Promising models for working with pregnant women and birth moms who struggle with their use of drugs and alcohol

1. Promising models for working with pregnant women and birth moms who struggle with their use of drugs and alcohol Lynda Dechief, M.Sc. Equality Consulting lynda@equality-consulting.ca 250-505-5350

2. Placing the burden “If you’re pregnant, don’t drink. If you drink, don’t get pregnant”. - Bus ad “We often place the burden of FASD prevention solely on the shoulders of pregnant women. Yet research and the experiences of women and those who work with them point to the need for multi-level, multi-sectoral responses” [1]

3. Outline • Explore reasons that women might be using drugs or alcohol during pregnancy • Examine barriers women may face in trying to find support and services • Review promising models (from BC) of comprehensive, integrated care • Introduce and discuss steps in developing such a model

4. Study of birth mothers of children with fetal alcohol syndrome • Of the 80 women interviewed: • 80% had a major mental illness (the most prevalent (77%) being Post-Traumatic Stress Disorder) • 100% had been seriously sexually, physically, or emotionally abused • 80% still lived with men who did not want them to stop drinking • 46% were still at risk of having an alcohol-exposed pregnancy [2]

5. Research on the links • One in ten women in the general population are currently experiencing abuse [3]. One in four / six / eight women who use substances are currently experiencing abuse [4]. • Among women who use substances, over one-third/one-half/two-thirds have been physically, emotionally, or sexually abused at some point in their lives [5]. • People with PTSD are twice/3 times/5 times more likely to use alcohol or drugs [6]. • More than 35% / 50% / 70% of those with Post-Traumatic Stress Disorder are women [6]. • As many as three / six / eight in ten people who use substances also suffer from mental illness [7].

6. Research on the links • Depression and anxiety disorders usually precede / result from the substance use [8,9]. • Studies show that the problematic use of substances almost always starts before / after experiences of violence or abuse [9,10]. • When women are able to escape their abusive relationship to a transition house, their levels of stress and use of substances begins to decline / increase [11].

7. Violence is central “What appears to be a constellation of symptoms or disorders may reflect a normal response to trauma and the social realities of continued isolation and danger” - Dr. Carole Warshaw [12]

8. Violence is central “Understanding that violence against women is pervasive and central to the development of addiction and mental health issues provides us with a foundation to move toward improved, safe and relevant service provision for women” - Norma Finklestein [13]

9. Power and control in women’s use of substances

10. Barriers women face • Exercise: walking in women’s shoes

11. harsh stigma and judgment fear of child apprehension contradictions between harm reduction and abstinence based programming differing views between the addictions and child protection fields feelings of shame, guilt and blame a lack of accessibility (due to transportation costs, child care, locally provided services, etc.) few services that attend to interconnected experiences violence, mental health, and addictions lack of available and appropriate programming [1,14-19] Barriers to Treatment for Substance-Using Mothers

12. Promising Models • Based on the complex issues women face, and the multiple barriers to care, program models have been developed in BC: Vancouver: Sheway Surrey: Maxxine Wright Community Health Centre & Housing Victoria: HerWay Home

13. Maxxine Wright CHC • An integrated, comprehensive model, with a range of health and social supports available to women and their children under one roof.

14. Partners in this project include Atira Women’s Resource Society, Fraser Health Authority, the Ministry for Children and Family Development, and OPTIONS: Services to Community Society. Maxxine Wright CHC

15. Maxxine Wright CHC • Opened in September 2005 with a multi-disciplinary team including: • Receptionist • Family doctor • Nurse practitioner • Public health nurse • Dental hygienist • Social worker • Aboriginal women’s outreach worker • Concurrent Disorders Therapist • Wraparound coordinator • Cook • Nutritionist • Pregnancy outreach worker • Coordinator

16. Maxxine Wright CHC • Physician is the only doctor in Surrey who can provide pre-natal care and prescribe methadone

17. Maxxine Wright CHC • Drop-in space, hot lunch and outreach are key

18. Maxxine Wright CHC • In its first year, 59 women and 30 children came for services • In 2009, 273 women and 228 children came.

19. Maxxine Wright CHC

20. Maxxine Wright Place • 12 units of short-term housing now open • Daycare opens November • 24 units of longer-term housing opening January

21. What women say “Without the support of the staff at Maxxine Wright, our success would have been in jeopardy. This place gave me hope, direction and support that kept me going through a dark time” – program participant “We need our weekly fix of Maxxine Wright. It’s better than doing drugs” – program participant

22. Common elements among programs • Drop-in • Multiple, integrated services • Health care • Outreach • Support and advocacy • Hot lunch • Housing • Practical items – diapers, clothing, strollers, bus tickets, etc.

23. Common principles • Collaborative partnership • Wraparound services • Women-centred (focus on mom AND baby) • Violence and trauma informed • Safety first • Avoid retraumatizing • Harm reduction • Cultural safety • Relational approach

24. Steps to developing program • Getting organized • Making decisions • Taking action • Offering services • Sustaining and improving

25. Step 1: Getting organized a. Identify who else cares about the issue b. Start meeting regularly to plan c. Connect with sister programs d. Figure out if/how can get paid coordinator for process/project e. Determine committee structure, decision-making process, conflict/dispute resolution strategy

26. Step 2: Making decisions a. Needs assessment, gaps/barriers analysis (include women) b. Come to consensus on principles, target population c. Develop program model & resources needed d. Determine education and advocacy needed e. Find strategic allies, invite additional members

27. Step 3: Taking action a. Develop fundraising/communication strategy - choose name (logo/branding), submit grant proposals, business plans b. Community outreach and education c. Develop research/evaluation plan d. Involve women in planning e. Secure funding (including in-kind), determine implementation phases* *the first phase may be what can be done WITHOUT any extra funding

28. Step 4: Offering services a.Planning committee becomes advisory/governance/implementation committee b. Find appropriate location(s), talk to neighbours c. Develop job descriptions, policies & procedures d. Prepare site, acquire needed resources, equipment e. Hire staff, team building and training g. Open program to women and children

29. Step 5: Sustaining and improving a. Integrate ongoing feedback from women and staff b. Ongoing evaluation c. Continue to find funding d. Adapt and expand services as needed and possible

30. Links to Program Information • Sheway brochure: www.vch.ca/media/sheway_brochure.pdf • Maxxine Wright Place Project for High RiskPregnant & Early Parenting Women report: www.atira.bc.ca/files/MaxxineWright.pdf • HerWay Home powerpoint: http://www.bcwomens.ca/NR/rdonlyres/C1AA97BC-FAAB-40E9-972D-F377EE729080/45395/HerWayHomeBBpresentation.ppt

31. References [1] Network Action Team on FASD Prevention (2007). Information Sheet, Women-centred approaches to the prevention of FASD: Barriers to accessing support for pregnant women and mothers with substance use problems, edited by Coalescing on Women and Substance Use: Linking Research. [2] Astley SJ, Bailey D, Talbot T, Clarren SK 2000). Fetal alcohol syndrome (FAS) primary prevention through FAS Diangosis: II. A comprehensive profile of 80 birth mothers of children with FAS. Alcohol & Alcoholism; (35)5:509-519. [3] Ratner, PA (1998) Modeling acts of aggression and dominance as wife abuse and exploring their adverse health effects. Journal of Marriage and the Family, 60, 453-65. [4] Kilpatrick, D. G., Resnick, H., Saunders, B., & Best, C. (1994). Victimization, posttraumatic stress disorder and substance use and abuse among women. In C.L. Wetherington & A.B. Roman (Eds,), Drug Addiction Research and the Health of Women (pp. 285-307). Rockville: U.S. Department of Health & Human Services, National Institutes of Health, National Institute on Drug Abuse.

32. References [5] Marcenko, M.O, Spence, M., & Rohweder, C. (1994). Psychosocial characteristics of pregnant women with and without history of substance abuse. Health and Social Work, 19, 17-22. [6] Kessler, R.C., A. Sonnega, E. Bromet, et al. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, (52), 1048–1060 [7] Volkow, N. D. (2000). The Dual challenge of substance abuse and mental disorders. NIDA Notes,18(5), p.3. [8] Morrow, M. (2003). Mainstreaming women's mental health: Building a Canadian strategy. Policy Series. British Columbia Centre of Excellence for Women's Health (13). [9] Stewart, S. (1996). Alcohol abuse in individuals exposed to trauma. Psychological Bulletin, 120(1), 83-112. [10] Stark, E. & A. Flitcraft, (1991). Spousal abuse. In Rosenburg, M & Fenley, MA (Ed’s.), Violence in America: A Public Health Approach, New York NY: Oxford University Press. [11] Greaves, L., Chabot, C., Jategaonkar, N., Poole, N. & L. McCullough (2006). Substance use among women in shelters for abused women and children: Programming opportunities. Canadian Journal of Public Health. 97(5), 388-392

33. References [12] Warshaw, C. (1997). Intimate Partner Abuse: Developing a Framework for Change in Medical Education. Academic Medicine, 72(1 Supplement), S26-S37. [13] Finklestein, N., (1994). Treatment Issues for Alcohol- and Drug-Dependent Pregnant and Parenting Women. Health and Social Work, 19(1): 7-12. [14] Poole, N., and B. Isaac (2001). Apprehensions: Barriers to Treatment for Substance-Using Mothers. Vancouver, BC: British Columbia Centre of Excellence for Women's Health. [15] Rutman, D., M. Callahan, A. Lundquist, S. Jackson, and B. Field (2000). Substance Use and Pregnancy: Conceiving Women in the Policy-Making Process. Ottawa, ON: Status of Women Canada. [16] Poole, N. A. (2008). Fetal Alcohol Spectrum Disorder (FASD) Prevention: Canadian Perspectives. Ottawa, ON: Public Health Agency of Canada

34. References [17] United Nations Office on Drugs and Crime (2004). Substance Abuse Treatment and Care for Women: Case studies and lessons learned. UNODC. August 2004 [18] Ashley, O. S., M. E. Marsden, and T. M. Brady. (2003). Effectiveness of Substance Abuse Treatment Programming for Women: A Review. The American Journal of Drug and Alcohol Abuse 29(1):19-53 [19] Godard, L., Cory, J. & A. Abi-Jaoude (2008). Summary Report. Building Bridges: Linking Woman Abuse, Substance use and Mental Ill Health. BC Women’s Hospital & Health Centre.