 This program is offered in connection with the National Victim Assistance Academy and is sponsored by the Office for Victims of Crime. It examines the relationship between victimization and substance abuse. It also explores techniques that victim advocates may consider using to be more helpful for victims who turn to drugs or alcohol as a means of coping with the trauma caused by crime and emphasizes the importance of collaboration in assisting victims with substance abuse issues. To the casual observer, a crime scene may be little more than a passing curiosity, flashing lights, yellow tape, police officers and guns seemingly fresh from the screen of a television police drama or action-based movie. There is a tendency to focus on the immediate drama and not issues that precede and follow the criminal incident. But for experts who try to prevent crime and for those who deal with the aftermath, it's become apparent that crime and the trauma that results is often correlated to the use of substances. Part of the thing that we've learned is that there's a strong relationship between victimization history, post-traumatic stress disorder and likelihood that you will have alcohol and drug abuse problems. It's true whether the crime becomes a public spectacle or whether no one but the perpetrator and the victim know about it. In Michael Pully's case, the crime happened when he was very young and by the time a treatment counselor got him to talk about it and examined the potential link between his victimization and substance abuse, he was in his fourth round of treatment for alcohol and drug abuse. At age 11, I was sexually molested by a fifth grade teacher. I went on for a quite a long period of time. My substance or alcohol abuse started approximately a year later. I was 12 years old. It was my first experience with alcohol. I got quite drunk. I liked the feeling of release that it gave me from reality. The abuse continued and progressed throughout my teenage years, getting into hard drugs in the late teens, early 20s and just continued the snowball effect from there. In Oklahoma City, the bombing of the Murrah Federal Building was much more visible and the resulting trauma was much more widespread. Thousands of victims and rescue workers were involved and in many cases substance abuse issues eventually came to the surface. With the rescue workers, it's the cumulative stress. It wasn't just the bombing. It's what happened before and what's happened since. The bombing certainly exacerbated that, but then it's the daily stress of their job. With the survivors and the family members, it's a different kind of thing. It's that traumatic grief issue more so than the job stress or the cumulative stress. Each are difficult to deal with. I think though that each use drugs or alcohol to mask that pain and deal with it. What we try to stress to the victims we work with is, it's going to be real easy to go home and drink a little scotch or whatever and ease your pain from the day and your feelings, but that's a real easy trap to get into and that can quickly become a habit that's out of control. But substances don't just affect victims after the crime. There's a good chance that the perpetrator was involved with drugs or alcohol when committing the offense. And recent national studies also indicate that substance abuse by victims can be a correlative but not a causative pre-victimization factor. That is to say a victim of assault who is intoxicated at the time the assault is committed may have made different choices that he or she had not been drinking. That does not mean however that he or she is in any way personally responsible for the fact that the perpetrator chose to commit the crime. Alcohol and other substances do not cause a crime to occur but it makes the crime more likely to happen. It predisposes the criminal to act out and it predisposes the victim to be more vulnerable for the crime to occur. The victim under the influence is less aware of what's going on and less able to respond appropriately and criminals by their sociopathic nature take advantage of both of those issues. And while substance abuse is certainly not a cause of crime the correlation between substance abuse and victimization is increasingly being examined as shown by the following sampling of research findings. An estimated 22 million Americans in 2002 were classified with substance dependence or abuse. An estimated 19.5 million Americans aged 12 or older were current illicit drug users in 2002. Also in 2002 about 1 million violent crimes occurred where the victim perceived the offender had been drinking during the time of the offense. In 2001 almost 44% of the offenders in rapes and sexual assaults acted under the influence of drugs or alcohol. Half of all spouse murder victims drank alcohol before the crime. Youth who witnessed violence were three times more likely to have substance abuse disorders. According to the American Psychological Association's Diagnostic and Statistical Manual 4 disorders relating to a variety of substances are divided into three primary categories. Substances most often become a problem if they create dependence with users perhaps developing a tolerance suffering withdrawal, increasing consumption being unable to reduce intake, spending excess time trying to obtain the substance or giving up normal activities and continuing use even though they recognize a problem. But alcohol and drugs can also cause trouble if users fall into the category of abusers where the substance may cause failure of the person to fulfill roles at home, work or school or where the user may put himself or herself at risk physically, legally or socially. Alcohol users are further defined as moderate drinkers who consume one to two drinks a day, binge users who have five or more drinks at least one time in the past month or heavy users who binge drank five times in the past month. While classifications for substance disorders are well established, the intricacies of cause, effect and correlation between substances and victimization aren't as well understood. I wish that the relationship were clear so that we could define what happens in terms of time and connection between trauma and PTSD and substance abuse. Right now, all that we know is that it's sort of a snarl in that all three of those things are highly correlated with one another. We know that in the general population, the prevalence of substance abuse is above 15%, with a population of people that have been victimized, it might be two, three, four times higher than that. And when victims are also substance abusers, their victimization may be compounded when defense attorneys try to protect the offender. I think that the biggest problem is that substance abuse and its legacy in the community reinforces the idea of victim blaming. And as long as we have any concept that reinforces victim blaming, it's going to be hard for victim advocates to bring that into the forefront. Resulting complications from the victimization may be the beginning of a downward spiral for victims. Faced with the immediate injuries, emotional trauma, or property damage from victimization, as well as subsequent stresses from the media, the justice system and recovery efforts, victims may rely on alcohol, illegal substances, or prescription drugs. Once you've been victimized, it would be very tempting to do drugs or alcohol to mask that pain because that pain, whether it's rape, whether it's having a child murder, whether it's being an attempted murder on yourself, you know, that pain or that fear or that experience is always going to be with you. It gets easier with time, but it's always there, and especially at first, it would be so tempting to use something to mask that pain or ease that pain. I think there's a wide range of reasons why victims will come to use substances, alcohol or other drugs, and they include the obvious in that it masks the pain. But in addition to that, there's a self-fulfilling prophecy that loss of control is reinforced when you're out of control using substances. Whether it's sexual molestation, assault, or some other offense, advocates often find that drugs and alcohol are complicating factors in recovery. It isn't always clear whether the substance abuse or victimization came first or the impact one has had upon the other. But it's obvious that advocates need to know more about the relationship between substance abuse and victimization. The National Survey of Adolescents was a study of a national household probability sample of 4,023 male and female adolescents between the ages of 12 and 17. We surveyed them about criminal victimization experiences they'd had during childhood and adolescent, as well as about alcohol and drug abuse and other substance use disorders. What we found was that a history of criminal victimization increased the risk that people would have substance abuse disorders. Several studies in general population samples have shown that there's a strong relationship between criminal victimization experiences and substance abuse problems. There are three possibilities that might explain that. The first is that substance use leads to increased risk of criminal assault. A second possibility is that a history of assault leads to substance abuse or usage. A third possibility is that substance use and assault have a reciprocal relationship. Someone has a child or adolescent victimization. This in turn leads to an increased risk of substance abuse and dependence problems. And this in turn leads to an increased risk of assault. We know more about alcohol and substance abuse prior to victimization than we do regarding the research for post-victimization. What we do know is that sexual assault victims are twice as likely to use and abuse alcohol than non-assaulted victims. Half of all domestic violence, victims of domestic violence use and or abuse alcohol. On the other hand, research indicates that 9 out of 10 women in alcohol and drug treatment today have been the victims of physical or sexual abuse. What we have here is a high correlation between these two, but no way to determine causation, we have a chicken and egg problem in which there needs to be much more research to find out exactly the level of substance abuse in post-victimization. Regardless of whether substance abuse started before or after victimization, there's an emerging consensus that both victim advocates and substance abuse professionals need to be assessing clients to find out if there might be a link. Anyone in the front lines who has seen someone that's been victimized by a crime needs to consider chemical dependency as a potential problem. I think as victim services providers we sometimes get so focused in on our particular victim population, and I'll use my early life as an example. I worked in Child Protective Services for a number of years. I would get on the elevator every Tuesday night as moms and dads and children were coming in for their various group therapies. Those elevators would be reeking with alcohol, and yet never once did I address the issue of substance abuse because I was focused on incest. Without considering substance abuse, victim advocates may miss crucial clues about treatment needs, and considering victimization, substance abuse professionals may miss an opportunity to uncover the root of a hidden problem. It was never mentioned, never hinted around to. No one asked the question. I don't know if I would have answered it if they had asked, but it was never put out there on the table. The last place I was at is when they asked. This was a couple years, three years ago. And when I began discussing this, they discussed it with me in length and recommended long-term therapy. In Michael Pully's case, a counselor's questions finally did uncover past victimization, and that started more successful treatment. It's just one example of why experts say advocates should always be on the lookout. As a clinician, when I'm evaluating someone, chemical dependency is always at the top of my list. It's one of the things that I'm always looking for as I'm getting to know someone. First of all, because of its prevalence in this population of people that have been traumatized. But secondly, it's crucial that I know whether this person is intoxicated or addicted in terms of helping them. It's very difficult to intervene with anybody who's actively dependent. But getting victims to reveal critical information that will help in the diagnosis is rarely an easy task. Victims don't know whether to talk about it or not talk about it. And knowing the dynamics of substance abuse as we do, we know that denial and minimization is a huge part of it anyway. So they are not going to bring it up. And if they don't bring it up with perhaps the most compassionate listener in their world, which would be their victim advocate, they probably won't bring it up to anyone. The first thing you do is you ask them the question. Usually, if they're heavily into the abuse, they're not going to be real honest with you. They're not going to come out and say, I'm going to get the day or whatever, or I use whatever a day. They will tend to minimize it. As they get to know you, they will probably be more honest. Although victim service providers are not substance abuse professionals, asking the right question carefully and at the right time can be an invaluable service for victims. A good entrance might be obviously have gone through a lot. What are you using to help yourself feel better? You can also do, like, the various substance abuse inventories. Do the various instruments on them, too. But usually, and you also, you can pick up other clues from job history, how many times they've lost a job, marriages. What was the cause of that marriage breakdown? There are other little clues that you look for. The National Center on Addiction and Substance Abuse at Columbia University just released a very large study showing that most physicians when facing potential substance abuse problems don't even ask the right questions. And I think this is very instructive to us. Informed advocates should be aware of potential substance abuse issues, ask questions, and look for indications. That does not happen until the time is right. In the midst of dealing with a crime, with a victimization, it is often not the best time to also confront a substance abuse issue. It is something that probably an intervention needs to be done probably much later, after the crisis is over with. Once a victim has begun to address his or her trauma issues, an advocate can begin dealing with the substance abuse. Usually that means working with other allied professionals to be able to effectively assess substance abuse problems and make appropriate referrals. I personally think that learning everything there is to know about substance abuse is more than we can expect of victim advocates. However, I think that victim advocates do need to know enough about how to screen for problems among their victims and they do need to know what are some good referral sources. I would add that the good referral sources are those that understand that you must address both the effects of the victimization as well as of the substance abuse and that do not treat those in isolation. A victim advocate has a responsibility to be able to respond to a diversity of needs that are presented by a victim. It may be in the area of cultural competence, it may be in the area of substance abuse, it may be in the areas of family dynamics and we're not going to have those kind of special skills developed to the level that other professionals will. So what we need to do is we need to have the capacity to identify the problem and then refer in a way that we can make sure that the services delivered in that area are high quality services. Because substance related client services are well established, many professionals believe that a correct diagnosis of dependency is the crucial first step towards successful intervention and treatment. Referral for treatment must then be handled carefully. It's not done with a message of rejection which is you've got a problem that I can't manage and you have to go somewhere else to have somebody take care of it. But we've spent some time identifying that drinking or taking drugs is interfering with your adjustment to what's happened and we need to get some more specialized care for this and I'm going to continue to work with you while you're getting that care. So I'm more concerned that people get that sort of message about a positive sort of way of referring people but it's terribly important for anybody that's doing victim's assistance to have really solid connections with the people in the community can help out with specialized sort of inpatient or outpatient intervention. And referring to the proper specialist is critical. In Michael Pulley's case, it took intensive treatment to make a difference. The last treatment center I went to approached treatment from a different standpoint than the other four I've been through. They seem to approach it from not only a substance abuse standpoint but a mental standpoint as far as what is causing you to use alcohol and drugs. Why are you using these to cope with the problems that you have in your life and what are these problems? They focus more on the root of the problem rather than the problem itself. It is also critical for service providers to be knowledgeable about and be able to refer to appropriate faith-based organizations for substance abuse counseling. It is appropriate to ask victims about their spiritual background for purposes of referrals. Many victims have strong roots in a faith community and this may be the most helpful avenue for them. Indeed, it may be the only avenue of help that they are comfortable pursuing. I think when you look at the levels of need with the community and the populations that we serve, I think the first entry level is the faith community. Being able to confide in, sometimes it's just another member of the church who then suggests that you go to someone on another level. I think that we get referrals from parents, from grandparents, from friends and relatives who say you need to talk with someone else and the faith community. I think we've been doing it all along and it's just been expanded and it's not been expanded because of the new legislation and the new administration, but we've been doing it for a number of years. Finding the proper avenue for treatment is critical, especially since the victimization and substance abuse arena is a highly complicated web of cause, effect and correlation. In fact, substance abuse can also become a problem for advocates as the result of suffering vicarious trauma and abuse scale disasters and stress. This possibility coupled with a natural tendency to protect victims can lead to a sort of unintentional, mutual denial. Substance abusers are masters at evading the issue and we, and I'm going to make a guess that a lot of us in this field, maybe a little co-dependent ourselves, tend to want to nurture people, hold hands, make things better, see people in their best light, focus on strengths rather than weaknesses. So you put that combination of perhaps a weakness in our discipline with what is going on with the victim and you have the synergism for everybody to deny that this is a real issue. Clearly, victim advocates often share the stress of a victim's circumstances and advocates are well advised to seek help themselves if that stress or substance use is interfering with their lives. It's also true that each victim comes into their respective situation with a different background. That means each advocate needs to avoid typecasting the individual problem based on statistical findings. The last thing that victims need is a helper who is trying to identify a problem on the basis of empirical sort of facts. What victims need is an engaging, caring individual that recognizes that this might potentially be a problem and to help them with it rather than defining it or diagnosing it. In Michael Pulley's case, that approach and an individualized recommendation for treatment worked extremely well. For the first time someone asked the question, they gave understanding and support. They also told me how to cope with the problem and what steps I should take to start this long process of being treated for not only substance abuse but the victimization as well. For example, the gentleman in Columbia asked me to say it would be a good idea if I moved to Charleston, South Carolina, to go to counseling. The counseling I received in Charleston was great because in some ways we did discuss alcohol and substance abuse along with the post-traumatic stress disorder. So the biggest help was people that I had contact with seemed to understand both aspects. Understanding the links between substance abuse and victimization, asking the right questions of victims, and knowing where to turn for expert help are all part of the recipe for victim advocate success. If we're going to be victim centered and we're going to provide the services we need to do, we need to understand that substance abuse has a drastic impact on a person's safety and that they're covering up a lot of things that they need to ventilate and be validated about, and that finally we need to be able to predict and prepare for them just what kind of path substance abuse as a coping mechanism will bring about in their lives. And if we do that and we stay focused on what our common issues are with our substance abuse professionals, collaborations should be simple. There are no easy answers to this highly complex problem. Victims of crime often suffer from both mental and physical pain. Alcohol and other drugs are frequently used to cope, and many times that coping mechanism further complicates the trauma and pain. But advocates who pay attention can help by talking, testing, and trusting their own instincts about a victim's situation. Learning about alternative treatment resources in the community, collaborating with substance abuse professionals, recognizing when the situation is out of their domain, and referring victim clients to the appropriate experts. For a list of community-based treatment programs in your community, contact your local mental health association, or contact the Substance Abuse and Mental Health Services Administration's National Clearinghouse for alcohol and drug abuse information at 1-800-729-6686.