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

1. Working at the Intersection of Substance Use Disorders,Psychiatric Disabilities and Violence Against Women Patricia J. Bland M.A. CCDC pjmbland@hotmail.com

2. 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 pjmbland@hotmail.com

3. 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 pjmbland@hotmail.com

4. 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) pjmbland@hotmail.com

5. Trauma pjmbland@hotmail.com

6. 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) pjmbland@hotmail.com

7. 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 pjmbland@hotmail.com

8. 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)

9. 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 Abusers Pose Risk to Partners pjmbland@hotmail.com

10. 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) pjmbland@hotmail.com

11. Substance Use Issues pjmbland@hotmail.com

12. 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) ________________________________________ pjmbland@hotmail.com

13. 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) pjmbland@hotmail.com

14. 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) pjmbland@hotmail.com

15. 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) pjmbland@hotmail.com

16. 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) pjmbland@hotmail.com

17. Barriers and Safety Issues pjmbland@hotmail.com

18. The Wrong Questions • Why doesn’t she just leave? • Why doesn’t she just quit using? • Why doesn’t she just pull herself together? pjmbland@hotmail.com

19. 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

20. 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

21. 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 pjmbland@hotmail.com

22. ( 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 reflexesBland, 1997; Illinois Dept. of Human Services, 2000) pjmbland@hotmail.com

23. 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 ) pjmbland@hotmail.com

24. 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) More Safety Concerns pjmbland@hotmail.com

25. Working with Women Affected by Multiple Abuse Trauma pjmbland@hotmail.com

26. Working with Women Impacted byCo-Occurring Problems A successful culturally competent intervention incorporates: • Awareness of one’s 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 one’s own values on others There is no “typical” substance abuser, client or victim, provide universal screening pjmbland@hotmail.com

27. Discussing Multiple Problems • DV/SA, Substance abuse or mental health issues impacting safety, sobriety and wellness may be easily missed if we don’t ask about these concerns in a non-threatening manner • Women may find it easier to talk about stress in their relationships or their partner’s substance use or mental health before talking about DV, sexual assault or their own substance use or mental health

28. 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

29. 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! pjmbland@hotmail.com

30. 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? pjmbland@hotmail.com

31. 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 partner’s physical or sexual behavior ever frighten you? pjmbland@hotmail.com

32. Sample Screening Question if Partner is User or Abuser • Many women tell me their partners don’t want to drink/drug/smoke alone. How often do you find yourself using when you don’t 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? pjmbland@hotmail.com

33. 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? pjmbland@hotmail.com

34. 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? pjmbland@hotmail.com

35. 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.

36. 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 partner’s 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. pjmbland@hotmail.com

37. 4 P’s • 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. pjmbland@hotmail.com

38. 4 P’s 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 P’s alcohol and other drug screening tool developed by H. Ewing, Medical Director, Born Free Project. pjmbland@hotmail.com

39. 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….

40. ABC’s of Advocacy Based Counseling • Acknowledge harm has been done and say this is not your fault. Your children’s 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 pjmbland@hotmail.com

41. 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 pjmbland@hotmail.com

42. Validate • You did not deserve this. I’m 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 children’s safety and well-being, too pjmbland@hotmail.com

43. 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? pjmbland@hotmail.com

44. 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: “I’m sorry this happened; it’s 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. You’ve been doing your best in these circumstances”

45. 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 pjmbland@hotmail.com

46. 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 pjmbland@hotmail.com

47. 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 Mini-Safety/Sobriety/Wellness Plan pjmbland@hotmail.com

48. ASSESS - Safety of Children Children often blame themselves for DV/SA or a parent’s 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 child’s 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? pjmbland@hotmail.com

49. 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) pjmbland@hotmail.com

50. Messages for Children • It’s not the child’s 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 pjmbland@hotmail.com