Guiding Principles

1. Guiding Principles

2. Best Practices • A number of elements have been identified in the Building Bridges findings, by women and providers and in the literature, which contribute to a successful framework of service provision, organizational structures and cross-sectoral collaboration

3. Elements of Best Practice Approaches • Violence-Informed Practice and Policy (VIPP) • Gender-Informed, Women-Centred Care • Holistic Approach • Flexibility • Harm Reduction

4. Guiding Principles Violence-Informed Practice and Policy

5. Violence-Informed Practice Recognizes the pervasiveness of violence in women’s lives and how dynamics of power and control shape women’s experiences. Recent reports from WHO indicate that 29%- 62% of women who have had a partner have been abused.

6. Violence-Informed Practice • Practitioners are serving a large number of women impacted by abuse, even though they may not be aware of this • Not all women disclose when asked routine screening questions • Focus on underlying safety concerns and the physical and mental health impacts of abuse

7. Violence-Informed Practice • When service providers have made accessibility their first priority, service recipients—the women themselves— valued their relationship with the service provider above all. • Programs should promote a model of staff and client relationships based on equality rather than power and hierarchy Sources: Grant (1996); Watkins & Chovanec (2006); The United Nations Office on Drugs and Crime (2004)

8. Violence-Informed Practice “For someone who has been abused… experiencing equality, safety, mutuality and empowerment are essential to the process of healing and reclaiming one’s sense of self and place in the world.” (Warshaw, 1997)

9. Violence-Informed Practice “Risk management needs to focus on how to ensure she can stay in the house, not how to exclude her.” - service provider “We get so caught up in our own professions and mandates and forget that what is at stake is a woman’s safety – and her kids.” – service provider

10. Keeping Women’s Safety Central “But, when I go to phone them they say, is this a safe line to leave a message on. Well, if I would have been with him, it wouldn’t have been a safe line to leave a message at my home. But I would have had them leave a message with my mom. And she would relay the message to me. And I would have been able to coordinate to get away from him, and get have a car to go to an appointment. And it would have helped me get out of that relationship faster and without doing self-harm.” - Faye

11. Guiding Principles Women-Centred Services and Gender-Informed

12. Female Providers and Women-only Groups Given that the majority of women are abused by male perpetrators that our findings from both providers, women with lived experience and the research highlight the importance of having female providers and women-only spaces to work on their recovery and healing.

13. Women-Centred Services ‘I think one of the best things is the Sexual Assault team. Because when a woman is raped they call the ambulance and you’ll end up getting big burly men come to pick a woman up in an ambulance. The last things they want to see are two big men after they got raped. I’ve seen women not get into the ambulance because they are too traumatized. It’s so great to have the sexual assault team cause it’s only women who come. There should just be women coming.” -Diane

14. Women-Centred Services • Women identify individual therapists’ skills and relational styles, availability and institutional responsiveness, female therapists and women-only groups, and shared experience and empathy as key factors

15. Women-Centred Services “When I was beaten up and they arrested him. They had an under cover lady come and there were two ladies came with me in the ambulance. I was lucky. I had to wait until they came and they took me to the hospital.” - Andrea

16. Gender-Informed Practice Shift from: ‘What is wrong with this woman?’ to ‘What has happened to this woman?’ Gender and other inequalities thrive on invisibility, so be alert to these inequalities and how they impact women’s safety

17. Women-Centred Services • The importance of establishing a relationship with women whose “lifelong experiences of abuse and abandonment taught them not to trust anyone.” Sources: Grant (1996); Watkins & Chovanec (2006); The United Nations Office on Drugs and Crime (2004)

18. What women say… “In [city], they have ladies AA groups but I’ve also heard men get really upset and say, ‘I may be an alcoholic but I’m not a batterer’. They seem to be sensitive about that. A lot of guys in AA, they just try to pick up women.” - Jenny

19. What women say… “That was a year ago I left so I’ve been talking to, I’ve been involved in a lot of support groups for women, I’ve been going to a therapist for about 6 months now. And I’m out there talking and I think that’s a big thing for women. For me, I didn’t tell anyone what was going on. I kept it all to myself. That’s when I just wanted to bury myself away. I couldn’t handle it. And I think that’s a big thing, women really have to reach out a talk to someone.” - Shayna

20. Quality of the Relationship • Early relationships, particularly at the assessment and early treatment stages, were key to engagement and retention. • Better therapeutic engagement is associated with an increased length of stay in services Sources: The United Nations Office on Drugs and Crime, (2004); Joe, Simpson, & Broome, (1998); Wisdom 2009

21. Guiding Principles Holistic View of Women

22. Holistic View of Women High probability that all of the factors that are currently and historically contributing her present situation are inter-related and need to be addressed together “It doesn’t work to address one issue without the other-they can’t be separated. When dealing with these issues women do not move forward towards healing in a standard, linear way.” – service provider

23. Holistic View of Women Support women as a whole person as opposed to just a woman with problems. “Wellness is complex and if not addressed holistically (all components) then a lasting improvement in wellness is not possible.”

24. Holistic View of Women Services are encouraged to employ staff from a range of ethnic minority backgrounds However, this is not always possible, so using a nurturing, respectful approach can bridge cultural differences. “It can be a drawing card in getting reluctant people in the door, but in the end if we relate as human beings that's more important. Having First Nations staff does not necessarily mean it will work.” (Engaging Pregnant Women Using Substances: A Review of the Breaking the Cycle Pregnancy Outreach Program).

25. Guiding Principles Flexibility

26. Flexibility • SAMHSA’s Women and Co-occuring disorders study found that around-the-clock availability played a significant role in formal treatment relationships with 56% of the women discussing this to some extent. (Stenius, V.M.K. & Veysey, B.W. 2005). • Women with addictions need the maximum number of opportunities to succeed in changing their lives and to reduce the harm caused by their drug use. J. Becker and C. Duffy (2002)

27. What Women say… “But to know you can you walk through those doors when you have that free minute away from that person and in there and say I really need help. And there’s a worker there at that time. Whether you get a counselor right away.” - Fran

28. Flexibility In addition to being able to respond to clients’ needs as they arose and adjust program policies accordingly, many programs found that they had to offer women flexible hours in order to retain them in treatment. Creamer & McMurtrie (1998)

29. Flexibility “You learn to be creative in how to bend the rules to help women access services.” “We bend our mandate to meet women’s needs. We have to.” “Transition houses have to bend the rules to keep women longer and this increases women’s anxiety.” - service providers

30. Guiding Principles Harm Reduction

31. Harm Reduction Not all women wish to leave the abusive relationship or pursue abstinence as their treatment goal Instead they would like support in reducing harm if they stay in the relationship or/and continue to use.

32. What women say… “… I was at a transition house and I went out and I got drunk one night because I had to deal with him and it brought back all this. And I came back …, and this one worker took me aside and said, ‘do you want to talk? Let’s talk this out’. And I thought, thank-you. Instead of cutting me down for drinking. Thank-you. That’s what I need. Don’t criticize me for drinking because that’s what I needed to do to cope right now. But she took that, and I thought, yes there are people that understand this. But I think they’re few and far between out there. And that really helped. And I didn’t drink, or want anything to drink for months later. I just needed someone to talk to.” - Betty

33. Harm Reduction For women who are living with abuse, substance use and/or mental ill health, service flexibility is paramount to whether they will successfully access services or not This can include varying opening times, women not needing to make appointments to access services and not penalizing women when they fail to make it to an appointment. Women say that services which are open to them “dropping in” when it is convenient for them enabled them to continue to return to the same service and begin to build relationships and trust.

34. Harm Reduction Because of the high demand for treatment and limited resources, women must often wait for a number of weeks to be admitted to treatment Women who are on the waiting list receive support from a counselor twice a week for preliminary chemical dependency education and personal updates. This strategy enabled women to ‘‘bond with the counselor and one another’’ prior to admission and ‘‘seem more ready to come in when their names come up on the waitlist.’’Wisdom, Hoffman, Rechberger, Seim & Owens (2009)

35. Recommendations

36. Recommendations • Service Integration • Comprehensive Services • Mothering Support • Outreach Services • Peer Support • Provider and Organizational Capacity

37. Service Integration • Women may be more likely to engage in treatment if violence and substance use were focused on in an integrated way • Integrated treatment for women with experiences of violence, substance use and/or mental ill health is more effective than treating the issues separately or sequentially Sources: Detrick & Stiepock, 1992; Durrell, Lechtenberg, Corse, & Frances, 1993; Kofoed, Kania, Walsh, & Atkinson, 1986; Markoff, L.S., Glover Reed, B., Fallot, R.D, Elliott, D.E. (2005).

38. Integration: Improved Outcomes • Outcomes for women with multiple and interrelated needs can be improved by comprehensive, integrated, trauma-informed, and CSR-involved services and that these effects are much more pronounced when services emphasize integrated counseling Sources: Easton et al (2000); Cocozza et al (2005).

39. What Women Say… The most help was … when they blended parenting with recovery. ..Because I’ve been to trauma therapy, counseling, churches, blah blah. I’ve taken every group therapy and counseling session. Everything… The best help that I ever got was that program because it was consistent, it blended parenting with recovery. Some of my closest friends I met in that group. It was small and quaint, there was one facilitator. We went out on walks. We had a great great woman. She was non-judgmental, she was experiential …. So she wasn’t a social worker telling us what to do or theoretically you should feel this way because I’ve learned it in a book. These are my experiences…..That group was the most beneficial that I’ve seen. - Catherine

40. Integration: Improved Outcomes • National cross-site study demonstrated that treatment programs that offered inclusive counseling for these women’s multivarious treatment needs demonstrated positive reductions in alcohol and drug use severity concerns and a decrease in mental health and posttraumatic stress symptoms. Sources: Cocozza et al., (2005); Wisdom et al (2009).

41. What women say… “To find a place to access somewhere to deal with all those things. If we can find a place where people understand. Where you can address all these issues because you cannot go and take care of one before you can deal with the others. You need to find somewhere to go and all of your issues can be dealt with at the same time.” - Sheila

42. Recommendations Comprehensive Services

43. Comprehensive Services • Given the multifaceted and complex nature of the lives of women impacted by abuse and substance use and/or mental ill health, responses need to be flexible and comprehensive

44. Comprehensive Services • Involves addressing the issues in the context of women’s lives rather than from a purely diagnostic framework • A variety of women’s needs are met through offering women health care, violence and trauma counseling, assistance with their financial, housing, employment, education, parenting and legal needs and support with MCFD involvement in one location.

45. Comprehensive Services “A comprehensive approach to the [above] issues provides women with a “one stop” place to look at their multiple barriers and understand themselves and the links between these issues.” - service provider

46. What women say… “Trauma, addictions, mental health they all go together but you need a place that can address them—need more places like this. Non-judgmental. Aware. Feel safe. Trauma people. You have to have a basic place to start, to access.” - Amy

47. Recommendations Mothering Support

48. Mothering Support Support for both mother and child(ren) would enable the children of women entering anti-violence services, treatment for mental health and substance use problems to receive services.

49. Mothering Support • One thing I really liked about SAGE house that I didn’t find other places or from talking to other women or maybe it’s out there in other places, they actually had a child care worker who worked with the children and she was awesome with the kids. And I really think some places I stayed, the woman came in and she was really distraught and the kids were running wild and the kids are hugely impacted by this stuff. And I really think there should be more services out there available when women leave, somebody working with the kids too. -Tara, focus group participant

50. What Women Say… • When he was born he was 8.6lbs, when we left the hospital he was 8.3lbs. And because I had a red flag on my chart… because my girls weren’t with me, and I was overweight… they said well you are a poor parent. I was timid, I didn’t know what to do… Literally when I was at Maxx Wright it was the only time I had time to myself. I came here every week so I could have 2 hours to myself. None of the doctors would listen to me about my concerns about my son. He wasn’t gaining any weight. But because I had a red flag no one believed me. Maxx Wright put me in touch with another doctor who listened to what I had to say and did some tests and realized that there was a hole. If they had closed it up months and months earlier it would have saved him and me from so much pain. - Brenda, focus group participant