Working at the Intersection of Substance Use Disorders, Psychiatric Disabilities and

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• Working at the Intersection of Substance Use
  Disorders, Psychiatric Disabilities and
• Violence Against Women
• Patricia J. Bland M.A. CCDC
•  
•  

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Introduction

• The primary goal of this workshop is to help
  advocates, counselors and other professionals
  better address the safety and recovery needs of
  women impacted by multiple abuse issues
• This workshop also provides participants with
  tools to better address service needs and options

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Domestic and Sexual Violence, Chemical
Dependence and Mental Health Issues all

• Involve power and control dynamics
• Impact entire families, often harming 3 or more
  generations
• Thrive in silence and isolation
• Carry great societal stigma and shame
• Limit freedom for members of our community
  resulting in oppression

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1 1 10 Tons of Trouble

• Safety is strongly compromised when domestic
  and/or sexual violence, substance abuse or mental
  health problems co-occur
• Severity of injuries and lethality rates climb
  for battered women with alcohol problems (Dutton,
  1992)

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Trauma
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Co-Occurring Problems

• A NIDA study noted 90 of women in drug treatment
  had experienced severe domestic and/or sexual
  violence from a partner during their lifetime
  (Miller, 1994)

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Violence and Trauma

• In another study, 104 of 105 women drug users
  experienced physical/sexual abuse trauma
  (Fulilove et al,1993)
• 59 reported PTSD symptoms including
• Sleep Disturbances
• Anxiety
• Hypervigilance
• Numbing of responsiveness

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Multiple Abuse Issues

• Women often initiate use as result of traumatic
  life event, such as past physical or sexual abuse
  (Ashley et al., 2003 Weiss et al., 2003)
• Women are often drawn into use by partners
  (Ashley et al., 2003)

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Abusers Pose Risk to Partners

• Introducing partner to drugs
• Forcing or coercing partner to use (e.g.dirty
  needles, cottons, noxious substances)
• Isolating partner from recovery and other helping
  resources
• Coercing partner to engage in illegal acts (e.g
  dealing, stealing, prostitution)

• Sabotaging recovery efforts
• Using drug history as threat (deportation,
  arrest, OCS, custody, job, etc.)
• Blaming abuse on partner use and benefiting from
• Lack of services for chemically dependent
  battered women
• Societal beliefs re women, addiction and
  parenting

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Substance Abuse and Violence/Trauma (Sharon
Ametetti, MPH, CSAT)

• Physical and sexual abuse among women in
  substance abuse treatment programs ranges from
  30 to more than 90 (Finkelstein et al., 2004)
• Illicit drug use rates among women in violent
  relationships are 2-3 times those of women in
  general population (Cunradi, 2000)
• In one recent study, 59 of women with drinking
  problems experienced past year severe intimate
  partner violence (vs. 13 with no drinking
  problem) (Weinsheimer et al, 2005)

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Substance Use Issues
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Scope of the Problem

• 74 of women in substance abuse treatment have
  experienced sexual abuse (Covington Kubbs, 2000)
• _______________________________________________
• Nearly 75 of wives of alcoholics have been
  threatened and 45 have been assaulted by their
  partners (AMA, 1994)
• ________________________________________

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Women have higher

• Blood alcohol levels than men after consuming
  equal amounts of alcohol (LaGrange, 1994 Lieber,
  1993)
• Prevalence and greater severity of
  alcohol-related liver disease with shorter
  duration of alcohol use and lower consumption
  levels than men (Kubbs, 2000)
• Death rates from alcohol-related damage (CSAT,
  1994)

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Prescription for Trouble

• Women are likely to use prescription medication
  much more often than men
• 70 of prescriptions for tranquilizers,
  sedatives and stimulants are written for women
  (Roth, 1991)
• And psychotropic medication is over-prescribed
  for battered women (Minnesota Coalition for
  Battered Women, 1992)

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Women Experience More Serious Health Problems

• Greater proportion of female alcoholics die from
  suicides, alcohol-related accidents, circulatory
  disorders, and liver cirrhosis (Smith Weisner,
  2000)
• Drug abuse is nearly twice as likely to be
  directly or indirectly associated with AIDS in
  women than in men (Weiss et al., 2003)
• Alcohol and other drug use is major risk factor
  for coronary heart disease and various forms of
  cancer (Harwood et al., 1999)

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Other Factors Substance Use and Infectious
Diseases (SUDs)

• Women with SUDs are more likely to have high-risk
  and multiple sex partners (U.S. DHHS, 1999)
• Women with SUDs are at increased risk for HIV,
  TB, Hepatitis and other STDs (Francis Cargill,
  2001)
• 35 of women living with AIDS in 2003 were
  exposed via injection drug use (HRSA, 2005)

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Barriers and Safety Issues
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The Wrong Questions

• Why doesnt she just leave?
• Why doesnt she just quit using?
• Why doesnt she just pull herself together?

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Service Barriers

• Women impacted by multiple issues are often
  ill-served in our programs and perceived as
  disruptive when their substance use or mental
  health symptoms becomes evident
• They often need our services the most yet are
  among those least likely to seek or receive
  services. When they do not receive services their
  children also remain invisible and at risk

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Barriers to Services

• Employment, housing, health insurance or child
  custody may be threatened by public disclosure of
  current or past substance abuse or mental health
  problems
• Access to treatment due to parenting
  responsibilities or to shelter because of the
  substance abuse or mental health issues may be
  denied
• This can lead to isolation, blame and shame

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Barriers to Accessing Help

• Lack of gender-specific, family-focused services
• Caregiver responsibilities fear losing children
• Social stigma and guilt
• They face tremendous stigma and are often
  considered bad mothers, bad people, bad victims
  and resistant to treatment
• Fewer economic resources
• Domestic and Sexual Violence

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Safety Concerns

• Acute and chronic effects of alcohol and other
  drug use or mental illness may prevent one from
  accurately assessing levels of danger
• One may feel an increased sense of power and
  erroneously believe self-defense against an
  assault is possible, not realizing the impact of
  substances on gross motor functioning and
  reflexes Bland, 1997 Illinois Dept. of Human
  Services, 2000)

• (

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Safety Concerns

• Substance use and misuse can impair judgment and
  thought processes (including memory) making
  safety planning more difficult
• Abstinence and recovery efforts may be sabotaged
  (For example, someone receiving methadone on a
  daily basis could easily be stalked )

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More Safety Concerns

• There may be reluctance to seek assistance or
  contact police for fear of not being believed,
  arrest, deportation or referral to OCS
• Compulsion to use and withdrawal symptoms may
  make it even more difficult for
  substance-abusing or addicted individuals
  impacted by DVSA to

• keep scheduled appointments for advocacy or
  access shelter or other services
• Recovering women may find the stress of securing
  safety leads to relapse
• If using now or in the past, a person may not be
  believed (Bland, 1997 Illinois Dept. of Human
  Services, 2000)

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Working with Women Affected by Multiple Abuse
Trauma
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Working with Women Impacted byCo-Occurring
Problems

• A successful culturally competent intervention
  incorporates
• Awareness of ones own biases, prejudices and
  knowledge about the people we serve and their
  culture
• Recognition of professional power (power
  differential between you and the program
  participant) in order to avoid imposing ones own
  values on others
• There is no typical substance abuser, client
  or victim, provide universal screening

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Discussing Multiple Problems

• DV/SA, Substance abuse or mental health issues
  impacting safety, sobriety and wellness may be
  easily missed if we dont ask about these
  concerns in a non-threatening manner
• Women may find it easier to talk about stress in
  their relationships or their partners substance
  use or mental health before talking about DV,
  sexual assault or their own substance use or
  mental health

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Discussing Multiple Issues

• Conversations must be respectful, private and
  confidential
• Children should not be present
• Communication should be age and developmentally
  appropriate as well as culturally relevant
• Use an interpreter when necessary
• Normalize questions find a way to discuss
  multiple issues that is comfortable for both of
  you

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ASK - Sample Screening Questions

• Women often report feeling stress in their
  relationship
• How does your partner show disapproval?
• Please describe any threats made by your
  partner. (How often, when was the last time.
  Were you afraid, were you hurt, can you tell me
  what happened)?
• Remember to ask direct questions tactfully and
  respectfully!

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ASK - Sample Framing Statement

• Domestic Violence and sexual assault are major
  problems for women. Because abuse is such a
  common experience for women, I ask everyone I see
  whether they feel safe.
• Women in treatment often tell me their partners
  complain about their using. How does your
  partner show disapproval?

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ASK - Sample Indirect Questions

• You mentioned your partner loses his temper with
  the kids. Can you tell me more about that? Have
  you ever felt afraid for yourself or your
  children -- can you tell me more about that?
• All couples argue sometimes. Does your partners
  physical or sexual behavior ever frighten you?

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Sample Screening Question if Partner is User or
Abuser

• Many women tell me their partners dont want to
  drink/drug/smoke alone. How often do you find
  yourself using when you dont really want to?
• When a partner spends family money on drug use,
  that is a form of economic abuse. Has your
  partner ever used food or rent money to drink or
  score drugs?

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Sample Framing Questions for Substance Abuse

• Women I see often tell me they feel stress.
  There are several ways to deal with stress. What
  works best for you?
• Many women tell me they try to sleep more, eat
  better or shop for baby things. Have you tried
  any of those ways of coping?
• Many women also tell me the best way to cope is
  to smoke a cigarette, have a drink or take
  something else. How often has that worked for
  you? Do you find it is still working?

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Sample Framing Questions for Substance Abuse

• Being involved in a court case/custody dispute
  can be stressful. Your partner may attempt to
  undermine you/ your parenting skills. Can you
  identify any reasons why drinking or using drugs
  right now could be harmful to your case? Can you
  share with me what your partner might say about
  your drinking or drug use?

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CAGE-D

• Have you ever felt you ought to cut down or stop
  using alcohol or other drugs?
• Has anyone annoyed you or gotten on your nerves
  by telling you to cut down or stop drinking or
  using drugs?
• Have you felt guilty or bad about how much you
  drink or use?
• Have you been waking up wanting to have an
  alcoholic drink or use drugs? Adapted from JA
  Ewing (1984) 'Detecting Alcoholism The CAGE
  Questionaire', Journal of the American Medical
  Association 252 1905-1907.

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CAGE-DV

• Have you ever felt Controlled or threatened by
  your partner?
• Has anyone Annoyed you or gotten on your nerves
  by expressing concern about your partners
  behavior towards you?
• Have you felt Guilty or bad about how your
  partner treats you?
• How often do you wake up anxious, afraid or
  wanting to Escape your partner?
• Adapted by P. Bland from JA Ewing (1984)
  'Detecting Alcoholism The CAGE Questionaire',
  Journal of the American Medical Association 252
  1905-1907.

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4 Ps

• Have you ever used drugs or alcohol during
  Pregnancy?
• Have you had a problem with drugs or alcohol in
  the Past?
• Does your Partner have a problem with drugs or
  alcohol?
• Do you consider one of your Parents to be an
  addict or alcoholic? Ewing H. Medical Director,
  Born Free Project. Contra Casta County, 111
  Allen Street, Martinez, CA 94553. Phone (510)
  646-1165.

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4 Ps DV

• Have you ever been hit or hurt by your partner
  during Pregnancy?
• Has your (current or former) partner been violent
  or abusive in the Past?
• Does your (current or former) Partner have a
  problem with violence or abuse now?
• Do you consider one of your Parents to be violent
  or abusive? Adapted by P. Bland from the 4 Ps
  alcohol and other drug screening tool developed
  by H. Ewing, Medical Director, Born Free Project.
  

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What do I do if she says, Yes?

• Explore options such as shelter, counseling,
  gender specific treatment, support groups
  addressing multiple problems, safety planning,
  linkage to advocate and providers
• Discuss options for children Discuss financial
  issues, insurance, etc.
• But before you do any of this.

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ABCs of Advocacy Based Counseling

• Acknowledge harm has been done and say this is
  not your fault. Your childrens safety is
  important and so is your safety
• Believe domestic and sexual violence, substance
  use problems and mental health issues are
  traumatic and painful
• Believe people do their best to survive
• Credit each individual for finding a way to cope
  and offer options to make coping and surviving
  safer

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Avoid Revictimizing

• People do not choose to develop multiple abuse
  issues
• Think before speaking...how would you
• like to be spoken to?
• Remember to offer respect, not rescue options,
  not orders, safe treatment rather than
  re-victimization

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Validate

• You did not deserve this. Im so glad you found a
  way to survive. Drinking/drugging/cutting, etc.
  can kill pain for a while but there are safer
  ways of coping that can cause you less grief
• You deserve a lot of credit for finding the
  strength to talk about this
• Addressing these concerns can help you and
  improve your childrens safety and well-being,
  too

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Acknowledge SuccessesIdentify Options

• You are here to day and you are doing quite a bit
  right. What have you done to keep
  safe/sober/well up until now? What have you been
  able to do to care for yourself and the welfare
  of your children?
• What has worked well for you and the children
  what has given you problems?
• Many people tell me they have tried_________.
  How often has this worked for you?

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ACKNOWLEDGE - You Hear

• Make person comfortable as possible assure
  confidentiality of records when applicable
• Affirm autonomy and right to control
  decision-making, validate concerns and use
  supportive statements
• Im sorry this happened its not your fault
• Right now you may be feeling stress but there
  may be some safer coping tools you might like to
  consider
• Give yourself credit. Youve been doing your
  best in these circumstances

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Express Concern

• Express concern about risks for both the
  individual and any children
• Assume the attitude that she is doing the best
  she can and wants what is best for herself and
  her children
• Provide objective information about legal and
  health consequences stemming from multiple abuse
  concerns
• Affirm her choices and explain benefits of safety
  planning/ stopping or reducing use/ seeking
  wellness
• Offer options and support

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Be Positive

• If woman is pregnant, convey message that
• A.) Any substance use is not safe during
  pregnancy and lactation
• B.) DV Homicide is leading cause of injury death
  for pregnant women
• C.) Provide info about trauma, postpartum
  depression or other mental health concerns

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Mini-Safety/Sobriety/Wellness Plan

• Strategize Steps to reduce risk/use/harm
• Develop Options to keep safe/sober/well
• Identify Trusted allies/safe sponsors/supports
• Plan Means to escape abuser/drugs/harm
• Discuss Referral resources
• Avoid Danger/persons, places,things/isolation
• Tools HALT/One day at a time/medication
• Caution Written materials, referrals can place
  DV/SA victims in danger

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ASSESS - Safety of Children

• Children often blame themselves for DV/SA or a
  parents substance use or mental health concerns.
• Have your children ever tried to stop it? How
  does your child cope?
• Sometimes children get hurt too.
• What concerns do you have for your childs
  safety?
• Does your partner use the kids to monitor your
  drinking?
• Is your child afraid to leave you alone?
• How often does you partner force you or the kids
  to ride in a vehicle after there has been
  drinking going on?

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Safety Planning for Children

• Leaving or hiding if there is fighting, heavy
  drinking/drugging
• Telephone a friend, the Alcohol Drug Help Line,
  or 911 in an emergency (e.g. battering episode or
  parent passed out, suicide threat or attempt)
• Run to get someone such as a friend, neighbor or
  an older sibling for help
• If the children do not know who to go to to get
  help, work with them to identify specific
  individuals and agencies who can assist and how
  to contact them (Source Alaska Family Violence
  Prevention Project, 1998)

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Messages for Children

• Its not the childs fault
• Each of us are responsible for our own behavior
• Feelings need not lead to substance abuse or
  violence
• Source Pediatric Family Violence Awareness
  Project, 1996

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Conclusion
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Each woman will tell you what she wants

• When I was using, I didn't have the ability to
  reach out for help, nor did I feel I needed it.
  Not using made me feel again, and when I felt
  again, I knew I needed help, because the pain was
  there. And that's when I reached out (for help
  with the DV/SA). If I would continue using, I
  would never have reached out.

• Once I walked away from that abuse (violence), I
  knew the next thing I had to do was do something
  about the substance abuse. And then, when I made
  up my mind that I wanted to quit the drugs also,
  the advocates were right there for me, and got me
  into a treatment program.

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• I don't think I could deal with one issue alone.
  It was critical that I deal with the abuse, to
  get away from it, because it was just getting
  worse and worse. But I couldn't deal with it if I
  was still getting all drugged up.
• You've got to be sober, at least a little bit,
  to be able to even look at the assault. But if
  you get sober, and you don't look at those
  issues, you're not going to stay sober, not in
  the long run.
• I couldn't recover from substance abuse if I was
  still being physically abused, mentally abused,
  sexually abused because I would be right back to
  using. So they walk hand in hand. I would not
  recover from one unless I address the other, and
  vice versa.

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Escaping Chemical Dependency

• Survivors of co-occurring problems can find
  safety and recovery options
• People address multiple abuse issues when it is
  safe to do so
• Offer supportive options for those seeking
  safety, sobriety and wellness

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  They were right there for
me They were right there for me
 

• Somebody wanted to show me support, listen to
  me, not yell at me, not scream at me, just look
  at some options instead of that. Through them
  showing love to me, I began to love myself. I
  didn't deserve the punishment for all that had
  happened in my life. The continuous bad
  relationships, continuous abusing the drugs, and
  shame and the guilt I felt from all that. I
  deserved better. It was also OK to heal from all
  that.

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B.A.D.A.S.S. is now our WIRC
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Forging Partnerships
Integrated Stages of Social Change

• Screening for Substance Abuse and Mental Health
  Issues
• Information and Education
• Advocacy based counseling, consider link with
  counselor
• 1-1 and Group
• Practical non-judgmental options and support
• Referral and Linkage
• Safety linked with sobriety and wellness
• Social Change Model

• Screening for Domestic and Sexual Violence
• Information and Education
• Solution Based Counseling, consider link with
  advocate
• 1-1 and Group
• Practical non-judgmental options and support
• Referral and Linkage
• Sobriety and wellness linked with safety
• Social Change Model

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Community Partners

• Advocates are your local experts
• Refer women to your local Domestic
  Violence/Sexual Assault program!

• Providers are your local experts
• Refer women to your local Chemical Dependency or
  Mental Health providers!

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Resources

• Getting Safe and Sober, Real Tools You Can Use by
  Debi Edmund and Patti Bland for the Alaska
  Network on DV/SA
• Note Spanish language version of above will be
  available January 2008
• Safety and Sobriety, Best Practices in Domestic
  Violence and Substance Abuse, DV/SA
  Interdisciplinary Task Force, IL DHS
• Beyond Labels Working with Abuse Survivors with
  Mental Illness Symptoms or Substance Abuse
  Issues, Safe Place, Austin, TX