personal gain and gratification: There is ego expansion and relief of tension when using substances and with the exertion of or threat of violence.
5. Initially tend to be restricted to the home environment, but in late disease stages may involve behavior expressed in the workplace.
6. Result in shame, guilt, decreased self esteem and emotional numbness.
7. Characterized by denial, minimization, and rationalization.
8. Domestic partners and family members have great difficulty intervening upon, or abandoning the affected individual
Violence and addictive disorders coexist.
Domestic violence and family violence are associated with substance-related disorders. Alcohol sharply diminished impulse control; drugs of greatest concern are stimulants, as they can increase paranoia and lead to preemptive violence. In a survey of 12,360 children from single-family households where at least one parent filled out an alcohol use questionnaire, children of women classified as problem drinkers had more than twice the risk of serious injury as matched controls. There was a statistically significant relationship between the number of alcohol-related problems the women had and the risk of injury to their children (Bijur et al, 1992). Nearly 75% of all wives of alcoholics have been threatened, and 45% have been assaulted by their addicted partners (AMA, 1992).
In a recent study of 62 episodes of domestic assault in which police were summoned, 92% of the assailants reportedly used alcohol or other drugs on the day of the assault, and 72% had a prior arrest for substance abuse (Brookoff et al., 1997).In a study of 400 women, 67% of their batterers frequently abused alcohol. However, not all batterers drink. To assume that alcohol causes battering is to relieve the batterer of responsibility and to deduce that violence will cease with abstinence. In actuality, while substance abuse and violent behavior frequently coexist, the violent behavior will not end unless interventions address the violence as well as the addiction (AMA, 1992.)
Not only is domestic violence perpetrated by the alcoholic spouse on the sober spouse, it is also inflicted on the alcoholic spouse by the sober spouse. This is particularly true when it is the woman who is drinking. Several studies have found an association between female drinking and increased victimization in marital violence (Miller and Downs, 1993; Kaufman-Kantor and Straus, 1989). According to a 1992 U.S. survey of alcohol and family violence, a wife¹s drinking, whether alone or with her husband, led to more severe violence both by and toward the wife (Wisnack et al., 1994). In a study of 100 alcoholic women physicians (Bissell & Skorina, 1987), 22 women had been beaten and 21 had beaten spouses or lovers themselves.
"Date rape" is also facilitated by substance abuse. Two studies show that up to 50% of sexual assaults by acquaintances involve alcohol consumption by the victim or the assailant (Koss et al, 1987; Muehlenhard and Linton, 1987). In an acquaintance rape situation, both men and women who learn about it consider the incident less likely to be a rape if the victim and assailant had been drinking together (Norris & Cubbins, 1992). Both men and women attributed more responsibility for the assault to an intoxicated rape victim than to a sober one; at the same time, the offender was blamed less when he was drunk than sober. This attitude makes women who have been sexually assaulted while drinking, more reluctant to report it.
Domestic violence in lesbian relationships occurs at about the same rate as in heterosexual relationships, and as in heterosexual relationships, alcohol may play a large role. Several studies report that almost one-third of all women who identify themselves as lesbians drink excessively or experience alcohol-related problems (Norris, 1994). In a mail survey of members of a lesbian organization, 37% reported being in a past or present abusive relationship. 64% reported that alcohol or drugs were involved prior to or during incidents of battering. Drinking was significantly correlated both with being the victim of abuse and with being the perpetrator (Schilit et al., 1990).
Addictive sexual disorders (Irons & Schneider, 1997) are frequently associated with domestic violence, although no statistical studies on this association are yet available. Many of the same factors that predispose an individual to the development of an addictive or compulsive sexual disorder can also predispose one to being a participant in a violent relationship.
Addictive sexual disorders
When a person evidences a pervasive pattern of sexual behavior over which there is loss of control, continuation despite adverse consequences, and which includes preoccupation or obsession, that person has an addictive sexual disorder. The range of fantasies, urges, and behaviors that can be considered addictive sexual disorders may be appreciated by reviewing the ten categories developed by Carnes (1991):
Table 4: Categories of Addictive Sexual Disorders
1. Fantasy sex: Sexual fantasy life and consequences due to obsession.
2. Seductive-role sex: Seductive behavior for conquest. Multiple relationships, affairs, and unsuccessful serial relationships.
3. Anonymous sex: Engaging in sex with anonymous partners, having one-night stands. Engaging in sex on the internet with people you don't know or barely know.
4. Paying for sex: Paying prostitutes/escorts for sex, paying for sexually explicit phone calls.
5. Trading sex: Receiving money or drugs for sex or using sex as a business. Highly correlated with swapping partners and using nudist clubs to find sex partners.
6. Voyeuristic sex: Forms of visual sex, including pornography, window peeping, and secret observation. Highly correlated with excessive masturbation, even to the point of injury.
7. Exhibitionist sex: Exposing oneself in public places or from the home or car, wearing clothes designed to expose.
8. Intrusive sex: Touching without permission, using position or power (e.g. professional, religious) to sexually exploit another person, mental coercion & lying, rape.
9. Pain exchange: Causing or receiving pain to enhance sexual pleasure. Use of dramatic roles, sexual aids, and animals are common themes.
10. Exploitative sex: Use or force or partner vulnerability (emotional/mental) to gain sexual access. Examples include sexual assault and professional sexual misconduct.
Schneider & Irons (1996) placed addictive sexual disorders within the context of the DSM-IV (1994). Addictive sexual disorders, although not a separate disorder within this manual, are subsumed within several diagnostic categories in the DSMIV: paraphilia, impulse control disorder, or sexual disorder not otherwise specified.
Five of Carnes¹ categories can be readily identified in the DSM-IV as specific paraphilias. Paraphilias are defined as recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations that occur over a period of at least six months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The five categories that constitute paraphilias include voyeuristic sex, exhibitionistic sex, pain exchange (sexual sadism, sexual masochism), some types of intrusive sex (frotteurism, or inappropriate touch), and exploitative sex (pedophilia). Four of the remaining categories may be correlated with paraphilias: fantasy sex may be associated with paraphilic urges not acted upon, anonymous sex may be used to express paraphilic behavior with decreased risk of consequences, and paying for sex and trading sex are means by which a partner who may permit paraphilic activity may be purchased. A few cases of sexual excess represent an impulse-control disorder; most cases can best be viewed as an addiction.
In an intimate relationship in which at least one of the partners has an addictive sexual disorder, domestic sexual violence may be part of the addictive pattern. Fearful of abandonment or rejection, the partner is often vulnerable to coercion into participating in unwanted sexual activities. In a study of 100 couples recovering from sexual addiction, 50% of the non-addicted partners reported having engaged in sexual activities with which they were uncomfortable. In some cases these activities included sex in public places or with additional sexual partners (Schneider, & Schneider, 1990).
Domestic violence predisposes the next generation to domestic violence and to addictive disorders.
Family violence, especially childhood sexual abuse, predisposes to addictive disorders. Among 424 women in primary care internal medicine practices who reported childhood or adolescent physical or sexual abuse, the prevalence of alcohol abuse was 4.7 times that among 1,257 women who reported never having experienced abuse (McCauley et al., 1997). The prevalence of incest and other childhood sexual abuse is significantly elevated among women in alcoholism treatment (Miller et al., 1993; Russell & Wilsnack, 1991).
Childhood abuse results in an impairment of the self that predisposes an individual to addictive behaviors in many areas (Young, 1990). Alcoholic women, female drug addicts, and bulimic women all have a high incidence of childhood sexual abuse (Young, 1990). Both male and female sex addicts have an extraordinarily high rate of childhood sexual abuse (87%), physical abuse, and emotional abuse (Carnes, 1991).
Carnes and Delmonico (1996), in a study of 290 recovering sex addicts, found that the greater the frequency of sexual and/or physical abuse in childhood, the greater the number of addictions they developed in adulthood. In addition to sex, the adult addictions included alcohol and other drugs, codependency, eating disorders, nicotine, gambling, spending, and working.
Family violence also predisposes to more violence. Sexual abuse in childhood or adolescence is often sustained and then repressed or split off during growth and development. Children may witness the expression of violence between their parents and infer hat this is a normative pattern between partners. They may remember not only the incident but also the associated emotionally-charged responses to these events. A confusing mixture of shame, pain, fear, guilt, excitement, and stimulation may be imprinted which is unconsciously and often indirectly expressed in a relationship decades later. Physical force or the threat of violence may then be used to assert power and control over a domestic partner.
Partner abuse, sexuality, and addictions.
Rape is a significant or major form of abuse in 54% of violent marriages (AMA, 1992). Of women over the age of 30 who had been raped, 58% were raped in the context of an abusive relationship (Warshaw, 1993).
Alcoholic women are more stigmatized in our society than are men, and are often considered to be sexually promiscuous, or more sexually available. This assumption leads to the acceptance of sexual aggression toward a drinking or drug-using women. Rape, domestic violence, and other victimization are far more common in the experience of chemically-dependent women compared to other women in their communities (Blume, 1994).
Physical violence may be brought into the couple's sexual relationship. Coercion may at first be exerted through the use of guilt, derogatory comments about sexual appetite or interest, threats to "go elsewhere" to meet sexual needs, and later progress to more overt coercion and insistence on sexual performance. The prospect of another argument or possible physical injury may lead one partner into a pattern of unwanted sex. Many women at this junction are at risk of developing an aversive sexual disorder. By now there may be a significant alteration in the patterns of sexual expression within the relationship. Sex may deteriorate into degradation, bondage, or even rape.
Under threat of further physical and/or emotional violence, the spouse may be coerced into unwanted anal sex (considered by some a common manifestation of domestic violence), into role play and dressing in objectionable articles of clothing, into using sex toys, exposing her body publicly, having unwanted cosmetic surgery, or submitting to other degrading or humiliating practices.
In some cases these activities indicate the presence of an addictive sexual disorder in the abusive partner. For some sex addicts, exerting dominance sexually can be extremely intoxicating and reinforcing. Rarely, a domestic partner will actually be a willing participant in a shared sadomasochistic disorder. More commonly, the partner's own vulnerabilities make him or her vulnerable to emotional intimidation, if not physical danger.
Discussion and Conclusions
Domestic violence is frequently associated with addictive disorders. Active drug use is often present during abuse episodes, and , for alcoholics and addicts, maintenance of sobriety is a key element in preventing further domestic violence. However, it must be stressed that chemical dependency is not the cause of domestic violence. The drug-abusing perpetrator of domestic violence must be considered to have two primary disorders, each of which requires separate treatment.
Domestic violence and addictive disorders do not just frequently coexist; they actually share many features. These include loss of control, continuation despite adverse consequences, preoccupation or obsession, tolerance and withdrawal, involvement of the entire family and in fact of multiple generations, and use of the, defenses of denial, minimization, and rationalization. In both cases it is difficult for the partner to leave. Viewing domestic violence within the addiction paradigm can help the clinician better understand this disorder and may suggest some treatment strategies for both members of the couple which have been helpful in recovery from addictive disorders. Fore example, domestic violence victims may benefit from attendance at mutual-help programs modeled after AA.
The connection between domestic violence, chemical dependency, and sexual abuse also needs greater attention. Childhood sexual abuse is a frequent antecedent of adult chemical dependency as well as adult addictive sexual disorders. Domestic violence is at times expressed sexually as well as physically. Sexual addicts at times impose their sexual agenda at home, either with their partners or, less commonly, by sexual molestation of their children; such coercion is a type of domestic violence. Sexual abuse of the adult partner or of the children may be facilitated by prior use of alcohol as a disinhibitor. When any of these disorders Ð domestic violence, chemical dependency, and sexual abuse --are in question, the clinician must elicit information about all of them.
One of the most disturbing aspects of domestic violence is that it is a multigenerational disease; when present in the family, it is likely to be transmitted to the next generation. It is important for health care professionals to intervene in the domestic violence/addictive disease cycle not only for the sake of the identified patient and his or her partner, but also because it is the most effective way to prevent violence and addiction in the next generation.
In order to accomplish this goal, physicians must become more proactive in identifying the presence of domestic violence as well as addictive disorders in our patients. Because of the high comorbidity between addiction and domestic violence, addiction treatment providers in particular are likely to have a large unidentified cohort of patients who are experiencing domestic violence, either as perpetrators or as victims Ð or both. It is incumbent upon addiction specialists to consider this diagnosis in our patients, to ask questions about domestic violence, to know the community resources available to help victims and perpetrators, and to develop a strategy for dealing with patients who are experiencing domestic violence. Guidelines for managing domestic abuse when male and female partners are patients of the same physician were recently published (Ferris et al., 1997); they will assist the clinician in managing this potential conflict of interest.
*Associate Medical Director, Addiction Recovery Services, Menninger Clinic, P. O. Box 829 , Topeka, KS 66601-0829.
**Arizona Community Physicians, 1500 N. Wilmot, Suite B-250, Tucson, AZ 85712
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