CONTENTS

About This Course

Table of Contents

1. Introduction to the Issues
2. Understanding Alcohol Abuse
3. Understanding Violence Against Women
4. Alcohol and Domestic Violence
5. Alcohol, Sexual Assault, and Rape
6. Prevention and Early Intervention
7. Screening and Assessment
8. Diagnosis and Treatment
9. Legal and Ethical Issues

Supplements
Fact Sheets
Videos
Resources

Silence Hurts:
Alcohol Abuse and Violence Against Women

Screening and Assessment

Health care professionals treat women at every age. Most women regularly see doctors, nurses or mental health professionals for routine check-ups, pregnancy issues, physical injury, or mental health concerns. During these visits, health care providers have the opportunity to do screenings and assessments for domestic abuse, sexual assault, and alcohol abuse. Unfortunately, many providers never ask questions or probe beyond the presenting problem to determine any underlying cause.

Screening. Within the context of violence and alcohol abuse prevention, screening is defined as a brief procedure used to:¹

• Determine the presence of a problem (e.g., mental health disorder, alcohol abuse)
• Substantiate that there is a reason for concern
• Identify the need for further evaluation

Screening is done early in the process of collecting information. It may be done by a questionnaire or checklist, and is not meant to provide a mental health or substance abuse diagnosis.

Assessment. This is a more comprehensive diagnostic and treatment planning process typically based on screening information. Assessments can take hours to complete and should help to prepare a treatment plan. Some goals of assessment are to:²

• Examine the scope and/or severity of the problem
• Identify other possible psychosocial problems that need to be addressed further
• Provide a foundation for treatment
• Identify possible strengths of the woman that can become part of treatment

Screening and assessment should be done by trained professionals with experience in violence or substance abuse issues. Specialized instruments are used to ensure reliability and standardization.

For Domestic Violence and Sexual Assault

In order to establish a bond of trust with a patient/client, a professional can use statements that normalize any situation a client may be facing. Examples of this include:

• "Because violence is so common in many people's lives, I've begun to ask all my patients/clients about it."
• "I'm concerned that your symptoms may have been caused by someone hurting you."
• The American College of Obstetricians and Gynecologists (ACOG) has developed the following tool. "Because sexual violence is an enormous problem for women in this country and can affect a woman's health and well being, I now ask all of my patients about exposure to violence and about sexual assault."
• Do you have someone special in your life romantically?
• Are you now, or have you been, sexually active?
• Has a friend, date, or an acquaintance ever pressured or forced you into sexual activities when you did not want them? Touched you in a way that made you uncomfortable? Anyone at home? At school? At work?

If a client was raped or sexually assaulted recently, it is important to know exactly when the rape occurred, if she sought medical attention afterwards, and if she sought mental health counseling.

For Alcohol Use and Abuse

There are many instruments available for alcohol screening. Instruments may be in the form of questions in an in-person interview, a written questionnaire, a computerized questionnaire, or a telephone interview. Any positive responses should lead to further questions. Alcohol screening in clinical practice should be consistent with other screening procedures in place.

Four popular screening instruments for alcohol abuse include:

• CAGE Questionnaire. This is one of the most well-known, validated, and widely used alcohol screens. It consists of four questions and can be administered formally or informally as part of an intake process. Positive responses are for lifetime problems, not current problems.³
• AUDIT (Alcohol Use Disorders Identification Test). This test is one a few tests that has been validated cross-culturally, so it is useful for identifying alcohol problems among ethnic minority groups.⁴
• MAST (Michigan Alcohol Screening Test). Like the CAGE, this test is a widely used tool. The measure is a 25-item questionnaire designed to provide a rapid and effective screening for lifetime alcohol-related problems and alcoholism. It has been used in many settings and with many population.
• SMAST (Short Michigan Alcohol Screening Test). This is a shorter version of the MAST for those settings with little time.

Because depression is a problem for a large number of people with alcohol problems, it may prove helpful to also screen for depression at the same time. There are many depression screens for purchase available. Two that are publicly available are the Goldberg Depression Questionnaire and the Center for Epidemiological Studies Depression Scale.

For alcohol assessments, two main structured instruments are available. These include the Structured Clinical Interview for DSM-IV (SCID) and the Diagnostic Interview Schedule for DSM-IV (DIS). They are both commercially available and may require special training for proper use. Assessment involves five important tasks:⁵

1. Assistance in diagnosing of the problem.
2. Establishing the severity of the problem.
3. Developing a treatment plan.
4. Defining a baseline that can be used to evaluate a client's progress in treatment.
5. Increasing the client's motivation to attend treatment.

Areas of assessment include alcohol use, social and family relationships, psychological functioning, legal status, medical conditions, and employment and educational status.

For more information for consumers, go to www.samhsa.gov/preventionpathways and click on "courses" to find the online course, "It Won't Happen to Me: Substance Abuse and Violence Against Women."

References

1. The National GAINS Center (2003). Policy Research Associates. Available at http://gainscenter.samhsa.gov.
2. Ibid.
3. Ewing, J.A. (1984). Detecting alcoholism: The CAGE Questionnaire. JAMA, 252(14),1905-7.
4. Babor, T.F., de la Fuenta, J.R., Saunders, J., Grant, M. (1992). AUDIT: The alcohol use disorders identification test: guidelines for its use in primary health care. Geneva, Switzerland: World Health Organization.
5. Domestic Violence/Substance Abuse Interdisciplinary Task Force of the Illinois Department of Human Services (2000, July). Safety and sobriety: Best practices in domestic violence and substance abuse.