Getting Safe and Sober: Real Tools You Can Use Patricia J. Bland, M.A. CCDC

1. This project was supported by the Office of Women’s Health Region X Grant # HHSP233200400566P and by Grant #’s 2003-MU-BX-0029, 2004-MU-AX-0029 awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions and recommendations expressed here are those of the presenters and authors and do not necessarily reflect the views of the Department of Justice, Office on Violence Against Women or the Office of Women’s Health. Getting Safe and Sober:Real Tools You Can Use 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 DV and their own or another’s substance use, misuse or addiction • This workshop also provides participants with tools to better address service needs and options pjmbland@hotmail.com

3. Scope of CD/DV Statistics CD-Gender Issues Overview pjmbland@hotmail.com

4. Safety or Sobriety :What do we do first? pjmbland@hotmail.com

5. 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) • While these problems frequently co-occur, most research indicates neither causes the other • Individually, each can be chronic, progressive and lethal; together they are especially dangerous pjmbland@hotmail.com

6. DV and Substance Abuse • Are different problems requiring different interventions • Denial serves different purposes: • Victims fear for their safety or may be coerced into denying the truth / Batterers avoid accountability and may falsely blame their behavior on their partner, substance abuse or anger • Alcoholics/addicts fear they won’t survive without using and deny to avoid pain pjmbland@hotmail.com

7. Domestic Violence and Chemical Dependency • 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

8. Scope of the Problem • A correlation between substance abuse and DV occurs in 44% to 80 % of reported DV incidents depending on what research you cite(Mackey, 1992) • Over 1/2 of reported DV cases involve drinking(Drug Strategies, 1998) 1 study found in 94% of DV calls to police --assailant had used ETOH alone or ETOH w/cocaine, marijuana or other drugs w/in 6 hrs of assault • 92% of assailants and • 42% of victims had used alcohol or other drugs on the day of the assault(Brookhoff et al, 1997)

9. Statistics • 1 in 4 women will be assaulted by an intimate partner(US DHHS) • 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

10. DV and Substance Abuse • A NIDA study noted 90% of women in drug treatment had experienced severe DV from a partner during their lifetime(Miller, 1994) • Similar findings have been noted on monthly client service reports from the Alcohol/Drug Help Line Domestic Violence Outreach Project in Washington State(Bland, 2003) pjmbland@hotmail.com

11. Substance Abuse and DV • The Women’s Action Alliance found 60-75% of women seeking shelter services over a 15 month period developed problems with their original coping mechanisms: alcohol and drugs (Roth, 1991 • A recent study of IL DV shelters reveals 42% of service recipients abuse alcohol or other drugs (Bennett & Lawson, 1994). • 1 in 4 women in an IA shelter/safe home sample had a lifetime diagnosis of alcohol dependence and another 1 in 4 had alcohol or other drug problems (Downs, 2002). pjmbland@hotmail.com

12. Trauma and Gender IssuesDomestic Violence and Substance Abuse pjmbland@hotmail.com

13. Substance Abuse and Addiction are Women’s Issues • According to the WSCWSAI, the physiological impact of substance abuse in women needs more attention • Women have higher blood alcohol levels than men after consuming equal amounts of alcohol (LaGrange, 1994; Lieber, 1993) • Women have a higher prevalence and greater severity of alcohol-related liver disease with shorter duration of alcohol use and lower consumption levels than men (Kubbs, 2000) • Women also have higher death rates from alcohol-related damage (CSAT, 1994) • In AK, FASD is highly correlated with DV 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. Important Gender Differences in Substance Use, Abuse and Dependence (Sharon Ametetti, MPH, CSAT) • 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) • Women use for different reasons – for example, young women use to improve mood, increase confidence, lose inhibitions, enhance sex or lose weight, while young men use for sensation seeking or to enhance social status(Weiss et al., 2003; National Center on Addiction and Substance Abuse, 2003)

16. 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

17. 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) pjmbland@hotmail.com

18. 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 • Domestic Violence pjmbland@hotmail.com

19. Relapse Prevention Needs(Sharon Ametetti, MPH, CSAT) • Importance of social supports and networks (National Women’s Health Information Center, 1999; Walton et al., 2001) • Depression and negative feelings are more common triggers among women (vs. anxiety and positive feelings among men) (Stocker, 1998) • Need to address violence/abuse issues while in treatment to help prevent relapse (Finkelstein et al., 2004; Fullilove et al., 1993 ) pjmbland@hotmail.com

20. Substance Abuse and Violence/Trauma • In one 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

21. 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

22. Working with Women Affected by DV and Substance Abuse Issues • Screening and Identification • Barriers to Safety and Sobriety • Model Protocols • Real Tools pjmbland@hotmail.com

23. “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 violence). 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 at the shelter were right there for me, and got me into a treatment program.” Each woman will tell you what she wants… pjmbland@hotmail.com

24. “I don't think I could deal with one issue alone. It was critical that I deal with the domestic violence, to get away from it, because it was just getting worse and worse. But I couldn't deal with the domestic violence 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 domestic violence. 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, 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.”

25. 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 shelter or treatment program participant) in order to avoid imposing one’s own values on others There is no “typical” substance abuser or victim, provide universal screening pjmbland@hotmail.com

26. Discussing DV and Substance Abuse • DV and Substance abuse or other issues impacting safety and sobriety 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 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

27. 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.

28. Sample Screening Questions for DV • How safe you feel in your daily living gives us important information about you and your safety. Please answer these questions as well as you can. • Do you feel safe? In your personal relationship? Within your home? In your own neighborhood? Other? pjmbland@hotmail.com

29. More Sample Screening Questions • Have you ever had your feelings repeatedly hurt, been repeatedly put down, or experienced other kinds of hurting? • Are you being, or have you ever been, hit, slapped, kicked, pushed or otherwise physically hurt? If yes, by whom? pjmbland@hotmail.com

30. Screening Questions Continued Are you experiencing, or have you ever experienced uncomfortable touching or forced sexual contact? If yes, by whom? • Husband • Multiple persons • Ex-husband • Stranger • Partner • Other (specify)_______ pjmbland@hotmail.com

31. ASK - Sample Screening Questions Women often report feeling stress in their relationship • How does your partner show disapproval? • When was the last time you felt threatened by your partner? • How often do you feel scared or hurt by your partner? • Remember to ask direct questions tactfully and respectfully! pjmbland@hotmail.com

32. 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 at home. • Women in treatment often tell me their partners complain about their using. How does your partner show disapproval? pjmbland@hotmail.com

33. ASK - Sample Direct Questions • Do you feel controlled or isolated by your partner? • Is your partner jealous? • Has your partner complained about your weight? • Has your partner sabotaged your recovery? pjmbland@hotmail.com

34. 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 behavior ever frighten you? pjmbland@hotmail.com

35. 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

36. 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

37. Sample Framing Questions for Substance Abuse • Being involved in a custody dispute can be stressful. Your partner may attempt to undermine 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

38. CAGE-D • Have you ever felt you ought to cut down or stop using 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? pjmbland@hotmail.com

39. 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? pjmbland@hotmail.com

40. 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? pjmbland@hotmail.com

41. 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 anger, violence or abuse now? • Do you consider one of your Parents to be violent or abusive? pjmbland@hotmail.com

42. What do I do if she says, “Yes?” • Offer alternatives • Explore safety, legal, shelter and other options • Include as recovery options: gender specific treatment, support groups addressing multiple problems, safety planning, linkage to advocate or shelter • Discuss options for children such as Alateen, Alatot, ADHL Teen Line and other counseling options • Discuss financial issues, insurance, etc. • But before you do any of this….

43. 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 addiction and domestic violence are 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 pjmbland@hotmail.com

44. Avoid Revictimizing • People do not choose to develop the disease of addiction 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 pjmbland@hotmail.com

45. Validate • You did not deserve this and neither do your children • I’m 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 children’s safety and well-being, too pjmbland@hotmail.com

46. 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? pjmbland@hotmail.com

47. 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”

48. 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 pjmbland@hotmail.com

49. 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 pjmbland@hotmail.com

50. ASSESS - Safety of Children Children often blame themselves for DV or a parent’s 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 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