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Partner Violence and Substance Abuse Are Intertwined: Women's Perceptions of Violence Substance Connections
Rebecca J. Macy, Connie Renz and Emily Pelino Violence Against Women 2013 19: 881 DOI: 10.1177/1077801213498208 The online version of this article can be found at: http://vaw.sagepub.com/content/19/7/881

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VAW19710.1177/1077801213498208Violence Against WomenMacy et al.

Article

Partner Violence and Substance Abuse Are Intertwined: Womens Perceptions of Violence Substance Connections

Violence Against Women 19(7) 881902 The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801213498208 vaw.sagepub.com

Rebecca J. Macy1, Connie Renz1, and Emily Pelino2

Abstract Research shows that co-occurring partner violence and substance abuse are problems for many women. However, less is known about womens varied experiences with partner violence and substance abuse. This exploratory, qualitative study investigates these two issues among a sample of 15 women in substance abuse treatment who experienced partner violence. Overall, findings show participants experience of violencesubstance connections varied in important ways; complicating factors exacerbate both problems; and domestic violence services and substance abuse treatments should account for these variations and complications. We discuss directions for providers, researchers, and policymakers concerned with partner violence or substance abuse. Keywords alcohol, domestic violence, drugs, partner violence, substances

The combination of partner violence and substance abuse are serious problems in the lives of many women (Bennett & OBrien, 2007; Logan, Walker, Cole, & Leukefeld, 2002; Najavits, Sonn, Walsh, & Weiss, 2004; Testa, 2004). At some point in their lifetime, 25% of women in the United States experience violence, including physical and
1University 2KIPP

of North Carolina at Chapel Hill, USA Indianapolis College Preparatory School, IN, USA

Corresponding Author: Rebecca J. Macy, School of Social Work, University of North Carolina at Chapel Hill, Tate-Turner-Kuralt Building, 301 Pittsboro Street CB #3550, Chapel Hill, NC 27599, USA. Email: rjmacy@email.unc.edu

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sexual assault, at the hands of current or former husbands, partners or boyfriends (Tjaden & Thoennes, 2000). A considerable number of partner violence survivors also experience substance abuse problems, with research indicating that survivors have substance problems at 5 times the rate of women in the general population (Logan etal., 2002). One longitudinal study showed that womens use of drugs nearly doubled the likelihood of experiencing an assault relative to women who did not use these substances (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997). Given the mounting evidence about the connections between these issues, unfortunate and significant knowledge gaps exist at the nexus of partner violence and substance abuse (Logan etal., 2002; Testa, 2004). These knowledge gaps are especially critical relative to domestic violence safety services and substance abuse treatment for women with these co-occurring problems (Fowler, 2007; Logan etal., 2002; Macy, Giattina, Sangster, Crosby, & Montijo, 2009; Zubretsky, 2002). The combining of domestic violence and substance abuse intervention approaches has been a recommended best practice for more than 10 years (Collins & Spencer, 1999; Fazzone, Holton, & Reed, 1997; Finkelstein, 1994). Specifically, the extant research proposes a two-pronged strategy in which violence and substance abuse are addressed concurrently (Bennett & OBrien, 2007; Covington, 2008; Edmund & Bland, 2005; Levine & Greene, 2000; Logan etal., 2002; Najavits etal., 2004: Tuten, Jones, Tran, & Svikis, 2004). In practice, substance abuse treatment providers are likely only to address the substance abuse problem and ignore safety and violence issues. Similarly, domestic violence service providers are likely to emphasize safety and violence cessation without acknowledging womens substance abuse. The problem with these single-focused approaches is that the co-occurring condition might never be addressed. Furthermore, the presenting problem might not be adequately addressed because the other problem plays a critical role in the maintenance of it. A significant barrier to the development of helpful interventions for co-occurring violence and substance abuse is the lack of evidence demonstrating how the domestic violencesubstance abuse connection manifests in womens lives (Stith, Smith, Penn, Ward, & Tritt, 2004; Testa, 2004). In particular, little research exists about the relationships among womens victimizations, substance abuse, and revictimizations (Logan etal., 2002). Likewise, members of our research team who have practical experience delivering domestic violence services and substance abuse treatment noted anecdotally that there was considerable heterogeneity in the relationships between these issues in the lives of the women with whom we worked. For some women, the violence perpetrator in their life is also the person who enables their access to the substance of their choice. Other women are able to access substances independently, but their violent partners use the womens substance abuse as a justification for perpetrating violence. Our team posited that women in such dissimilar situations need safety and substance abuse interventions that have been tailored to their different needs. Unfortunately, there is little research identifying the ways that co-occurring partner violence and substance abuse manifest in womens lives (Collins & Spencer, 1999). To help address this knowledge gap, we conducted a qualitative study to explore these connections. We first discuss the prior research that guided this study.

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Partner Violence and Substance Abuse

A growing body of literature has shown a relationship between partner violence victimization and substance abuse of various types, including cocaine, marijuana, opioids, and prescription drugs (Clark & Foy, 2000; El-Bassel, Gilbert, Schilling, & Wada, 2000; El-Bassel, Gilbert, Wu, Go, & Hill, 2005; Macy, Ferron, & Crosby, 2009; Roche, Moracco, Dixon, Stern, & Bowling, 2007; Testa, Livingston, & Leonard, 2003; Weinsheimer, Schermer, Malcoe, Balduf, & Bloomfield, 2005). However, one metaanalytic review found insufficient research to investigate the relationship between illicit drug use and partner violence victimization (Stith etal., 2004). Although recent research shows a strong relationship between relationship violence and greater frequency of alcohol intoxication (Hill, Nielsen, & Angel, 2009; Hill, Schroeder, Bradley, Kaplan, & Angel, 2009), the overall evidence regarding whether a womans abuse of alcohol increases her likelihood of experiencing partner violence has also been described as weak (Stith etal., 2004; Testa, 2004). In spite of recent studies, the dearth of research on the topic of substances and partner violence has meant that the mechanisms of how these issues relate to one another over the course of womens lives remain largely unknown (Collins & Spencer, 1999; Testa, 2004). Some suggest a bidirectional interaction of partner violence and substance use. Evidence shows that partner violence victimization increases the likelihood of substance use, and substance use increases the risk of partner violence (El-Bassel etal., 2005; Salomon, Bassuk, & Huntington, 2002; Testa etal., 2003). In their longitudinal study, Kilpatrick and colleagues (1997) described a vicious cycle in which victimization increased substance use and substance use increased victimization (Logan etal., 2002). However, other research shows that the longitudinal relationship between partner violence and substance use may not be so sharply defined (for example, Martino, Collins, & Ellickson, 2005). These varied findings might be the result of differences in the types of violence (i.e., physical, sexual, psychological, or combination of all the three) and the type of substance abuse studied (e.g., alcohol, cocaine, or prescription drugs; Testa, 2004). Another complicating factor is that substance abuse might also increase womens vulnerability to violent victimization perpetrated by persons other than their partners, such as associates and friends who use substances or those persons the women encounter in their efforts to obtain substances. Research is needed to investigate the dynamic relationship between partner violence victimization and substance abuse, including the potential heterogeneity and the various complicating factors between these two issues.

Trauma-Informed Substance Abuse Services

Trauma-informed substance abuse services represent an important and innovative treatment approach that accounts for womens experiences of trauma, including various forms of violent victimization (Covington, 2008; Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005; Fallot & Harris, 2002). Recommended trauma-informed service strategies

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include maximizing womens control over their treatment plan, and minimizing the use of interventions that might retraumatize (e.g., the use of physical restraints in psychiatric settings). Findings from several randomized controlled trials of Seeking Safetyan evidence-supported trauma-informed treatment designed for individuals with co-occurring posttraumatic stress disorder (PTSD) and substance abuseshowed positive results (Najavits, 2007). Unfortunately, research on the efficacy of trauma-informed service strategies is nascent and more work is needed to establish the efficacy of this service framework. For example, findings from a multisite, quasi-experimental study showed that even though the implementation of trauma-informed strategies had positive benefits for womens mental health symptoms, such strategies did not produce similar effects for substance abuse symptoms (Morrissey etal., 2005). Such findings point to the need for empirical knowledge about the relationship between trauma and substance abuse generally, as well as specific forms of trauma, such as partner violence, in particular.

Research Aims
To address these knowledge needs, we investigated the relationship between partner violence and substance abuse with the aim of understanding the ways in which the connections between substance abuse and partner violence manifest in womens lives. We wanted to learn about womens experiences with partner violence and substance abuse, including womens perspectives on how these two issues connect in their lives (if at all). Our research team used exploratory, qualitative methods for this investigation because the nuanced and varied processes associated with the co-occurrence of partner violence and substance abuse are potentially complicated and not well understood. We selected qualitative methods because we wanted to emphasize the experience, perspectives, and opinions of women who have struggled with partner violence and substance abuse.

Method Data Collection

All data collection activities took place at a university-affiliated substance abuse treatment agency in the southeastern United States. The agency provides a comprehensive, gender-specific, trauma-informed substance abuse treatment program for low-income women who are pregnant or already mothers with children. The program offers several treatment modalities, including individual counseling, family counseling, and relapseprevention groups; these services are delivered either through intensive outpatient treatment or as part of long-term (i.e., one-year) residential treatment. The agency staff members reported that many clients experienced recent partner violence before entering treatment, as well as lifetime partner violence. The agencys data collection from 2009 showed that 70.6% of the women entering into treatment (N = 77 out 109 new admissions) reported lifetime partner violence. Of these 77 women, 28.4% (n = 31) stated they felt unsafe with their present partner, and 58.4% (n = 45) reported

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that they had had more than one abusive partner in their lifetime. The agency staff had a strong desire to better understand the co-occurrence of partner violence and substance abuse among their clients. The principal investigator (PI) of this research and the director of the substance abuse agency (i.e., the first and second authors of this article, respectively) collaborated on all phases of the research including designing the study, collecting and analyzing the data, and writing this article to ensure that findings could usefully inform practice. Using a standardized, open-ended interview guide, the PI conducted in-depth, individual interviews with partner violence survivors who were receiving treatment at the study agency for a substance use disorder. We chose to collect data through individual interviews to capture the full diversity of perspectives among participants; protect participants confidentiality; and promote participants comfort to speak honestly and openly about the sensitive topics of partner violence and substance abuse. Before beginning data collection, the study protocol was approved by the Institutional Review Board of the research teams university. Rationale for recruiting participants from a substance abuse agency. Our research team used a purposeful sampling strategy by recruiting participants from a substance abuse treatment agency that treated only women with serious substance abuse problems. The women receiving services at the study agency have a substance use dependence disorder that meets the criteria given in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000). Our team chose purposeful sampling with three goals in mind: to generate information-rich data about partner violence and substance abuse, to identify factors that connect partner violence and substance abuse, and to illuminate the nuanced interactions between partner violence and substance abuse. Consistent with using a sampling framework geared toward extreme cases, information garnered from partner violence survivors who have serious substance abuse problems is relevant to improving coordinated domestic violence and substance abuse services generally (Patton, 2002). Sample.The study recruited 15 women from among the agencys current clients enrolled in either the outpatient or residential treatment programs. We used two recruitment strategies. First, recruitment flyers were posted in the study agency, which provided information about the study and how those who were interested in participating could contact the PI. Second, agency staff members were given a briefing about the research and provided with flyers so that they could inform clients about the research. The flyers invited clients who were interested in participating in the research to contact the PI by telephone to receive further information and study eligibility screening. As part of the initial telephone contact with potential participants, the PI screened each caller to confirm that the woman met the study eligibility criteria. Participants were required to be (a) 18 years and older, (b) female, and (c) currently in an intimate relationship or have been in an intimate relationship within the past 5 years; in addition, while in this intimate relationship; participants had to (d) report an experience of control, threats, or violence perpetrated by the partner. For this study, we defined an

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intimate relationship as dating, living with, or being married to a partner. Our research team defined partner violence broadly (i.e., an experience of control, threats, or violence) to recruit women with a wide range of violent experiences. An experience of control, threats, or violence was as defined by one or more of the following characteristics: (a) being made to feel unsafe by an intimate partner; (b) being scared or threatened with words or actions by an intimate partner; (c) being physically harmed by an intimate partner; or (d) being sexually assaulted by an intimate partner. All the women (N = 15) who contacted the PI met these criteria and were offered an individual interview. The criteria for study inclusion were included in all of the recruitment materials, so it is possible that women contacted the PI only if they met the study criteria. Interviews. The PI used a standardized interview guide to conduct in-depth interviews with the participants. The interview guide was developed using open-ended questions in a semi-structured format to allow for the widest range of responses, and to encourage respondents to generate information that was not constrained by the research teams expectations. The interviewer asked each woman about her experience of threats and violence from her partner; her substance use history and the role her partner had in that history; and the relationship between violence and substance use. During the interviews, some participants reported having had more than one intimate relationship characterized by violence. These participants were asked to respond to the interview questions focusing on the most recent violent relationship. All interviews were conducted in a private room at the study agency after informed consent was given by the participants. The length of the interviews ranged from 45 to 140 min with most interviews lasting about 90 min. At completion of the interview, the PI spent time with each participant to thank her for her time, assess her for any signs of distress because of the interview questions, and refer the participant to services at the agency as necessary. All participants were given a US$30 gift certificate to a local food store as a thank-you gift. All interviews were audio recorded and transcribed. Transcription accuracy was verified by checking transcripts against the audiotapes.

Analysis
The interview transcripts were independently coded by two analysts (i.e., the first and third authors) using an open-coding approach (Padgett, 1998; Patton, 2002). The analysts assigned working definitions to each code using constant comparison procedures and sought to identify common themes and divergent perspectives (Glaser & Strauss, 1967). The two analysts organized codes into umbrella codes and subcodes, as well as conferred about new codes until the analysis showed convergence and saturation. Throughout analysis, codes were evaluated alongside the data to ensure the codes represented participants meaning. The analysis identified eight key themes. Regarding the connections between partner violence and substances, five key themes were identified: (a) substance initiation and progression; (b) something in common; (c) drugs was a huge factor; (d) he was like a damn drug; and (e) substances and relationships dont mix. Three additional

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Table 1. Participant Descriptive and Substance of Choice Information (N = 15a). Age (mean) 34.8 years n Present source of income Temporary assistance to needy families program Social security income Child support Full-time work Race African American/Black Biracial White Substance of choiceb Alcohol Crack cocaine Cocaine Marijuana Methamphetamine More than one substance of choice
aOne bTen

887

% 57.1 21.4 21.4 07.1 50.0 14.2 35.6 0.07 46.7 0.07 0.07 0.07 26.7

8 3 3 1 7 2 5 1 7 1 1 1 4

participant declined to give information about her source of income. participants reported that they usually abused multiple substances, including alcohol, cocaine, crack cocaine, marijuana, and methamphetamines.

themes were identified: (a) a descriptive theme about participants experiences with partner violence and other victimizations; (b) a theme about substance initiation and progression unrelated to partner violence; and (c) a theme about participants efforts to establish substance recovery and safety. We report verbatim quotations to convey participants perspectives accurately. All identifying information was removed to eliminate any possibility of deductive disclosure given the sensitive nature of the information presented here. Demographic information is reported in aggregate for the sample.

Findings
Participants demographic and substance of choice information is presented in Table 1. Most participants income was from Temporary Aid for Needy Families (TANF) or Social Security. The majority of participants described themselves as African American, Black, or biracial, with the remaining women in the sample describing themselves as White. All study participants identified their violent partner as male. As shown in Table 1, most participants reported their substance of choice was crack cocaine. A number reported more than one substance of choice. Many reported that they used multiple substances, including combinations of alcohol, cocaine, crack cocaine, marijuana, and methamphetamine. One participant comment illustrates the experience of those who reported abusing multiple substances:

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I know I cant be around alcohol, because back [a few months ago] I had two drinks, and I wanted to smoke some weed. I know if I smoke weed that Im going to want to do meth. Its a domino effect. I cant do one without doing something else.

Partner Violence and Other Victimizations

Participants experiences with partner violence. All participants described a combination of violent experiences, including psychological, physical, or sexual violence perpetrated by their partners. The violence described by participants was notable for its severity. All participants related experiences of verbal abuse, including one woman who gave the following phrases as examples of language her partner would typically use with her: You bitch. You whore. Youre a slut. Youre scum. I picked you up off the street. Participants also reported that their partners threatened them, controlled them, and isolated them from others. Participants described partners who kept them from seeing friends or family; who took complete control of their finances, not allowing the woman access to any money; who sabotaged cars to keep the woman from driving to work; who prevented the woman from seeking health care services after physical violence; and who threatened to take the womans children away. One participant reported that her partner removed her children from her care and did not allow her access to her children, even though the partner had no legal authority to do so. Another participant described the destruction of her personal property: I remember that night he told me, Im going to make me a little campfire, so you aint going nowhere. He burned all of my clothes. Everything I had hanging up in the closet, he burned. Another participant explained how her partner would make death threats to frighten and control her: He would threaten my life. He had it planned out that he was going to kill me and where he was going to bury me. In addition to verbal and psychological violence, participants also reported severe physical and sexual abuse. Participants described beatings, punching, kicking, and strangulation. One participant described an incident of physical and sexual violence in this way:
He beat me, and choked me until I passed out, and when I woke up, he was spitting in my face. After he was spitting in my face, he tore my clothes off, and I was like, Please dont do this . . . Please dont. And he raped me.

Most, but not all, participants reported sexual violence. Among participants who reported sexual violence, all mentioned forced sexual intercourse by their partners. A few participants also described other forms of sexual abuse such as being forced by their partners to participate in group sexual activity with others. Childhood abuse. In addition to partner violence, most participants reported childhood psychological, physical, or sexual abuse, most of which was perpetrated by close family members including parents and caregivers. One participant stated, My mom . . . her husband molested me when I was 3 years old, and [then] she gave me away to my grandmother. My grandma used to beat me. My cousin molested me. However, a few

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participants reported no history of childhood abuse. One participant described this distinction between her childhood and adult experiences:
I had a perfect childhood; I had a perfect life. Dont ask me what drew me into a violent marriage. I couldnt tell you. I had no abuse, no drug abuse, no alcohol abuse, nothing like that when I was growing up. I had a great life.

Violence from other partners. Some participants reported having had more than one violent intimate relationship as an adult. To maintain focus in the interviews, these participants were asked to respond to questions based on the most recent relationship in which they experienced partner violence. Participant comments indicated that many of their first violent intimate relationships occurred in adolescence or early adulthood. Violence connected to trading sex for substances or money. Some participants reported trading sex for substances or money to buy substances. One participant stated, I used to go out. I aint going to call it prostitution. I dont know what Ill call it. You know, Id go sleep around to get money. Among participants who engaged in sexual activity in return for money or substances, several described violence as part of these activities. One participant stated, I [had] many, many horrible experiences . . . working as a prostitute and being on the streets. [Theres] a lot of pretty rough stuff that Ive been through.

Substance Initiation and Progression

The majority of the study sample reported initiating substance use in childhood or adolescence, before meeting their present partners. Most often, these participants stated their substance use began with either alcohol or marijuana, which they were introduced to by a family member (often older siblings) or peers. Many of these participants declared that their partners facilitated their progression toward substance abuse and dependence. Some of these participants reported that they progressed from substance use into abuse and dependence for reasons unrelated to partner violence. Such reasons included (a) substances were a way to manage feelings of loss and grief experienced from the death of a close other; (b) substances were a way to cope with mental illness, including depression and bipolar disorders; (c) substances were a way to cope with life problems (e.g., lack of money, lack of housing, unemployment); and (d) substances led to a great feeling. Regarding this last reason, one participant stated,
[When I was using] I felt like I had control. I felt like this is fun, this is my world right here. I know they say youre out of control. I felt like I had control . . . I enjoyed the high. I hear a lot of people say they never had fun, but I enjoyed it . . . because I felt control.

Overall, most participants began using substances before they met their violent partners, and some participants progressed from use to abuse for reasons unrelated to partner violence.

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Connections Between Partner Violence and Substances

Substance initiation and progression. As discussed hereinbefore, a majority of participants reported that they began using substance early in their lives, well before they met their violent partners. However, partners facilitated substance initiation for some participants. One participant described how her partner introduced her to substances in the context of sexual activity: He claimed it [the substance] would make the sex better. Something crazy like that, but I didnt even know what sex was. It was just something I did because he wanted to. In addition, some participants declared that partner victimization facilitated their progression from substance use to abuse. One participant stated:
I got so addicted to [crack]; it made me not think about what hed done. It just numbed me. Id take [my kids] to McDonalds, put them in front of the TV, and Id go to my bathroom and smoke crack.

Other participants described initiating more potentially addictive substances to cope with victimization. One participant stated, I know I started crack because of what I went through. That might sound like an excuse, but thats my feeling on it. Something in common. Other participants described substance use as an activity they shared with their partners that helped initiate and develop the relationship. For most participants who began using substances before they met their partners, substance use was something that brought these participants together with their partners. One participant stated,
I guess what turned us on to each other is he smoked and I smoked, and when we were younger, he had a big crush on me. So, we started seeing each other, living together, smoked, drank, and tripped on acid.

Another participant described how substance use with her partner brought emotional closeness:
A lot of times we would be at home [using], just me and him. Thats when we had our most intimate conversations. Thats when we would sit around and just do things together . . . and I thought that was special. [That] could be done without the drugs. But I was like, This is cool; its just me and him and not a bunch of people around.

Many participants described their substance use as a pleasurable activity that they and their partner would use together during sex. One participant stated, It was fun. I mean, it just made sex better. Drugs were a huge factor. Other participants declared that they were attracted to their partners because these men provided access to substances. As one participant stated,

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In a relationship I had to have drugs. Im addicted to drug dealers, or somebody who could buy drugs. I dont want them [the partners] to use; but I want them to sell. You know, so they can provide it for me.

This comment illustrates that among some participants an important reason to initiate and sustain a relationship was if their partners could ensure their access to substances. In fact, some participants stated that substances were significant reasons for why they remained in violent relationships. One stated, Had the drugs not been involved, I would have been more willing to make a drastic move to get away from him. But the drug was a huge factor. Another found a way to gain her own access to substances as a strategy to end the violent relationship. She stated,
I didnt want to lose that steady stream of drugs. But . . . when I got a job myself and I made my own [drug] connections, I didnt give a damn. He could have had a trash bag full of cocaine; I still wanted it to be over.

This participants experiences were striking, because she established her safety by securing her own access to cocaine apart from her violent partner. He was like a damn drug. For another participant group, the relationship and the substance use went hand-in-hand. One participant described her relationship with her violent partner in terms of addiction: He was like a damn drug. Another stated,
I know now that I was totally addicted to him. I mean, I loved him, but then it went from love to an addiction, cause I had to have him. But that went hand-in-hand with my using.

These participants also described their partners as a trigger for their substance use. One participant stated, I know that if I get back with him I will be right back on drugs because hes like my addiction. For these participants, their relationship with their partners was closely tied to their substance abuse. Substances and relationships dont mix. In addition to describing powerful connections between their partners and substances, many participants described how the couples efforts to obtain, share, and use substances together led to problems, conflict, and violence. One participant stated, Everything was going fine until drugs got involved. And both of us started using drugs and he began to threaten my life, we began to fight a lot. Another participant described how substance use becomes incompatible with intimate relationships:
Crack and relationships dont mix. You either have one or the other; you cant have both. Because you and your partners going to fall out. I have seen where guys will try to get their girlfriends to have sex with other guys for [money or substances], and the girls wouldnt want to do it. But [the girls] go ahead on and do it. And it just dont mix. Drugs and relationships dont mix.

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Some participants related that their partner coerced their sex-trading. One participant stated, He made me responsible for getting the drugs, me responsible for basically selling myself to get money, and it made my self-esteem real low. Another participant described how her partner would verbally harass her into trading sex for substances:
Hed be like, Just go one more time. And Id be like, No, and he would fuck with me until Id be like, Ok, fuck it. Im leaving. Hed put me down like, Youre nothing but a dirty bitch anyway. You aint no good mama . . . and all such stuff. So Id eventually go out and do another [trick] for him and bring back [drugs], and then when it was nearly all gone, hed be like, Get away from me, bitch, and he just throw [the rest] all in my face.

Participants who were coerced into trading sex perceived that activity as clearly connected to partner violence. For these participants, sex-trading was also a doubleedged sword for their addicted, violent partners. Their partners wanted them to engage in trading sex for substances. However, the partners would then castigate the participants for their sex-trading and use those activities as a so-called justification for violence. Another group of participants described a distinct conflict with their partners about substance abuse. These participants related how even though they met their violent partners through substance use, their partners no longer wanted the participants to use once they became a couple. One participant described this change as flipping the script:
I used to come home, and he [would be] waiting to sell me crack, before we started going together. Then we started going together, and he just flipped the script. He didnt want me getting high anymore; he didnt want me doing nothing. So every time I got high, when I got home I got beat.

Taken together, these findings about how substances and relationships dont mix show how violence and substances are connected overall, as well as how these connections manifested in various ways for different participant groups.

Recovery and Safety

Investigating womens reasons for seeking recovery, substance abuse treatment, and safety services, was not a primary focus of this study. However, during the interviews participants offered insights into their reasons for help-seeking that shed light on the connections between substances and violence. Participants universally stated that their children were a primary reason they decided to seek substance abuse treatment. Given the important role children played in many participants recovery, this comment indicating one participants perspective about her interactions with child protective services was striking:
Maybe had I known that [even if I were] admitting drug use, theyre not going to take my kids away, or Im admitting being in an abusive [partner violence] situation, theyre not

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going to take my kids away either. Had they just said, Were going to get you the help you need, and were not going to take your kids, that would have made all the difference in the world to me.

This participants comment illustrates how the possibility of losing custody of their children may impede womens efforts to seek safety and recovery. Likewise, another participant described her experience with a TANF worker in this way:
I went to [the TANF office] with a black eye, and [the workers] asking me all these questions. Shes like, Howd you get the black eye? I used the ran-into-the-door story. I might as well have just said, My boyfriend hit me. She was asking me all these questions about substance abuse and about domestic violence, and I gave her the answers that I wanted her to hear. There was absolutely no way I was going to go in there and say, You know what? My boyfriend gave me this black eye, and he sells cocaine and I use it on a daily basis. I was not at all prepared for the changes that would bring, and I was scared of the repercussions.

Some participants sought help from domestic violence programs, and they also offered service insights that shed light on the connections between substances and violence. Participants reported that program staff skirted the issue of substance abuse. For these participants, the lack of attention to their substance abuse meant that they continued to abuse and were at risk of returning to violent partners to access substances. One participant stated:
Yeah, [name of domestic violence program] were helpful, but they didnt directly address the drug use. I guess that they relied on other agencies to take care of [survivors substance abuse problems]. But I think that had the shelter [staff] said to me, Because of your history, it is required [for you to attend substance abuse treatment] and that you go to three NA [Narcotics Anonymous] meetings a week, I think I would have had to do it. I think that could have benefited me. Also, it might have made a difference if we had had an NA meeting on site. Because I think that, absolutely the two [partner violence and substance abuse] are intertwined.

Nearly all the participants described the importance of learning about healthy romantic and intimate relationships as a necessary part of their recovery from substances, as well as their efforts to establish violence-free lives. One participant comment exemplified the perspective of many:
I didnt know it was domestic violence. I thought it was just part of marriage. And thats sad because I was never taught that thats not love. You do not hit somebody if you love them. You dont injure them, you dont cause somebody pain if you love them. You dont do it. You try to encourage them. Youre going to get angry, youre going to be frustrated, youre going to be stressed. But you have to talk about it, or if you cant talk to your partner, find somebody you can talk to.

This healthy relationship finding is notable because it suggests that many participants in this sample did not recognize violence as unacceptable in the context of intimate relationships.

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Discussion
This exploratory, qualitative study investigated partner violence and substance abuse with the aim of understanding the various connections between these two issues in womens lives. Overall, participants described close, intertwined connections between partner violence and substance abuse. However, the connections between these two issues varied among participants. In addition, there were complicating factors exacerbating partner violence and substance abuse.

Connections Between Partner Violence and Substance Abuse

This research suggests that a dynamic relationship exists between partner violence and substance abuse, and that the connections between these two issues can manifest through varied ways in womens lives. Although some women indicated that their violent partners facilitated their initial substance use, most women reported beginning substance use at an early age and well before they met their partners. Some participants reported that their progression from substance use to abuse occurred for reasons unrelated to their partners. As discussed earlier, the dearth of longitudinal research on these two issues means that the mechanisms of how violence and substances relate to one another over the course of womens lives remain unclear (Collins & Spencer, 1999; Testa, 2004). This studys findings suggest that the co-occurrence of substance abuse and partner violence may have origins early in womens lives and that these co-occurring problems may beginfor somewith substance misuse. We recommend that providers of domestic violence services and substance abuse treatment be mindful that women with these cooccurring problems might have long-standing histories of substance abuse beginning in childhood. Furthermore, we echo other researchers calls for longitudinal research on the dynamic relationship between these two issues to determine the various etiologies of the co-occurrence of substance abuse and partner violence. This research also shows that some violent partners facilitated participants use of substances; initiated an escalation in participants substance use through greater frequency of use or use of substances with more addictive potential (e.g., he introduced cocaine when she was typically using marijuana); and facilitated participants progression from substance use to abuse and dependence. Several participants reported abusing substances to cope with the violence they experienced from their partners. To summarize these findings, women might initiate substance use early in life, but violent partners facilitate their progression from use to addiction. Furthermore, womens early substance initiation might be a critical risk factor for the co-occurrence of partner violence and substance abuse later in life. Thus, this research suggests that early intervention with at-risk girls and adolescent females might prevent adult partner violence victimization and adult substance abuse problems. We encourage other researchers to investigate womens early substance use (i.e., in childhood and early adolescence) as the beginning of a risk process that leads to partner violence and substance abuse. We encourage such research with the aim of developing prevention interventions for partner violence and substance abuse.

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This study showed heterogeneity in how co-occurring substance abuse and partner violence manifest in womens lives. The findings also suggest that women in dissimilar situations need tailored safety and substance abuse interventions. In particular, violent partners were dealers or suppliers for some of the study participants. For these participants, the womans substance abuse became a significant barrier against her working toward a safe, violence-free life, because she needed to maintain her relationship with the partner to access substances. The significance of this connection was underscored by the experience of the one participant who established access to substances independent of her partner. Although we do not endorse this participants strategy as a safety intervention, her experience shows the critical nature of addressing womens substance abuse problems in conjunction with their safety. This finding highlights the long-standing call to better integrate domestic violence safety services with substance abuse treatment (Collins & Spencer, 1999; Edmund & Bland, 2005; Levine & Greene, 2000; Logan etal., 2002; Najavits etal., 2004). For other participants, their emotional and sexual intimacies with their violent partners were intertwined with substance abuse. These participants used substances with their partners for recreation, relaxation, and to enhance sexual experiences. As part of their substance recovery, as well as their efforts to establish violence-free lives for themselves and their children, nearly all the participants in this sub-group related the importance of learning about healthy romantic and intimate relationships. Thus, psychoeducation interventions that teach women (in the words of one participant), you do not hit somebody if you love them, might be especially helpful for women who have conflated their feelings of intimacy with the effects of substances in the context of a violent relationship. Women with such experiences might need relationship-focused therapies to establish and maintain their substance abuse recovery; establish and maintain safety from their violent partners; and prevent revictimization in new relationships. We also highlight here the findings about womens sexuality. Greater attention to womens sexuality by researchers and service providers could be potentially important for addressing the co-occurrence of partner violence and substance abuse. Our findings also suggest the importance of helping women understand how their violent partners may be a trigger for substance use. Substance abuse treatment providers may especially need to help women manage their interactions with and feelings about their partners to prevent substance abuse relapse. All participants in this sample had children in common with their violent partners and had to maintain contact with these men. Attention to such substance abuse prevention relapse strategies may be especially useful for survivors in recovery who must be in contact with ex-partners for co-parenting. For a few participants, the connection between substances and partner violence was that their partners found it unacceptable for the participants to use substances. In this scenario, the womans substance use became the partners so-called justification for his violence. For women with this connection, providers may need to help women address their feelings of guilt, shame, and remorse. Providers should also address the possibility that these women truly believe that the violence was justified because of

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their substance abuse. Women with these experiences of co-occurring partner violence and substance abuse will benefit from treatments that address and correct these erroneous feelings and beliefs (Covington, 2008).

Complicating Factors
Childhood abuse. Although not universally experienced by all participants, the study showed that childhood abuse was a complicating factor for many. Given these findings, we echo prior research and encourage providers to assess and account for histories of childhood abuse in their treatment planning (Covington, 2008; Elliott etal., 2005; Najavits etal., 2004). When considering how to address the issues of childhood abuse, we again emphasize the participants recommendations about healthy relationship interventions. Such interventions may be especially helpful for women who have histories of victimization beginning in their families-of-origin. Indeed, violence may be so closely associated with these womens concepts of caring, family, love, and intimacy that they may not readily consider that violence perpetrated by their partners is unacceptable. For most participants who began substance use early in their lives, childhood abuse may have been a contributing factor for their early substance use. Thus, we encourage researchers to investigate the relationships among childhood physical and sexual abuse, partner violence, and substance abuse (Testa, 2004). Trading sex for substances. Another complicating factor identified by this research was that a group of participants reported trading sex for substances. For all who engaged in sex-trading, the additional victimizations they experienced further complicated their trauma, safety, and recovery intervention needs. Women with these histories may especially benefit from psychoeducational therapies that explicitly attend to womens sexuality. In addition, we encourage researchers to investigate the relationships among trading sex for substances, partner violence, and substance abuse, giving attention to the unique consequences that trading sex holds for womens health and well-being, especially when trading sex for substances is coerced by intimate partners.

Safety Services and Substance Abuse Treatment

Human service systems. Participants apprehensions about human service providers actions concerning their children were a significant barrier that prevented help-seeking among the women in this study. As participants noted, a disclosure of partner violence or substance abuse might result in reports to authorities or removal of children from a womans care. Even in the face of such concerns, participants described their childrens well-being as the most important motivator for help-seeking. Thus, child protection, welfare, and TANF service providers should be well prepared to help female caregivers with co-occurring partner violence and substance abuse when these problems are identified in families. As part of service planning, referral, and coordination, female caregivers with these problems should receive domestic violence safety services, as well as gender-specific substance abuse treatment. Not all women may

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avail themselves of such services. Nonetheless, female caregivers who come to the attention of human service systems because of partner violence and/or substance abuse may be strongly motivated to participate in safety and recovery services out of concern for their children. Women who are struggling with these co-occurring problems should be offered the opportunity to participate in services that can help them to achieve safety from violence and recovery from substance abuse. Unfortunately, prior research shows that TANF welfare workers do not provide safety services to partner violence survivors even when workers have the resources to do so under the Family Violence Option of TANF (Lindhorst & Padgett, 2005). Likewise, a national study determined that child welfare workers tend to underidentify partner violence considerably among female caregivers (Kohl, Barth, Hazen, & Landsverk, 2005). Kohl and colleagues (2005) also determined that this underidentification is exacerbated when female caregivers are struggling with substance abuse in addition to partner violence. In light of these prior studies and our current findings, we call for greater attention to the co-occurrence of partner violence and substance abuse in the child protection, welfare and TANF service systems. We also encourage greater practice, research, and policy attention to the well-being of children in the lives of women with co-occurring partner violence and substance abuse. This attention should focus on efforts to help women achieve safety and recovery, while also ensuring the safety and well-being of children. Domestic violence and substance abuse treatment services. Overall, this research suggests that domestic violence safety services and substance abuse treatments should account for the varied connections between partner violence and substance abuse in womens lives. This study also suggests specific practice recommendations for domestic violence programs and substance abuse treatment agencies. The research findings show that at least some domestic violence service providers may continue to have a Dont ask, dont tell philosophy when it comes to substances despite the long-standing calls for assessment of substance abuse problems in the context of domestic violence services. Thus, we urge domestic violence service providers to assess women at program entry for substance abuse. Following the recommendation of one participant, domestic violence service providers should encourage women who report substance abuse problems to participate in gender-specific substance abuse treatment programs. When such treatment programs are not readily accessible, then survivors with substance abuse problems might be encouraged to attend Alcoholics Anonymous and/or Narcotics Anonymous meetings. Consistent with participants recommendations that substance abuse services be available on site at domestic violence programs, we also encourage domestic violence programs to collaborate with substance abuse treatment programs and providers. For example, domestic violence service programs could fruitfully contract with substance abuse programs to offer assessment and treatment services on site in shelters for survivors who have substance abuse problems. Likewise, there is increasing enthusiasm for and implementation of traumainformed substance abuse services. We share this enthusiasm; there is much promise

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in the trauma-informed approach to help women with co-occurring partner violence and substance abuse. However, such services are not offered universally. In addition, some research on trauma-informed interventions does not show long-term effects for substance use (e.g., Morrissey etal., 2005). In light of this prior research and our current findings, we speculate that trauma-informed service strategies might be enhanced by the addition of interventions to address specific forms trauma, especially in the case of recent or ongoing partner violence. Our studys findings suggest that treatment providers might need to give systematic attention to survivors need for safety planning (e.g., obtaining a protection order, establishing survivors own financing or housing independent from the perpetrator) in addition to providing trauma-informed substance abuse services. We encourage substance abuse service providers to assess women at program entry for partner violence and to connect survivors with advocacy services to obtain helpful legal remedies to ensure safety and protection. We recognize in making these service recommendations that we are underscoring long-standing proposals that domestic violence and substance abuse services be better integrated. Thus, we also call for increased research, policy attention, and funding to the study of how best to integrate domestic violence services with substance abuse treatment. With some noteworthy exceptions (Bennett & OBrien, 2007), limited empirical research has been conducted on how domestic violence services and substance abuse treatments can best be coordinated, integrated, and concurrently delivered. Such investigations should take the form of services, program, and policy research. This study also determined findings about the severity of violence, as well as polysubstance abuse that suggest additional service recommendations for domestic violence service and substance abuse treatment providers. Particularly, the findings about the severity of violence experienced by the participants indicate the extreme danger and lethality with which many in this sample struggled. In light of these findings, providers should be prepared to evaluate womens safety and the possibility of partner violence lethality during initial assessments. Similarly, we highlight the finding about the participants polysubstance abuse. This finding demonstrates that service providers should be prepared to assess women for intoxication and the need for detoxification from various substances (Edmund & Bland, 2005). These two findings also hold implications for future research. We especially encourage investigations on the myriad of substances women use singularly and in combination. We also encourage future research concerned with how partner violence severity, as well as how the different types of partner violence (i.e., psychological, physical, and sexual) may relate to womens substance abuse. The mixed findings about alcohol use, substance use, and partner violence discussed earlier may be due to the various ways in which women use substances, as well as the various types of violent victimizations they experience. Thus, we encourage researchers to build from and extend our preliminary findings about the various connections between substances and partner violence to investigate the complex heterogeneity between these two issues. Undoubtedly, such research will be a challenging undertaking. However, these efforts are necessary to illuminate the complex and dynamic relationships between these two issues.

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Limitations. This research was intended only to be exploratory in nature; nonetheless, the results of this research are based on 15 interviews. The participants were purposively selected to represent the perspectives of survivors who had serious substance abuse problems to generate information-rich data. However, survivors who abuse substances but have less-severe problems may have offered different perspectives and experiences. We recommend that future efforts seek to interview women with a broad range of substance use, misuse, and abuse behaviors. To reduce the possibility of deductive disclosure as well as increase participants comfort to speak frankly, we have included limited information regarding participants characteristics. Because the protection of participants confidentiality is essential, we were unable to present some information to illuminate our findings, which is also a research limitation. Although efforts were made to ensure participants confidentiality, some participants may have felt that they could not be fully honest in their responses for fear of the consequences of disclosure. It is possible that other connections between partner violence and substance abuse exist that were not elicited by our interviews because we failed to include relevant questions. However, we made efforts to address this limitation by (a) using open-ended questions in the interviews; (b) using probes to solicit further information; (c) and seeking disconfirming cases during analysis. In conclusion, we emphasize that the lack of comprehensive attention to partner violence and substance abuse creates significant problems for the organizations that address these intertwined problems. Unfortunately, the limited attention to promote safety and recovery concurrently means that many women who struggle with co-occurring partner violence and substance abuse are not likely getting the help they desperately need. By investigating the connections between partner violence and substance abuse, it is our hope that this research will help provide information to guide the development of interventions that promote safety and recovery simultaneously. Acknowledgments
We acknowledge Carmen Crosby, Melissa Magee, Mary Giattina, and the staff at Horizons Program for their help with this research. We also acknowledge Diane Wyant for her comments on earlier drafts of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a Jane H. Pfouts research grant from the School of Social Work at the University of North Carolina at Chapel Hill, as well as a University Research Council Grant from the University of North Carolina at Chapel Hill.

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Author Biographies
Rebecca J. Macy, PhD, ACSW, LCSW, is the L. Richardson Preyer Distinguished Chair for Strengthening Families and the Associate Dean for Academic Affairs at the University of North Carolina at Chapel Hill School of Social Work. She joined the faculty in 2002, after receiving her doctoral degree in social welfare from the University of Washington in Seattle. In 1993, she received her MSW from Tulane University in New Orleans. Her research is concerned with multiple forms of violence, including domestic violence, sexual assault, sex trafficking, and child maltreatment. Her research focuses on the development of community-based preventions and interventions to promote violence survivors resilience and well-being. Connie Renz, MSW, LCSW, LCASW, is the director of the Horizons Womens Substance Abuse Treatment Program, which is in the University of North Carolina at Chapel Hill School of Medicine, Department of Obstetrics and Gynecology. In addition to her 18 years of experience directing the Horizons substance abuse treatment program, she has worked in child protection and domestic violence services. She received her social work graduate degree from the University of North Carolina at Chapel Hill in 1974. She specializes in and conducts research on gender-specific substance abuse, as well as substance abuse and domestic violence. Emily Pelino, MPH, MSW, is an assistant school leader for the KIPP Indianapolis College Preparatory School. She received her public health and social work graduate degrees from the University of North Carolina at Chapel Hill in 2008.