Invisible No More: Safety Planning and Relapse Prevention

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Invisible No More Safety Planning and Relapse
Prevention

• Patricia J. Bland, M.A. CCDC CDPTraining Project
• Alaska Network on DV/SA
• Phone [phone]

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DV Programs Balancing Policy and Practice

• Agency policies supporting a substance-free
  environment must be balanced with a multi-step
  approach providing opportunities for
  substance-abusing women to safely discuss their
  daily struggle with sobriety, their compulsion to
  use and their parenting concerns
• This effort will help battered women achieve
  both justice and freedom from abusers and
  perpetrators who often use their victims
  substance use, misuse or addiction to gain or
  maintain power and control

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1 1 10 Tons of Trouble

• Safety is strongly compromised when DV, substance
  abuse or chemical dependence co - occur
• Together, severity of injuries and lethality
  rates climb for chemically dependent battered
  women (Dutton, 1992)
• Individually, each can be chronic, progressive
  and lethal together they are especially dangerous

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Advocacy Includes

• Alcohol and other drug education
• Exploring safer coping skills
• Providing self - help groups
• Offering treatment and medication options
• Addressing internalized oppression and gender
  stereotypes
• Developing more research rooted in the experience
  of battered women with substance use issues

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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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Important Gender Differences . (Sharon Ametetti,
MPH, CSAT)

• Differences in Processing/Metabolism
• Women have higher fat to water ratio and
  diminished activity of the primary enzyme that
  metabolizes alcohol thus reach higher blood
  alcohol levels after drinking same amounts as men
  (NIAAA, 2000 Angove Fothergill, 2003)
• Menstrual cycle phase has an effect on both mood
  and tobacco withdrawal symptoms for women trying
  to quit smoking (Williams, 2002)
• Some pharmacologic treatments for substance abuse
  may be less effective in women due in part to
  differences in metabolism, hormonal genetic
  factors (Weiss et al., 2003)

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Important Gender Differences cont. (Sharon
Ametetti, MPH, CSAT)

• 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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Important Gender Differences cont. (Sharon
Ametetti, MPH, CSAT)

• Substance Involvement and Disease Progression
• Women in general, and adolescent girls in
  particular, become addicted more quickly than
  males (Weiss et al., 2003)
• Cigarettes are an important factor is womens
  progression to illicit drugs (vs. alcohol for
  men) (Kandel, 1998)

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Important Gender Differences (Sharon Ametetti,
MPH, CSAT)

• Barriers to Accessing, Entering and Remaining in
  Treatment
• Lack of gender-specific, family-focused services
• Caregiver responsibilities fear losing children
• Social stigma and guilt
• Fewer economic resources

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Important Gender Differences (Sharon Ametetti,
MPH, CSAT)

• Relapse Prevention Needs
• Importance of social supports and networks
  (National Womens Health Information Center,
  1999 Walton et al., 2001)
• Need to address violence/abuse issues while in
  treatment to help prevent relapse (Finkelstein et
  al., 2004 Fullilove et al., 1993 )
• Depression and negative feelings are more common
  triggers among women (vs. anxiety and positive
  feelings among men) (Stocker, 1998)

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Safety and Relapse Issues

• Battered women, with substance abuse or addiction
  issues typically experience barriers to services
  and discrimination
• Employment, housing, health insurance or child
  custody may be threatened by public disclosure of
  current or past substance abuse problems
• Access treatment due to parenting
  responsibilities or shelter because of the
  substance abuse issues may be denied
• Societal attitudes tend to view addiction as a
  moral failing rather than as a health problem
• This can lead to isolation, blame and shame
• And is compounded when a woman is battered,
  substance abusing and a mom

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Other Factors Substance Use and Infectious
Diseases

• 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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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/mental health issues as threat
  (deportation, arrest, CPS, custody, job, etc.)
• Blaming abuse on partner use and benefiting from
• Lack of services for women with substance abuse
  or mental health issues
• Societal beliefs re women addiction

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Women talk About barriers to safety.

• This man tried to strangle me. After that
  happened, then I relapsed. And I was in relapse
  mode off and on for a whole year after that.
• And drinking kept me in the relationship longer.
  When you're drinking and you're in that vicious
  circle, the other vicious circle doesn't matter.
  All I cared about was getting another drink.
• For me, once I pick up the alcohol or the other
  substances, it's like that safety plan goes out
  the window.

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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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Adult Survival Skills

• Being devious to survive, lying to the abuser and
  others
• Encouraging an abuser to drink until the pass out
  point so no one gets hurt
• Reasoning with abusers, expressing disapproval
• Lying about abusers criminal behavior
  

• Trying to improve the relationship
• Creating internal space through fantasy that
  abuser cant touch
• Having sex to placate abuser and protect children
  from violence
• Drinking and using drugs to numb pain (Ganley and
  Schector, 1996)

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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 victims in danger

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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 Intimate Partner 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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Safety Concerns
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Review Safety Concerns

• Acute and chronic effects of alcohol and other
  drug use may prevent one from accurately
  assessing levels of danger
• Under the influence, one may feel an increased
  sense of power and erroneously believe
  self-defense against physical assaults is
  possible, not realizing the impact of substances
  on gross motor functioning and reflexes

• Substance use and misuse can impair judgment and
  thought processes (including memory) making
  safety planning more difficult
• Alcohol and other drug use may be encouraged or
  forced by an abusive partner or perpetrator as a
  mechanism of control (Bland, 1997 Illinois Dept.
  of Human Services, 2000)

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More Safety Concerns

• Abstinence and recovery efforts may be sabotaged
  (For example, someone receiving methadone on a
  daily basis could easily be stalked )
• There may be reluctance to seek assistance or
  contact police for fear of arrest, deportation or
  referral to CPS
• 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 Impacted by Co-Occurring DV
and Chemical Dependence

• 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 shelter or
  treatment program participant) in order to avoid
  imposing ones own values on others
• There is no typical substance abuser or
  victim, provide universal screening

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Discussing DV and Substance Abuse

• DV and Substance abuse or other issues impacting
  safety and sobriety 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 before talking about DV, sexual assault or
  their own substance use
• They may also be willing to discuss concerns
  about their children if we are not perceived as
  judgmental

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Discussing DV and Substance Abuse

• 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 safety
  and sobriety issues that is comfortable for both
  of you
• Note Substance use in and of itself does not
  require a mandatory CPS report unless there are
  other factors (e.g. drinking and drunkenness are
  not crimes being drunk and having a designated
  driver is not a crime, drunk driving is a crime,
  drunk driving with a child in the car is
  reportable) DV against an adult generally does
  not require mandatory reporting.

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What do I do if she misuses substances?

• Offer alternatives
• Explore safety, parenting and health plans
• Include as recovery options gender specific
  treatment, support groups addressing multiple
  problems
• Discuss options for children such as Alateen,
  Alatot, ADHL Teen Line and other counseling
  options
• 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 addiction like domestic violence is
  traumatic, painful and unsafe
• 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 the
• disease of chemical dependence any more than
  they pick out batterers
• Think before speaking...how would you
• like to be spoken to?
• Remember to offer respect, not rescue options,
  not orders, safe treatment rather than
  revictimization

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Validate

• You did not deserve this and neither do your
  children
• Im so glad you found a way to survive. Drinking
  or drugging 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 the drinking/DV may help you get
  safer/sober your health and safety can 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 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 of DV and specific substances
• Affirm her choices and explain benefits of safety
  planning/ stopping use for both her and her
  children
• Offer options and support

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Be Positive

• Emphasize the benefits of
• A.) Reducing or stopping use as soon as possible
• B.) Developing a safety plan
• 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
• Explore options
• Explain any legal ramifications
• Tailor resources to meet her needs

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How can we help women dealing with DV and
Substance Abuse?

• Listen
• Advocacy and treatment may look different
• Treatment Provides structure, consistency
• Shelter Provides flexibility, options
• Ensure unconditional positive regard is provided
  by someone recommend options
• Shelter 12 step programs, treatment options,
  other support systems, sobriety planning for
  safety
• Treatment DV support groups, shelter options,
  legal advocacy, safety planning for sobriety
• Provide positive messages
• Know and partner with local treatment and victim
  service resources

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Forge PartnershipsIntegrated Stages of Social
Change

• Screen for DV/Substance Abuse Issues
• Provide information and education about impact of
  DV and SA on safety, parenting and health
• Provide advocacy based counseling, consider link
  with substance counselor/DV Advocate
• Prioritize 1-1 and Group options
• Provide practical non-judgmental options
• Offer options such as support, resources,
  referral and linkage
• Link safety with sobriety
• Develop a Social Change Model Provide Systems
  Advocacy

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ASSESS - Safety of Children

• Children often blame themselves for DV or a
  parents substance use.
• 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)
• 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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Protocol
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Assess Risk

• Assessing immediate risk to program participants
  from DV as well as from alcohol and other drug
  overdose and withdrawal is essential because both
  DV and substance misuse can be lethal
• Addressing the impact of
• A) Substance abuse on safety
• B) DV on recovery
• C) Both issues on empowerment

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Partnerships for Safety and Sobriety

• Address the impact of substance abuse on safety
  and DV on recovery
• Develop integrated tools for screening and
  referral
• Provide integrated training on domestic violence,
  sexual assault, substance use, abuse and
  dependence

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For Program Participants with DV and Substance
Dependence Issues, Safety Planning Includes

• Developing a relapse prevention plan and
  continuing support after relapse for women
  choosing to continue to work on their safety and
  recovery
• Linking to a range of DV and chemical dependency
  assistance options, such as medical detox,
  inpatient or outpatient treatment, advocacy based
  counseling, shelter, 12 Step meetings, and other
  support groups, etc.
• Providing relevant written materials

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Program Development Must Include

• Developing a budget to implement comprehensive
  support services to battered women and children
  impacted by substance abuse
• Developing on-site integrated support groups to
  address safety issues for program participants
  and their children who are impacted by their own
  or anothers substance use, misuse or addiction
• Periodic training of staff
• Monitoring of the program

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Overview A Multi-Step Approach

• Basic elements necessary to provide appropriate
  services for women and children impacted by
  substance use, abuse and addiction issues include
  the following recommended steps
• Screening and identification
• Initial intervention and follow-up
• Information and referral
• Alternatives to substance use/Relapse prevention
• Safety planning
• Emotional support

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Screening and Identification

• Because women with chemical dependence may be at
  greater risk for injury and lethality, screening
  for both DV and substance abuse is an important
  tool for identifying barriers to safety and
  offering options for recovery
• The best way to protect children is to ensure
  safety and recovery are possible for their
  non-offending parents
• We can support women seeking safety and sobriety
  by reducing program service barriers and ending
  isolation for chemically dependent battered women
  and their children

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DV-Initial Intervention and Follow-Up

• Advocacy and safety planning will look different
  depending on whether the following is identified
• 1.) No significant problem with substance abuse
• 2.) Significant problem with substance abuse
• 3.) Chemical Dependence
• A.) Recovering
• B.) Active in Addiction

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CD-Initial Intervention and Follow-Up

• Treatment and recovery planning will look
  different depending on whether the following is
  identified
• 1.) No significant problem with domestic violence
  or sexual abuse/assault
• 2.) Significant problem with DV and or sexual
  abuse/assault in the past
• 3.) On-going DV or sexual abuse/assault
• A.) Abuser has access to partner and/or victim
  assessment of risk is high
• B.) Risk for Child Abuse and Neglect is
  established (past or present)

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Information and Referral

• Providing advocacy-based counseling for battered
  women and their children impacted by DV and
  substance abuse is enhanced when
  advocates/counselors are non-judgmental and
• 1.) Informed about options and community
  resources
• 2.) Participating in cross-training to increase
  awareness of safety and sobriety issues
• 3.) Willing to provide APPROPRIATE service
  options

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Safety and Sobriety Plan

• Identifying who to call for help (e.g., sponsor,
  counselor, Alcohol/Drug Help Line advocate)
  forming support systems, knowing about safe
  meetings
• Knowing information and education about addiction
  and DVSA
• Removing substances and paraphernalia from the
  home
• Recognizing unsafe persons, places, things
• Understanding how to deal with legal and other
  problems stemming from addiction and DV (e.g.,
  health, CPS involvement, poor nutrition)
• Assembling paperwork to determine

• eligibility for assistance or to begin seeking
  employment, school, housing or other options
• Knowing how domestic violence and sexual assault
  can be a relapse issue
• Understanding physical, emotional, cognitive,
  environmental and other cues indicative of risk
  and having a plan to deal with it recognizing
  role of stress and craving, having a plan to deal
  with it
• Learning how to parent, engaging in
  relationships, developing sober friendships
• Knowing when and where to run in a
  life-threatening situation that puts sobriety and
  safety at risk

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Community and Emotional Support

• Examine own values and beliefs
• Non - judgmental, non - blaming, non -punitive
• Safety, Belief, Validation and Connection
• Empowerment
• Make a commitment Contact your local substance
  abuse provider or advocate today and build a
  bridge to safety and sobriety for women and
  children impacted by both DV and Substance Abuse

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Safety Options to Support Sobrietyand Prevent
Relapse

• One to one advocacy and support group sessions
  should provide information that offers an
  alternative to substance use as part of a safety
  plan for both adults and children
• Since addiction is marked by relapse, and relapse
  is often triggered by stress, women and children
  in recovery experiencing domestic violence may
  need additional support.

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Recovery and Empowerment

• Relapse Prevention and Safety Planning
• Anger vs. Violence
• HALT
• Safety and Sobriety Gifts to Ourselves
• What is working for you now? What has worked in
  the past? Explore additional options

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Forging PartnershipsCommunity Support for
Safety, Sobriety and Wellness Social Justice

• Our freedom was not won a century ago, it is not
  won today but some small part of it is in our
  hands
• Every step toward the goal of justice requires
  the tireless exertions and passionate concern of
  dedicated individuals
• We are marching no longer by ones and twos, but
  in legions of thousands, convinced now it cannot
  be denied by any human force (Martin Luther King,
  Jr.)

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Escaping Violence Escaping Substance Abuse

• Survivors can thrive
• Safer coping tools are available
• People escape oppression when it is safe to do so
• Offer supportive options for those seeking
  safety, sobriety and justice

• Safety, Sobriety and Justice are possible

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Community Partners

• Battered womens advocates are your local experts
  
• Refer women to your local DV program!
• Domestic Violence Hotline[phone] v/TTY
• (WA only)

• CDPs and MHPs are your local experts
• Refer women to your local Chemical Dependency or
  Mental Health programs!
• Alcohol Drug Help Line 1-800-562-1240
• Crisis Clinic
• 1-800-244-5767 (King County only)

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Coordinated Community Response

• East Side Domestic Violence - My Friends Place,
  Bellevue, WA
• 425-562-8840
• SISTR Program, Dillingham, AK
• 907-842-2320
• Ginger Baim
• New Beginnings Seattle, WA
• 206-522-9472
• Cindy Obtinario

• Alaska Network on DV and Sexual Assault
• pbland.andvsa_at_alaska.com
• 907-586-3650 ext 34
• Patti Bland
• Alcohol Drug Help Line DV/CD Intervention
  Project, King Co. WA
• 1-800-562-1240 (WA and AK only) or 206-722-3700
  
• Gerry Coughlin or Joan Norton