Building Bridges:

1. Building Bridges: Exploring the Links Between Woman Abuse, Substance Use and Mental Ill Health

2. BC Women’s Hospital and Health Centre Woman Abuse Response Program: Jill Cory jcory@cw.bc.ca AlexxaAbi-Jaoude aajaoude@cw.bc.ca Louise Godard lgodard@cw.bc.ca Amber Hay ahay2@cw.bc.ca Academic Partners: Dr. Amy Salmon asalmon@cw.bc.ca Dr. Marina Morrow mmorrow@sfu.ca

3. We Started Through Dialogue Invited anti-violence partners for 2 days to talk about what they were observing on the frontlines related to woman abuse, substance use and mental ill health Lead to a report of recommendations, development of a provincial Building Bridges Steering Committee and a successful proposal funded by Vancouver Foundation for $45,00.00

4. Project Methodology BC Province-wide workshop/consultation with N=460 service providers representing mental health, substance use and anti-violence sectors from 82 communities 15 Focus groups with N=100 women affected by woman abuse, substance use and mental ill health 9 interviews with policy leaders

5. INCLUSION CRITERIA Self-identify as a women Be 19 years old or greater Have past or current experience(s) of abuse Have past or current experience(s) of either substance use or mental health issues or both Have received support, currently or in the past, for their experience(s) of abuse

6. DATA COLLECTION • Focus groups were facilitated using a semi-structured interview schedule • How they experienced the links between abuse, substance use and mental health issues? • How they experienced accessing anti-violence, addictions and mental health services? • What kinds of improvements would they recommend to better support women?

7. DATA ANALYSIS Located all data related to service experiences, needs, gaps, outcomes Identified repeated observations Collated those observations into themes and subthemes Made comparisons and connections between themes and subthemes Applied coding labels Selected quotations to illustrate key points

8. Understanding Women’s Experiences of Abuse

9. Woman abuse is most commonly defined as: • Any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life (United Nations, 1993, p. 3).

10. What women say… “There has been several times especially in [ ]. My hip was broken. My partner had broken my hip and I chose not to go until I was out of the situation. He had refused to take me. He had basically stopped me from going. I heard people say that you make your own choices you can do whatever you want. And to an extent I agree but when you make that choice, you and your children could be killed if you do it, so you choose not to. To an extent that choice is made for you.”- Natalie

11. EXPLOSION HONEYMOON TENSION CYCLE OF VIOLENCE

12. What women say… “A lot of it was just verbal, but I wished he would have hit me instead of said what he said. The words were just as bad as, they hurt more than probably any being could have. And they did more damage for the long term.”– DJ

13. Connecting health issues "When I did finally get out of the relationship, I didn’t feel good about anything. I was a failure as a mother, I was a drug addict. I was in horrible shape. I’d lost so much weight. I was old and haggard looking. I’d lost all my friends. I was nothing. I didn’t think I was going to make it. It’s pretty tormenting. And to think that somebody can brainwash you to that extreme, or beat the hell out of you to that extreme. If it wasn’t for my son constantly saying ‘I love you Mommy. I need you, Mommy’ I would have given up and just died." - Dot

14. Health Impacts of Abuse Exhaustion, trouble sleeping, insomnia, nightmares or repetitive dreams Stomach pain, anorexia, bulimia, GI pain Fainting, seizures, chest pain, hypertension, headaches, back pain, palpitations, dizziness and hyperventilation STIs, HIV/AIDS, forced pregnancies, menstrual pain Bruises, lacerations, burns, sprains, back pain, fractured bones, broken teeth, choking, head or abdominal injuries Hearing loss, visual impairment, disfigurement, brain damage, or paralysis Substance use, mental health issues Eberhard-Gran et.al, J Gen Intern Med, 10.2007

15. Health Impacts of Abuse • Women impacted by physical and/or sexual abuse reported 6.0 somatic symptoms and 1.5 diseases (mean) • Compared to women not experiencing abuse, who reported 1.8 and 0.5 • Eberhard-Gran et.al, J Gen Intern Med, 10.2007

16. Not taking women’s (health) concerns seriously • “I agree, my abuse was 18 years ago and no one believed me and [I thought] it was my fault. The things that happened were my fault and it didn’t happen the way I said they did. And my ex was good ‘cause he knew how to beat me so that I didn’t have any visible bruises. And they didn’t believe me. And I would go to the hospital, and I wasn’t even doing drugs at the time, and they would say ‘you are just trying to get drugs for a pain that was non-existent’. Meanwhile he had beaten me and raped me… And I didn’t get any help. And it was my fault. And maybe if you were a good little girl and sat back and be quiet that wouldn’t happen to you.”

17. Violence against women and mental health

18. Linking Woman Abuse and Mental Ill Health There is evidence that many mental health problems post-date experiences of abuse “Mental health issues should be treated as effects of abuse and not as mental disorders per se.” - Flitcraft

19. Women, Violence and Mental ill Health “I don’t call it mental health, I call it symptoms of abuse, because to me that is what it is.” Gail, woman abuse survivor Cathy Humphreys, Mental Health and Domestic Violence: a research overview. Conference Presentation for Making Research Count, Coventry, 2003

20. Women, Violence and Mental ill Health 70% of women in psychiatric in-patients and 80% of those in secure settings have histories of physical or sexual abuse (Phillips, 2000) More than 70% of those with post-traumatic stress disorder (PTSD) are women(Kessler, ‘95). “It’s just taken a toll on me. I don’t know where to turn. I thought I was going mentally insane.”

21. Women, Violence and Mental ill Health • Between 35 – 73% of abused women experience depression or anxiety, which is at least 3x as great as for the general female population. (Golding, 1999, Fikree & Bhatti, 1999) “In the end, I ended up doing self harm to my wrists. It was superficial…It was a way to get out of that relationship after two years of physical and mental abuse.” - Kathy

22. Women, Violence and Mental ill Health • Generally rates were 2 x greater than in the control group in different sectors across the study. eg. In-patients -  prevalence of depression was 32% in exposed and 17% in unexposed women (Cascardi et.al., 1999) • Primary care  - prevalence of depression was 69.9% in ‘exposed’ and 31.9% in ‘unexposed’ women (McCauley et.al., 1995) • Domestic Violence intervention services - prevalence of depression was 83% (Campbell et.al, 1995)

23. Women, Violence and Mental ill Health • Demonstrated that rates of depression in women leaving a refuge fell from 83% to 41% in 6 months if no recurrence of abuse occurred but only fell to 71% if women were re-abused in the 6 month follow-up. (Campbell et.al, 1995)

24. Women, Violence and Mental ill Health • Rates of female suicide attempts are as high as 44% for women who have lived in refuges (Golding, 1999) • 30% of female suicide attempts presenting at accident and emergency were the subject of woman abuse (Stark and Flitcraft, 1995) • Risk ratio for suicide was 20.9 in women diagnosed with personality disorders, one of the highest risks of any category studied (Baxter and Appleby, 1999)

25. Women, Violence and Mental ill Health Psychological impact of woman abuse not determined by the severity or frequency of physical assault, but by exposure to dominance “Whether it was verbal abuse or physical abuse. The physical abuse actually was a little better because the bruises go away. But the mental and verbal abuse really sticks with a person for a long time.” - Cheryl

26. Women, Violence and Mental ill Health “What appears to be a constellation of symptoms or disorders may reflect a normal response to abuse and trauma and the social realities of continued isolation and danger.” - Warshaw, 1997

27. What women say…Perpetrators Grooming Others “I used to get, “Oh, your crazy?!” He always presented himself in a good way. Most of them do and you’d never know…People don’t know what goes on behind closed doors.” – Maggie “And that’s what he was going out and tell everyone, ‘well the reason I’m like this [abusive] to her is because [she drinks]’” - Janet

28. Abusers may exploit a woman’s vulnerability Keep medications from her, give her too much medication, demand she takes medication Take advantage of changes in her symptoms and moods (eg. encouraging suicidal feelings) Threaten to take her children away and tell child protection authorities or the court of her illness Minimize her credibility

29. What women say… “Because he always participated. This is another barrier. He always participated in my sessions with my mental health worker. He had them believe, for the little while, that he was Mr. Support. Hugely. He couldn’t do that with the Stopping the Violence Program. He insisted. And they agreed, “OK”. My partner insisted and allowed him to. So I could never speak completely freely or anywhere freely about the relationship. All that was being dealt with was the mental health issue. But the mental health issue had so much to do with the relationship issues.”- Vivian

30. What women say… “Mine was happy that I was getting mental health care. Because I was in an extremely low depressive state. But I had to sneak around to get the type of help that I really need in order to be able to climb out of that hole. He wanted mental health and addictions to fix me so that I would be his mould. And that I could go back to living in the bedroom of the RV and not coming out and bugging him and just doing what he told me to do when he told me to do it. That would be his idea of fixing me.” - Emma

31. What women say… “Whereas my first encounter with the social worker was after I attempted suicide and so he put himself out there like he could help. So he was welcome.” - Sam

32. Violence against women and substance use

33. Violence against women and substance use Partner may be the primary or sole supplier of drugs, increasing her dependence on him by exploiting her dependence on drugs “He wouldn’t let me not drink, he would bring alcohol over, or you had to drink just to be near him. He would put a glass under my face, he knew I didn’t want to drink.”

34. Violence against women and substance use Substance use may begin or escalate as a response to victimization/ woman abuse “My addiction was the solution- my problem is abusive relationships and molestation when I was 6 or 7 years old” - Stella “It went from mental abuse to physical to emotional. The way I dealt with it was by drinking all the time. That’s the only way I could cope.” – Naomi

35. What women say… • Between 60-80% of women in treatment have experienced sexual or physical abuse at some point in their lives. • Alcohol dependency is 15 times more prevalent among women impacted by abuse than the general public.

36. Violence against women and substance use • Between 55 and 99% of women who have substance abuse issues have been victimized at some point in their lives(Moses et.al, 2003) • Between 67 and 80% of women in substance abuse treatment are IPV victims(Cohen et;al, 2003;Downs, 2001). • Between a quarter and a half of the women receiving victim services for IPV have SA problems (Bennett and Lawson, 1994; Downs, 2001; Ogle and Baer, 2003)

37. Violence against women and substance use • 60% of substance abusing females were victims of domestic violence and 42% of women who were victims of violence and receiving domestic violence treatment were substance abusers. (Bennett and Lawson, 2004). • The prevalence of domestic abuse within the substance treatment population is reported to be between 60-80% range but rises to between 90-100% when psychological abuse is accounted for (Downs 1999, Stringer, 1998)

38. Violence against women and substance use Efforts to stop using substances may precipitate abusive partners' use of increased violence or other control tactics. “I went from a mentally abusive household to a husband who physically abused me and did drugs. And my home was so full of drugs, I had no control over what he was selling in the house, what he was doing in the house or doing to me.” - Amy

39. Violence against women and substance use Some women drink alcohol or use other substances to numb or escape the emotional and physical trauma of violence/abuse “One starts with one- the abuse and then you have the abuse and then you start with alcohol and then a bit of coke and carry on from there and keep going. Just trying to be numb...” – Alice

40. What women say… • “With drugs it’s not really a means of addiction, it’s more a means of survival. You do them to sell them and to get away from the guy you’re with you go to a house and do drugs instead of sit at home and be abused. “ And that’s been my life history. My brothers, my father, my forefather.” - Willie

41. What women say… • Substance use can placate her abusive partner and create temporary safety for her “We use the drugs to try and mask the abuse. And once you stop using them flashbacks come. It’s just a constant. We just self-medicate. Trying to push those memories out.” - Christine

42. Medicating Impacts of Abuse Women in abusive relationships may be addicted to medications prescribed by health care providers for health concerns related to abuse. For example: Chronic pain Chronic headaches abdominal pain joint and muscle pain anxiety and depression sleep disorders

43. Medicating Impacts of Abuse • “I don’t understand. Oh, ‘we’ll help you, we’ll help you’. Whatcha going to do, give me a teddy bear? Basically, that’s what it was. Doctors, they give me medication I’ve never had before. So I’m walking around like gumbie. So I can suppress it.”

44. Medicating Impacts of Abuse • I was thrown down by my partner a couple of years ago… went to the DTES clinic for T3s. And they never asked me what happened. Never asked me what I wanted to do about it. I told them what happened.”

45. Medicating Impacts of Abuse • “A person might think ‘how did you all of a sudden start get involved in drugs when you were married and never done them before?’ How it started for me was I started with prescriptions. Sleeping pills, and anti-depressants and valiums. That was the way my doctor tried to help me deal with my loss. From there you need more pills and you go find people who you think can get you something and that leads to other things. So that’s how it happened to me.”

46. Linking Woman Abuse, Substance Use and Mental Ill Health

47. What women say… “The abuse part… I think sometimes times the abuse comes first, for some of us, and then I think the abuse continues because of the drugs and alcohol. It changes your personality… especially if you have mental health. Mental health, get some crack in there and some meth in there… you’re a different person.” - Kathy

48. Linking Woman Abuse, Substance Use and Mental Ill Health Not an equal triad Links to woman abuse are often missed in services Language of co-occuring, concurrent disorders conceal root causes Conflating trauma and woman abuse leads to inappropriate and sometimes unsafe practices

49. Linking Woman Abuse, Substance Use and Mental Ill Health • The largest contributions to the burden of disease associated with woman abuse are mental health and substance use issues, accounting for 73% and 22% of the total disease burden, respectively (Vos et al., 2006).

50. Linking Woman Abuse, Substance Use and Mental Ill Health • When services address only one problem- either abuse or substance use or mental health issues- at anytime, one or the other issue(s) becomes secondary and the opportunity to address all three issues together is lost (Humpreys, Regan et al., 2005; Humphreys, Thiara, et al., 2005).