Transcript Support Group Format and Topics

She’s Got All Kinds of Troubles:
Working at the Intersection of Substance Use
Disorders, Trauma, and Violence Against
Women
Patricia J. Bland M.A. CCDC
ANDVSA
1, Patricia J. Bland
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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
2, Patricia J. Bland
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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
3, Patricia J. Bland
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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)
4, Patricia J. Bland
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Trauma
5, Patricia J. Bland
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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)
6, Patricia J. Bland
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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
7, Patricia J. Bland
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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)
8, Patricia J. Bland
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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)
9, Patricia J. Bland
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• 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
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)
10, Patricia J. Bland
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Substance Use Issues
11, Patricia J. Bland
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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)
________________________________________
12, Patricia J. Bland
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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)
13, Patricia J. Bland
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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 overprescribed for battered women (Minnesota
Coalition for Battered Women, 1992)
14, Patricia J. Bland
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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)
15, Patricia J. Bland
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Other Factors: Substance Use and
Infectious Diseases (SUDs)
• Women with SUDs are more likely to have highrisk 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)
16, Patricia J. Bland
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Barriers and Safety Issues
17, Patricia J. Bland
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The Wrong Questions
• Why doesn’t she just leave?
• Why doesn’t she just quit using?
• Why doesn’t she just pull herself
together?
18, Patricia J. Bland
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Service Barriers
• Women impacted by multiple issues are often illserved 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
19, Patricia J. Bland
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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
20, Patricia J. Bland
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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
21, Patricia J. Bland
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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)
22, Patricia J. Bland
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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 )
23, Patricia J. Bland
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Safety Issues:
Distortions in Perception
• Passing Out - falling asleep or becoming
unconscious from excessive AOD consumption
• Euphoric recall - memories formed under the
influence (Johnson, 1980)
• Blackout - an amnesia like period often associated
with heavy drinking (Kinney & Leaton, 1991)
24, Patricia J. Bland
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24
How does AOD Use Affect
the Interview?
• Memory of the event may be completely or partially
unavailable.
• Elements of the event may be missing or out of
chronological order
• The amount of alcohol consumed is underreported
(Ekholm, 2004)
• The individual may not be able to identify people,
places or details of the event.
25, Patricia J. Bland
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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 substanceabusing 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)
26, Patricia J. Bland
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Working with Women Affected by
Multiple Abuse Trauma
27, Patricia J. Bland
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Working with Women Impacted by
Co-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
28, Patricia J. Bland
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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 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
29, Patricia J. Bland
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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
30, Patricia J. Bland
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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!
31, Patricia J. Bland
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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?
32, Patricia J. Bland
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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 partner’s
physical or sexual behavior ever frighten you?
33, Patricia J. Bland
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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?
34, Patricia J. Bland
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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?
35, Patricia J. Bland
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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?
36, Patricia J. Bland
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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.
37, Patricia J. Bland
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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 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: 19051907.
38, Patricia J. Bland
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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.
39, Patricia J. Bland
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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.
40, Patricia J. Bland
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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….
41, Patricia J. Bland
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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
42, Patricia J. Bland
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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
43, Patricia J. Bland
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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
44, Patricia J. Bland
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Acknowledge Successes
Identify 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?
45, Patricia J. Bland
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ACKNOWLEDGE - You Hear
• Make person comfortable as possible; assure
confidentiality of records when applicable
• Affirm autonomy and right to control decisionmaking, 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”
46, Patricia J. Bland
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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
47, Patricia J. Bland
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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
48, Patricia J. Bland
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Mini-Safety/Sobriety/Wellness Plan
•Strategize
•Develop
•Identify
•Plan
•Discuss
•Avoid
•Tools
Steps to reduce risk/use/harm
Options to keep safe/sober/well
Trusted allies/safe sponsors/supports
Means to escape abuser/drugs/harm
Referral resources
Danger/persons, places,things/isolation
HALT/One day at a time/medication
Caution: Written materials, referrals can place
DV/SA victims in danger
49, Patricia J. Bland
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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?
50, Patricia J. Bland
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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)
51, Patricia J. Bland
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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
52, Patricia J. Bland
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Conclusion
53, Patricia J. Bland
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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.”
54, Patricia J. Bland
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• “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.”
• “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.”
55, Patricia J. Bland
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Escaping
• 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
56, Patricia J. Bland
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“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.”
57, Patricia J. Bland
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B.A.D.A.S.S. is now our WIRC
58, Patricia J. Bland
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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
59, Patricia J. Bland
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• 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
Community Partners
• Advocates are
your local experts
• Refer women to
your local
Domestic
Violence/Sexual
Assault program!
60, Patricia J. Bland
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• Providers are your
local experts
• Refer women to
your local Chemical
Dependency or
Mental Health
providers!
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 Free to download at: andvsa.org
• 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
61, Patricia J. Bland
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