Natalie Davies examines the need to address drinking problems in the context of domestic abuse and presents serious case reviews as an important adjunct to academic research. Read about the link between alcohol and domestic abuse, the impact of alcohol interventions on violence and abuse in intimate relationships, and what it means to be positive about change when there is a threat of serious harm.
When the World Health Organization reviewed what makes someone more likely to experience domestic abuse, they identified over 50 ‘risk factors’ – factors that increase a person’s likelihood of being a victim or a perpetrator of domestic abuse. Alcohol problems featured on this list, along with a range of other factors that can have an influence at the level of individuals, relationships, communities, and society, such as poverty, unemployment, traditional gender norms, and acceptance of violence.
Defining the relationship between alcohol and domestic abuse
Heavy drinking fits with the prevailing image of domestic abuse: there is some kind of disagreement in a chaotic relationship, which escalates to anger and aggression, and culminates in someone pushing or striking the other. While this may be based on a kernel of truth – on some people’s experiences – the complex and insidious problem of domestic abuse calls for a more nuanced view of the role of alcohol, and indeed a more nuanced view of domestic abuse.
Domestic abuse typically involves a pattern of abuse (rather than a one-off event), and is perpetrated by one person against another, which enables them to exert power and induce fear in their partner. However, this broader context of control may not always or immediately be obvious to outside observers, particularly when overshadowed by signs of conflict and physical violence, and/or when the perpetrator, the victim, or both exhibit drinking problems.
In May 2021, UK Parliament signed the Domestic Abuse Act 2021 into law, following the suit of Northern Ireland earlier that year, Scotland in 2018, and Wales in 2015. The UK Act presented a broad definition of domestic abuse, stating that it can include physical abuse, sexual abuse, violent or threatening behaviour, economic abuse, psychological or emotional abuse, and controlling or coercive behaviour in an intimate personal or familial relationship.
Drinking problems alone are not believed to cause domestic abuse, but may increase the risk of domestic abuse occurring and increase the risk of serious harm resulting from domestic abuse, for example by increasing aggression and increasing disinhibition (1 2 3 4). From a prevention perspective, the evidence of a link between alcohol and domestic abuse raises the possibility that reducing access to, and consumption of, alcohol could lead to reductions in domestic abuse, or at least reductions in the harm caused by domestic abuse.
Assessing the impact of alcohol interventions and guiding treatment services
Reviews in 2010, 2014, and 2019 concluded that there has been insufficient research into the impact of alcohol interventions and policies on domestic abuse. Still, the World Health Organization was optimistic, concluding a decade ago that there was encouraging “emerging evidence”, in particular around reducing alcohol availability (e.g. by restricting hours of sale), increasing alcohol prices, and providing treatment for alcohol use disorders to perpetrators of domestic abuse.
The key here was that the World Health Organization was analysing the evidence for alcohol interventions alongside the evidence for interventions and policies addressing tens of other risk factors; alcohol was not the primary focus, it was ‘one cog in a very large machine’ – in other words, something that is necessary to address, but of small significance without work to address all the other mediating factors.
In a recent report funded by Alcohol Change UK, colleagues at Liverpool John Moores University and King’s College London identified very few interventions targeted at perpetrators with drinking problems to address their domestic abuse. Referring to an earlier systematic review, they found 13 studies in total, but only three had sufficient numbers of participants to be given due consideration. These studies revealed some positive effects, for example when brief alcohol interventions were used as an ‘add-on’ to domestic abuse perpetrator programmes, but these effects were often not sustained, and applied to people who were heavy or risky drinkers and not necessarily dependent on alcohol.
In the UK, the perpetrator programmes that alcohol treatment can supplement are predominantly based on the understanding that domestic abuse is rooted in the perpetrator’s desire to have power and control over their partner. For example, regardless of whether there is (alcohol-related) conflict between two people, the interventions are tuned to the fact that perpetrators may be using intimidation, isolation, coercion, and threats against victims behind closed doors.
Due to limited availability of perpetrator programmes, alcohol treatment services who suspect domestic abuse may need to work within local multi-agency systems, such as Multi-Agency Public Protection Arrangements (MAPPA) and Multi Agency Risk Assessment Conference (MARAC), to manage the level of risk and protect the safety of victims. It is not recommended that alcohol services refer to anger management or couples or family counselling, even in the absence of specialist perpetrator programmes. Against Violence and Abuse (AVA), a national charity working to end violence against women and girls, warns that anger management fails to account for controlling behaviours associated with domestic violence, and couples or family counselling can add to the belief that victims are somehow to blame for the abuse and may provide a space for perpetrators to reinforce this.
Preventing serious harm and promoting the possibility of change
In their practice-facing resource Complicated Matters, AVA advises that when someone discloses or alludes to abusive behaviour, practitioners should provide positive feedback and promote the possibility of change, saying something like the following:
“Change is possible. You are in control over whether you change your behaviour and no-one else. The problem is not you, it’s your behaviour.”
Encouraging the belief that change is possible has also been a central message of the Blue Light Project, an initiative spearheaded by Alcohol Concern to develop alternative approaches and care pathways for drinkers who have complex needs, but who are not in contact with treatment services – for example, people who “have been offered services in the past, or have been to services in the past, but have either not benefitted from services or have actively resisted going to those services”.
In 2016, AVA and Alcohol Concern collaborated on a joint project which sat at the intersection of domestic abuse and alcohol problems, and continued this theme of promoting the possibility of change. The project involved an analysis of Domestic Homicide Reviews, and workshops with around 600 people working in domestic abuse, health, criminal justice, substance use and housing settings.
Domestic Homicide Reviews were made a legal requirement in 2011 to ensure that, after someone had been killed by an intimate partner (a ‘domestic homicide’), all agencies involved reviewed their actions, or lack of actions, in order to change their practices, and reduce the risk of a similar homicide happening again.
Out of a total sample of 39 Domestic Homicide Reviews, 27 involved alcohol-related harm. These pointed to a “clear pattern of an alcohol problem being identified, a referral being made, but the person not taking up the offer”. As the authors said, this pattern was not too surprising. Public Health England had suggested to the authors that at any one time 75% of dependent drinkers are not engaged with services, and an analysis by Drug and Alcohol Findings found that alcohol treatment may only be engaging the equivalent of about 1 in 5 of those whom official guidance suggests are in need of treatment. However, resignation to this ‘treatment gap’ was far from what the authors were seeking to cultivate.
One of the main conclusions of the report on Domestic Homicide Reviews was that alcohol-related domestic abuse can create a context in which fatal violence is more likely, yet is particularly difficult to prevent, especially in cases where both the perpetrator and victim have drinking problems but are not engaged with treatment services. This alone speaks volumes to how vital alcohol treatment services are in addressing the public health problem of domestic abuse, even as researchers continue to connect the dots between alcohol problems and domestic abuse, and to question whether domestic abuse can be prevented through alcohol interventions.
Choose from one of our recent publications on the topic of domestic abuse, including an interview about domestic homicides and a briefing on the Domestic Abuse Act 2021, or click here to view all other content on domestic abuse on the SSA website.
[Author’s note: title was edited for accuracy on 23 June 2021]
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