A case study of domestic violence and addiction, including treatment options

1. MATILDA
A case study of domestic violence and
addiction

2. Initial incident
Matilda’s son has been arrested
for shoplifting.
During further investigation by
police and social services, the
family have been identified as ‘at
risk’.
A multi-agency ‘team around
the child’ will now be formed in
order to determine how to
progress with the case.

3. Matilda’s background…
 Matilda is a mother of 5
 She has spent her life as a ‘victim’ of domestic violence
 She is addicted to heroin, as well as other substances
 Her partner is her dealer who controls her supply
 He is also violent and is suspected of coercing her into prostitution in
exchange for drugs
 Her previous partner was also dealer who was violent towards her
 She came from a family where violence was normal
 She is extremely isolated and has no contact with family or friends

4. Matilda’s mental health
 Matilda has been diagnosed
with depression, anxiety and
agoraphobia
 These may be pre-existing
conditions, co-morbid with
complex PTSD, which may be
the root cause of the symptoms
 Matilda has extremely low self-
esteem and suffers from
paranoia (which unfortunately,
may be justified) about the
opinions others hold of her and
her abilities as a mother.

5. Matilda’s children
 Three of her five children have been diagnosed with attentional and
behavioural issues, such as ADHD
 This is more likely to be a result of a combination of complex PTSD,
complex grief and Matilda’s impaired parenting skills
 They have learned to be suspicious of ‘services’ in general and are
have become adept at hiding their problems.
 They are ‘outcasts’ at school, due to mild neglect i.e. poor diet,
unclean clothing

6. Perceptions
Without any knowledge, from an external perspective, Matilda is:
An addict
A prostitute
Am abusive/neglectful parent
The negative perceptions which are attached to these labels can have
a serious impact upon the way in which her case will be perceived by
service providers

7. Judgement
Many individual perspectives have an influence on the way that Matilda is treated.
Judgements from:
Social Workers
Teachers
Police men/women
Doctors
Judges
What judgement do you think that they should make?
Should the children be taken into care?
Should Matilda be prosecuted for her drug abuse?
Should she be prosecuted for prostitution?

8. Service provider perceptions
Research has shown that despite the extremely challenging
circumstances which Matilda is living in, some professionals harbour
negative perceptions in relation to victims of domestic violence.
Gover et al. (2011) & Horwitz et al. (2011) found that police officers
could not understand why victims did not leave their relationships
 DeJong et al (2008) found that victims were perceived to be
uncooperative

9. Service user perceptions
This is exacerbated by Matilda’s suspiscion and fear of services. A
study by Leisenring (2012) discovered that there were five main
themes for victims of IPV which affected their ability to interact with
police officers:
1. People who experience DV do not always identify themselves as
victims due to stigma
2. Women who seek assistance do so for different reasons
3. Some women are dissatisfied with police response
4. Women often believe that they will be wrongly arrested.
5. Women’s previous experiences with police affect their perceptions
of the CJS.

10. How best to intervene?
As previously discussed, one of the major reasons that women do not
report abuse, is due to threats for their partners and fears that police
will mishandle their case.
Matilda falls into this category. She also fears service providers.
Outreach Approach Criminal Justice Approach
Supports victims psychological
needs
Retribution & prosecution
Adapts programme based on
those needs
Rigid approach based on requirements
of system
Community care based Formal CJS system i.e. police, judge,
court

11. How to intervene?
Research by DePrince et al. (2012) found that when intervention was
outreach, rather CJS based, experiencers of IPV showed significantly
improved outcomes on scores for:
Depression
PTSD
Revictimisation
These are the major risk factors for women who have experienced
IPV.

12. How to intervene?
 Matilda fears both services and her partner
 Based on this evidence, in order to ensure her long-term
engagement in treatment, it may be more appropriate to take a care
based approach, rather than attempting to prosecute her partner for
violence against her.
 It would help to reassure her of her safety and make a permanent
break from her partner more likely in the long term.
 Even if Matilda’s partner will not be prosecuted for his behaviour,
the LA and partner agencies will still be required to carry out an
analysis of both risk and protective factors for the family.
 Both sides will be carefully considered before a care plan is
developed.
 This may include initiation of a care order.

13. Care proceedings
Ministry of Justice (2010) guidelines state that:
LA takes lead role in application for a care order
Certain thresholds must be met in relation to risk of significant harm
Where appropriate, partner agencies will be involved in an inter-
agency assessment of risk and protective factors.
This would include support from child and clinical psychologists.
A meeting is held with parents to discuss care and, if child is to stay
with parents, conditions which the LA expects to be met.
Parents are legally required to comply with conditions…

14. Risk Factors…
RiskFactor Impact
Long term abusive cycle and risk of revictimisation Severe
Psychological and physical harm to children Severe
Mental health issues (complex PTSD, depression, anxiety,
agoraphobia, repressed trauma, complicated grief)
Severe
Addiction Severe
Poor parenting skills (relationship is damaged and
imbalanced)
Significant
Isolation Significant
Fear of services Moderate

15. Protective factors…
Protective factor Impact
Has never lived without domestic violence High
Loves children and is scared of losing them Very high
Dislikes and has anger towards abusive partner – does not
identify as a ‘victim’
High
Children still attend school despite issues High
Although children’s activity is concerning, it could be worse! Moderate

16. Risk vs. Protection
The biggest decision service providers have to take is whether to take
Matilda’s children into care…
A review by Troutman et al (2000) found that attachment disruptions
were exacerbated by frequent changes in carer and that there was a
risk of unresponsive foster care.
Pilowsky & Kates (1996) found that many mental health crises in
young children were precipitated by a change in foster carer.
Bear in mind that there are five children – chances of placing them
together is slim

17. Risk vs. Protection
As we can see, taking children into care might reduce their risk of
harm but it does not necessarily ensure their wellbeing.
Generally, the decision to take children into care is made when the
local authority applying for the care order believes the child to be at
risk of significant harm which is “considerable, noteworthy or
important”.
The guidelines are quite fluid to allow LA’s to judge each case
individually…

18. Mitigation…
There is no doubt that the children are at significant risk of harm.
However, the LA has to weigh risks against protective factors in order
to ensure the best outcomes from the children.
In mitigation:
Matilda says she loves her children.
Many people have the false perception that a mother who loves her
children would not expose them to risk
Although Matilda’s parenting skills are lacking, this does not mean
that she does not love her children
Instead, it may mean that she has never learned the best way to
express this

19. Long-term effects of childhood
IPV
Is this surprising when you consider:
Matilda grew up in an extremely abusive home and has no model for healthy love
She has been under constant threat of violence since childhood.
Research by Bensley et al. (2003) found that:
Women reporting childhood physical abuse or witnessing interparental violence were at
a four- to six-fold increase in risk of physical IPV and twice as likely to sufferpoor
physical health
Women reporting any of the experiences measured were at three- to four-fold increase
in risk of partner emotional abuse
Women reporting childhood physical abuse were at increased risk of poor physical
health, and women reporting any type of childhood family violence were at increased risk
of frequent mental distress.
In addition, Henning et al. (1996) found that:
Women who have witnessed interparental violence may perceive violence as a normal
part of intimate relationships

20. Parenting skills in abused
women
Levendosky & Graham-Berman (2001)
IPV related to PTSD and depression
Lack of social support is correlated with impaired psychological
functioning (recommends support groups)
Slight correlation between childhood abuse and impaired parenting
As parenting skills are impaired children are affected by IPV inflicted
on mother (warmth, control, child-centeredness, and effectiveness)

21. Mitigation
In addition:
The stress (and possible PTSD) means that she is constantly stuck in
fight or flight and has impaired decision making, if higher cognitive
functions has developed at all
She is likely to be repressing a great deal of negativity which will be
likely to spill out into her parenting.
Despite all of this, Matilda is not violent towards her children

22. Family genogram

23. The risk assessment is being made based upon the current
circumstances within the home.
If Matilda were to:
Leave her partner;
Receive treatment for addiction and mental health issues;
Receive support in relation to parenting skills;
The risk posed to the children may be significantly reduced. This also
has to be balanced alongside the potential negative effects from taking
the children into care.
Although protection of the children must be paramount, it must also be
balanced against the chances that the family could recover together in
a healthy way.

24. Leverage…
 Another positive from this decision would be improved motivation
Matilda may have to recover. If her children were to be taken away,
it removes the main protective factor which will aid her recovery.
 There has not been one point in her life this far where she has had
the opportunity to be who she really is, or wants to be.
 If the children stay with Matilda, the chances of this for all of them
are significantly higher

25. Treatment
If the family were to stay together, the best way to approach treatment
would be to help Matilda meet the conditions set by the panel:
These would be likely to include:
Ending family contact with abusive partner
Receive treatment for addiction and mental health issues;
Receive support in relation to parenting skills;
These are huge areas which will require significant support from the
partner agencies involved.
Clinical psychologists would assist in the first two areas, therefore the
treatment of these is what will the remainder of the presentation will
focus on.

26. Treatment
It is important to bear in mind that Matilda is in a extremely difficult
situation:
Separately, the psychological effects of domestic violence and
addiction are extremely challenging to treat.
In effect, Matilda is ‘double bound’ and is under the control of both
her partner and her addiction. This is exaggerated in Matilda’s case as
her abusive partner is also her dealer.
Breaking out of one of these scenarios of these is extremely
challenging.
The hold her partner has over her is huge and should not be
underestimated.
She has already been diagnosed with agoraphobia, depression and
anxiety
We need to consider her fears and insecurities when we first try to

27. Matilda’s fears
 That she is being negatively judged by professionals and is very
scared that her children will be taken away
 She has also stated that she is extremely scared of leaving her
partner, due to threats he has made against her and her family
Unless we acknowledge her fears and worries, she will be significantly
less likely to cooperate with us.
 Each year, around 2 women per week are killed by violent partners
– Women’s Aid (2014)
 Therefore Matilda’s fears are very real.
 To understand these fears fully, we must understand her partner
and her relationship.

28. The psychology of a violent
abuser
In order to understand how to help Matilda, we must understand the traits
of an abusive personality as well as the dynamics of an abusive
relationship
Abusers often meet criteria for personality disorders, such as
psychopathy (Swogger et al, 2007), or borderline personality disorder
(Dutton,1988)Psychopathic Traits – low emotion Borderline Traits – high emotion
Callousness Intense personal relationships
Limited remorse and empathy Manipulation
Superficial charm Emotional instability
Impulsive behaviour Masked dependency
Arrogance and anger Intense angerand demanding
behaviour
Deceit and manipulation Poor sense of self
Consistent irresponsibility Intense fear of abandonment

29. The psychology of a violent
abuser
In simply viewing behaviours, it is extremely easy to demonise individuals with abusive
personalities.
However, it is important to remember that research also indicates that many of these
individuals have experienced serious trauma during formative stages.
Rounsavilie (1978) found that 39% of the violent abusers were reported to have been
beaten in childhood and 45% had been permanently separated from their parents.
Walker's (1984) study of 281 female partners of batterers found that 81% of the
partners had knowledge of battering in their husband's family of origin
Hotaling and Sugarman (1986) found that husband-to-wife violence was associated
with childhood witnessing of IPV in 88% of studies, and with childhood experience of
violence in 69% of studies.
However, it should also be taken into account that Hare (2003) found that those on the
psychopathic spectrum can be resistant to treatment and are much more prone to
redecivism.
In Matilda’s case, the abuse seems to be more transactional, rather being charactarised
by an intense interpersonal relationship. Given the risk to the children and Matilda, it
would be more appropriate to end the relationship, rather than to treat them as a family.
To achieve this Matilda will needs help to understand the abusive cycle which she lives

30. Walker (1979): The cycle of
abuse
 Many people struggle to understand why victims
stay with their abusers. What they do not
understand is that many abusers cycle between
polarised personalities.
 The first can be extremely charming and
manipulative and is generally used to placate
the victim and keep them under control once the
abuse has escalated.
 The second is the violent abuser. Although this
aspect can appear randomly, abusive
relationships tend to be characterised by an
oscilation between the two.
 This is known as the ‘cycle of abuse’ and keeps
the victim unbalanced.
 An abusive act takes place, the abuser then
repents/manipulates and the couple enter the
honeymoon period.
 Tension builds and the victim is often aware that
the ‘honeymoon period’ is about to end. Abuse
happens and then the cycle begins again
 The constant tension will exacerbate Matilda’s
mental health problems.

31. Effects of abusive relationships
Coker et al (2002) found that female victims of IPV were more likely to
experience:
Depressive symptoms
PTSD
Chronic mental health issues
Substance abuse
Poor physical health
Less likely to report abuse than male victims

32. Effects on Matilda
It is already documented that Matilda is suffering from:
Depression
Anxiety
Agoraphobia
Low self-esteem
These are clearly classic effects of IPV and are likely to be comorbid
with PTSD

33. IPV & Addiction
However, Matilda’s mental health issues are also comorbid with addiction.
This makes the issue significantly more difficult to treat.
Among other substances, Matilda is addicted to heroin.
This is one of the most difficult addictions to recover from.
The first high that users experience has been described as ‘absolute bliss’ or
‘meeting god’
It is a state which is extremely difficult to achieve naturally.
Addiction is often comorbid with mental health issues. This is because many
addicts are attempting to escape from negative mental states.
Imagine going from heaven to hell with one hit and then having to return to an
even worse hell than the one you started with…
Users just want to feel better and to escape from their problems.
Important to rememberthat Matilda’s partneris currently controlling her
supply and using this to manipulate her…

34. Comorbidity between mental
health issues and addiction
Khantzian (1985) Self Medication Hypothesis:
Found that addiction was often comorbid with severe mental health
issues
Theorised that addicts use substances to alter negative affective
states
Shift from previous perceptions related to pleasure, peer pressure
etc.
Drugs used as a ‘prosthetic’ to cope with deficiencies in ego structure

35. Comorbidity between mental
health issues and addiction
 For Matilda, this means that her
partner is control of her ability to
control the negative affective
symptoms which she is suffering
with.
 It gives him significant power over
her and it is suspected that he is
using this to manipulate her into
prostitution
 How can we help Matilda to break
this hold?

36. Long term recovery from
addiction
In a study of long term recovery from addiction
(33 years) Hser (2007) found the following
correlations:
Negative Positive
Spouse who also abused drugs Positive relationships
Lack of social support Positive social interaction and
support
Negative emotional states (anxiety,
depression)
Recovery from mental health issues
Poor self-efficacy and lack of
constructive coping skills
Commitment to maintaining
abstinence

37. Addiction treatment: Methadone
One of the most common treatment for heroin addiction is methadone.
In a study by of methadone users by Gourlay et al (2005) it was found
that those who identified as ‘addicts’ were more affected by stigma and
isolation than those who identified as non-addicts.
As a result, it was found that the following factors aided recovery when
using methadone:
Access to resources
Opportunities for personal development
Experiences that support non-addict or functional self-concepts

38. Long term recovery from
addiction
From this evidence, it would appear that the most vital factors in
recovery from addiction relate to
Successful treatment of mental health issues
Positive self-image
Development of constructive coping skills
Improved self-efficacy
Development of social support and positive relationships
Development of personal skills
Therefore, treating Matilda’s psychological issues will be paramount to
her ability to control her addiction.

39. Impaired decision making
MacLean (1990)
Triune Brain Theory:
Behaviours
Emotions
Decision Making
Being stuck in behaviour and emotion limits
development or activation of neocortex and
impairs decision making.

40. Impaired decision making:
PTSD
Aupperle et al (2011):
“The sig nificant pro ble m s we face in life canno t be so lve d at the le ve l
o f thinking that cre ate d the m . ”
Albert Einstein
Research found that decision making was impaired and that this
increased when trauma was experienced
Response inhibition and attentional capacity were affected
Contributes to hyper-vigilance and arousal
PTSD treatment should be focused upon development of higher
cognitive function.

41. Impaired decision making:
Addiction
 Bechara & Damasio (2001) supported this hypothesis. They found
that when faced with decisions resulting in negative consequences,
addicts consistently made poorer decisions
 Research suggested that addicts suffer from impaired linkage
between the amygdala and the prefrontal cortex.
 This means that they cannot access this part of the brain to make
decisions and therefore rely on emotional feedback.
 This would exacerbate addictive problems as addicts are focused
on moving out of extreme negative affective states

42. Issues in treating comorbid
addiction and PTSD
Najavits et al. (1997) found the following issues in treating comorbid
addiction and PTSD:
Behavioural exposure and flooding models for treating PTSD trigger
too intense emotional states in addicts and might cause relapse
Benzodiazepines for anxiety can’t be used by addicts
AA groups often contain men and the stress of the initial stages
(sharing publicly) may trigger relapse
Found greater success in programmes specifically designed for
women with comorbid disorders

43. Successful Treatments
Researcher(s) Effective treatment Benefits Comparison
Ouimette et
al (1998)
Substance abuse and trauma should be treated together
More assistance required in traditional addiction programmes
Referral to self-help groups beneficial
Hien et al
(2004)
Seeking safety: Integrated CBT treatment for PTSD and
addiction
Reduced
revictimisation
and relapse at 9
months
Superior to community care
Hester &
Westmarlan
d (2005)
Cheshire Domestic Violence Outreach Service (CDVOS)
aimed to provide an early response via structured one-to-one
outreach support to women experiencing domestic violence.
Included group work
Contact with other women in same circs reduced
isolation and increased support
Gained perspective on the abuse by sharing with
others
Emotional support – ‘not going mad’
Camden Safety Net
individual counselling and group work for women to develop
long-term resilience through increased confidence and
knowledge of options.
Sharing with women who could understand
Regaining self-esteem
Emotional support. Knowing they were not alone
or going crazy
Being listened to and learning to voice what had
happened
Gaining hope for the future and for being able to
cope without a man
Recognising that both they and their children were
better off without the abusive partner
Romero et al
(2009) Case
study
Family BehaviourTherapy
Designed for women evidencing child neglect, substance
dependence, domestic violence and other comorbid
problems.
Treatment included contingency management, self control,
stimulus control, communication and child management
Improvements in:
Child abuse potential
Home hazards
Domestic violence
Drug use

44. Successful treatment: Key
factorsResearcher Areas Benefits
Hester &
Westmarlan
d (2005)
Advocacyand
support:
• Together advocacy and support should be wide ranging, holistic and
preferably based in a one-stop-shop.
• Advocates should help women navigate the criminal and civil justice
systems and others agencies as they attempt to access needed
resources.
• Women should have the same advocate or support worker to focus on
specific needs and enable them to deal with fear and safety issues.
• Workers may assist women end their emotional attachments to the
violent partner by encouraging them to invest emotionally in learning new
life skills and skills which assist them in finding paid employment.
Stayingsafe: • Advocates, support and outreach workers should carry out regular risk
assessments with women and their children, including assessing
potentially changing tactics by perpetrators.
• Safety planning should be carried out.
• Measures should include panic alarms and home security.
Movingon: • Once women have dealt with immediate issues they should be offered
groupwork to deal with emotional issues arising from the domestic abuse
and to meet other women with similar experiences.
• Groupwork should take a structured approach and preferably be at least
ten weeks in length.

45. Reccomended treatment plan…
Treatment type Aims Outcomes
One to one support
from professional
specialising in
comorbid addiction,
PTSD and IPV to
include:
• Development of safety plan and security measures
• Emotional support in relation to fears and anxieties
• Addressing injuries and physical health issues
• Advocacy with health re: medication and addiction treatment
• Advocacy with Children’s social care re: conditions
• Advocacy with housing and benefits
• Child management skills
• Training exercises
• Financial management
• Improved sense of safety
• Reduction in fear based symptoms
• Improved self esteem and self-
efficacy
• Sense of connection with others
• Move from existing area
• Improved mental and physical
health
• Improved decision making
• Improved financial control
• Improved parenting skills
Integrated CBT for
PTSD and addiction
• Development of self control
• Development of stimulus control
• Control of addiction
• Development of improved decision
making
• Recognition of long-term
consequences
• Development of long-term
treatment plan
Attendance at support
groups designed for
addicts and victims of
PTSD (at least 10
weeks)
• Emotional support
• Understanding from others in a similar situation
• Ending dependence on partner
• Communication
• Development of positive sense of
self
• Support in ending relationship
• Reduction in isolation
• Increase in supportive relationships
• Sense of understanding and
connection with others

46. Conclusion
 As we have seen, Matilda is in an extremely challenging situation
and has many hurdles to overcome
 The achievement of this will largely be dependant on the type of
support and advocacy that she receives from professionals and
members of support groups who interact with her
 All the research suggests that recovery will be largely based upon
emotional support, connection with others and improvement of her
mental health, thought patterns, self image and self-efficacy.
 Without recognition of the issues Matilda faces, she would be likely
to be drawn back into an abusive relationship and addiction
 This would have severe, lifelong consequences for both her and her
family

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