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Invisible No More: Safety Planning and Relapse Prevention

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Title: Invisible No More: Safety Planning and Relapse Prevention


1
Invisible No More Safety Planning and Relapse
Prevention
  • Patricia J. Bland, M.A. CCDC CDPTraining Project
  • Alaska Network on DV/SA
  • Phone 907-586-3650

2
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

3
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

4
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

5
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)

6
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)

7
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)

8
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)

9
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

10
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)

11
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

12
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)

13
(No Transcript)
14
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

15
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.

16
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)

17
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)

18
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

19
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

20
Safety Concerns
21
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)

22
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)

23
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

24
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

25
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.

26
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.

27
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

28
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

29
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

30
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?

31
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

32
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

33
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

34
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

35
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

36
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?

37
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)

38
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

39
Protocol
40
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

41
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

42

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

43
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

44
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

45
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

46
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

47
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)

48
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

49
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

50
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

51
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.

52
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

53
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.)

54
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

55
Community Partners
  • Battered womens advocates are your local experts
  • Refer women to your local DV program!
  • Domestic Violence Hotline1-800-562-6025 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)

56
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
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