Traumainformed DV services

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Trauma-informed DV services

• For women with substance abuse and/or mental
  health issues
• Gabriella Grant

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Agenda

• 900-930         Introductions
• 930-1045         Trauma and its effects
• 1045-1100       Break (might be a little later)
• 1100-1200        Trauma-informed services
• Volunteer timekeeper?

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DV MH/SA project
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TraumaThe connection between domestic violence,
mental health and substance abuse
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DV Women with multiple vulnerabilities

• Multiple vulnerabilities simply means that a
  woman leaving a domestically violent situation
  often presents with co-occuring conditions that
  affect her safety, decision-making and priorities

• early childhood trauma
• collective historical trauma
• cognitive impairment
• mental health issues
• substance use/abuse
• health problems
• HIV/AIDS or other STIs
• repeated victimization
• no health insurance
• low educational attainment
• poor work history

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Health Outcomes of Violence Against Women
Partner Abuse Sexual Assault Child Sexual Abuse
Fatal Outcomes
Nonfatal Outcomes

• Mental Health
• Post-traumatic stress
• Depression
• Anxiety
• Phobias/panic disorder
• Eating disorders
• Sexual dysfunction
• Low self-esteem
• Substance abuse

• Physical Health
• Injury
• Functional impairment
• Physical symptoms
• Poor subjective health
• Permanent disability
• Severe obesity

• Homicide
• Suicide
• Maternal mortality
• AIDS-related

• Chronic Conditions
• Chronic pain syndromes
• Irritable bowel syndrome
• Gastrointestinal disorders
• Somatic complaints
• Fibromyalgia

• Negative Health
• Behaviors
• Smoking
• Alcohol and drug abuse
• Sexual risk-taking
• Physical inactivity
• Overeating

• Reproductive Health
• Unwanted pregnancy
• STDs/HIV
• Gynecological disorders
• Unsafe abortion
• Pregnancy complications Miscarriages/low birth
  weight
• Pelvic inflammatory diseases

Source Center for Health and Gender Equity
(CHANGE) 1999
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Adverse childhood experiences (ACE)
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ACE Before 18

• Recurrent physical abuse
• Recurrent emotional abuse
• Contact sexual abuse
• An alcohol and/or drug abuser in the household
• An incarcerated household member

• Someone who is chronically depressed, mentally
  ill, institutionalized, or suicidal
• Mother is treated violently
• One or no parents
• Emotional or physical neglect

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ACEs have a strong influence on

• Adolescent health
• Teenage pregnancy
• Smoking
• Alcohol abuse
• Illicit drug abuse
• Sexual behavior
• Mental health disorders
• Risk of victimization
• Stability of relationships
• Performance in the workplace

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ACEs and Suicide Attempts
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ACEs and Smoking
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ACEs and Alcoholism
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ACEs and Teen Sexual Behaviors
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Mental heath
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Mental Health Issues among CA Women in DV
Shelters
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MH and DV rates

• Depression and IPV 70 vs 13 of women in the
  general population
• PTSD 55-92 vs. 10.4
• Anxiety 19-55 vs. 14
• Phobias 27-36 vs. 10
• (Helfrich et al, 2008)

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Substance abuse
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Continuum of substance use

• Abstinence
• Experimental use
• Responsible or social use
• Episodic or situational abuse (most DV clients)
• Chronic abuse
• Dependency
• Treatment
• Relapse
• Abstinent again
• Harm reduction

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Stages of Change

• Pre-contemplation (Who, me?)
• Contemplation (Yes but)
• Its not so bad (denial).
• I cant (low self-efficacy).
• I dont care (low self-worth).
• Preparation
• Action
• Relapse (learning opportunity)
• Maintenance
• (Prochaska et al. 94, Health Psychology)

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Substance Abuse Issues among women in DV shelters
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DV and sub abuse rates

• 60-75 of women seeking shelter services
  developed problems with their original coping
  mechanisms alcohol and drugs (The Womens Action
  Alliance, Roth, 1991)
• 42 of Illinois DV shelter residents abused
  alcohol or other drugs (Bennett Lawson, 1994).
  
• 50 of the women in an Iowa shelter/safe home
  sample had a lifetime diagnosis of alcohol
  dependence or other drug problems (Downs, 2002).

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MA-Dependent Women and Trauma/DV

• When asked about current or previous partners
• 89 of those in severe violent relationships had
  been sexually, physically, or emotionally abused
  as children.
• 85 of all severe MA users were abused as
  children.
• 64 had been prevented from entering or leaving
  the house, seeing friends, or using the phone.
• 61 had been threatened to be hurt or killed.
• 20 had been prevented from getting/keeping a job
  or continuing education.
• 15 had been prevented from seeking medical or
  drug treatment.
• Data from a broad sample of MA-Dependent women
• from CA, HI, and MT

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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)
• Prescription pain relievers were most commonly
  misused, followed by tranquilizers, stimulants,
  and sedatives. (NIDA 2000)

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DAWN emergency department19972002

• Selected prescription medications DAWN
• 1997 2002 Change
• Hydrocodone 11,570 25,197 117.8
• Oxycodone 5,012 22,397 346.9
• Methadone 3,832 11,709 205.6 Morphine
  1,300 2,775 113.5
• Nonprescription medications
• Marijuana 64,720 119,472 84.6
• Cocaine 171,894 207,395 20.7
• Heroin 70,712 93,519 32.3
• MDMA (Ecstasy) 637 4,026 532.0

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Poverty
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Complicating challenges
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Poverty is a link

• Better Homes Fund Report looking at intimate
  partner violence among extremely poor women
• More likely to have suffered childhood sexual
  abuse
• More likely to have had a foster care placement
• Lower current self esteem
• Partner much more likely to abuse substances
• Parents more likely to have fought physically
• Mother much more likely to have been battered
• The female caretaker (mother) more likely to have
  had mental health problems
• (2001 Bassuk, et al)

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Percentage of CALworks Clients with Barriers

• Mental Health 85.3
• Alcohol/Drug 60.6
• Domestic Conflict 55.8
• Attitude 35.5
• Education 32.9
• Children 30.4
• Work 25.6
• Medical Problems 22.4
• Housing 19.6
• Legal 16.8
• Transportation 15.9

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Intergenerational cycle

• The CalWORKS found that in families facing
  depression, DV and sub abuse problems
• Children (aged 6 and under) are at 2-5 times
  greater risk for
• Homelessness
• Use of food banks
• Lack of needed medical care
• Unreliable or unsafe child care
• Placement in foster care by child welfare
  services

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Complex DV

• Sheltered battered women average 8.1 traumatic
  events over lifetime violent, poor lives
  (Humphrey et all 1999)
• Women in shelter have significantly higher rates
  of depression, PTSD, anxiety, phobias 59 v.
  22 (Helfrich et al 2008)
• PTSD predicts severity of violence more than
  help-seeking behaviors, helpfulness of behaviors,
  social support tx focusing on PTSD to escape
  cycle of violence (Perez, Johnson 2008)

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California DV shelters

• DV shelters should expect that at least
• 50 of their clients will have a diagnosable MH
  issues
• 40 of their clients will cope using AOD
• Most of these clients will have both MH/SA
• Most have a history of early childhood trauma
• Most will be very poor
• Treat trauma and focus on safety

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Understating traumas aftereffects
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Triggering Situations for Women Survivors of
Trauma/ Violence

• Lack of control-powerlessness
• Threat or use of physical force
• Observing threats, assaults, others engaged in
  self-harm
• Isolation
• Being in a locked room or space
• Physical restraints - handcuffs, shackles
• Interacting with authority figures

• Interacting with men, in general
• Lack of privacy
• Removal of clothing strip searches, medical
  exams
• Being touched pat downs
• Being watched suicide watch
• Loud noises
• Fear based on lack of information
• Darkness
• Intrusive or personal questions

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Behaviors and Symptoms

• Associated with trauma
• Multiple layers of clothes
• Hypervigilence
• Anonymity of large shelters
• Fear of shelters
• Not bathing
• Not willing to seek medical of dental attention

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Behaviors and Symptoms

• Associated with Trauma
• Aggressiveness
• Not taking medications
• Use of drugs and alcohol
• Participation in the sex trade
• Self-destructive behavior
• Suicidality

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Trauma Symptoms and Substances Associated with
their Relief
Symptom
Substance

• Depression Cocaine, methamphetamines
• Anxiety Alcohol tranquilizers
• Inner turmoil pain Opioids methamphetamines
• Emotional numbness Cocaine methamphetamines
  
• Passivity Alcohol, PCP
• Excessive anger/rage Alcohol, marijuana,
  opioids
• Sexual numbness Alcohol amyl nitrate
  hallucinogens, methamphetamines

Harris and Fallot (2001)
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Negative coping

• Behaviors are adaptations not pathologies
• Symptoms are courageous attempts to cope with
  trauma
• Behaviors, coping and symptoms are clues to
  uncovering ways the woman interprets the world.
• Resistance, non-compliance and rule-breaking are
• Windows into the woman
• Effects of trauma (a trauma response to events)
• Emerging self-efficacy (good news!!)

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Positive Coping

• Initial establishment of safety looks at
  identifying and modeling safe, positive coping
• Staff as models
• Shelter as first step toward healthy
  relationships (honesty, boundaries, etc.)
• Identification of options
• Agency goals and womans goals in alignment
• Seeking Safetys 100 safe copings

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Voluntary Exercise 15 min

• Positive coping list seeking safety
• Think of a challenging situation (personal or
  professional)
• Review coping list
• What would have worked to make the challenge
  easier?
• What made you personally feel good right now?
• Anyone care to share which copings they felt good
  about?

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Trauma Informed DV Services

• Whats the deal?

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Core texts

• Using Trauma Theory to Design Service Systems
• Maxine Harris and Roger Fallot, 2001
• Community Connections, Wash DC
• http//www.communityconnectionsdc.org/
• Trauma and Recovery, Judith Herman
• Beyond Trauma, S Covington
• Seeking Safety, Lisa Najavits

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The advocates toolbox

• Trauma theory and evidence-based practices
• Harris and Fallot
• Institute for Health and Recovery
• Seeking safety (WCDVS)
• Motivational interviewing
• Training and practice
• Strengths-based advocacy
• Effective program design and PP

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Dimensions of care

• Self-care
• Consumer and staff (direct customer services)
• Structure and design (program)
• System interaction (policy/advocacy)

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Stages of Trauma Recovery

• Stage One ESTABLISHING SAFETY
• Securing safety
• Stabilizing symptoms
• Fostering self-care
• Stage Two REMEMBRANCE MOURNING
• Reconstructing the trauma
• Transforming traumatic memory
• Stage Three RECONNECTION
• Reconciliation with self
• Reconnection with others
• Resolving the trauma
• Judith L. Herman, 1992

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A paradigm shift?

• Being informed about trauma
• To know the history of past and current abuse in
  the lives of the consumer
• To understand the role that violence and
  victimization play in the lives of women with
  DV/MH/sub abuse
• To use that understanding to design service
  systems that accommodate the vulnerabilities of
  trauma survivors
• To allow services to be delivered to facilitate
  consumer participation in treatment.

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Trauma-informed vs. Traditional

• Trauma-informed
• How do I understand this person?
• Services are strengths-based
• Minimize risk to consumer, weighing risk to
  providers
• Services a collaboration between consumer and
  provider
• Trust and safety earned and demonstrated over
  time
• Both parties acknowledged for bringing
  information and expertise to the relationship.

• Traditional
• How do I understand this symptom/problem?
• Services are crisis-driven
• Minimize risk to system/service
• Consumers perceive services as hierarchical
• Trust and safety assumed from beginning
• Can recreate abuse dynamics in which the trauma
  survivor was forced to accept an unequal
  relationship to avoid worse treatment

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Basic principles

• The experience of trauma is central and
  pervasive
• Employ universal precautions a client should
  not have to disclose to be treated as if they are
  survivors of trauma (informed consent)
• Attitudes and behaviors are often attempts to
  cope with the effects of trauma
• The goal of treatment is safety

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The agency assessment

• Go over silently or go over together
• Is there anything in the assessment that pops
  out?
• What should we focus on?

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A trauma-informed DV agency

• Welcoming and appropriate to the special needs of
  DV survivors with histories of trauma, mental
  health and substance abuse
• Understanding that violence, abuse and subsequent
  coping have altered her worldview.
• Understanding her and her situation and offering
  new modes of relating and coping
• Connected to a larger system of care that is
  likewise trauma-informed and integrated.

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Administrative commitment

• Departs from the outlook that violence, addiction
  and mental health problems form a complex and
  interrelated network of connections within the
  lives of women and within the experience of any
  given woman.
• Commitment begins with the people who allocate
  resources, set priorities and sponsor or design
  programs that assert that trauma and its
  aftermath are an important part of what ails
  people.

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Universal screening

• Screening all individuals seeking services to
  determine whether they have a trauma history
• Example SBCS universal screen
• It gets everyone thinking about trauma
• Agency sees itself as a place where histories of
  violence and victimization matter.

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Training and Education

• All staff from receptionists to ED have an
  overview of trauma and its effects
• Better a general introduction for the many than a
  in-depth knowledge for the few.
• What is Trauma by Community Connections
• Example An Intro to Trauma for Women on Short
  Stay

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Hiring Practices

• Hire one or two trauma champions
• Front-line worker who thinks trauma first
• How is this womans situation/behavior related to
  violence or abuse?
• How can I relate to her in a trauma-informed way
  about her situation/behavior?
• What can we learn from the situation/behavior?
• Can appear overly-zealous but over time the clear
  message influences others

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Questions?

• Next steps
• Additional training needs
• Coordination and connection

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Thank you!

• Gabriella Grant, Project Manager
• ONTRACK Program Resources, Inc.
• 916-267-4367
• g.grant_at_ontrackconsulting.org
• www.getontrack.org