WORKING AT THE INTERSECTION OF SUBSTANCE USE DISORDERS, PSYCHIATRIC DISABILITIES AND VIOLENCE AGAINST WOMEN PATRICIA J. BLAND, M.A. CCDC CDP ALASKA NETWORK ON DOMESTIC VIOLENCE AND SEXUAL ASSAULT There are very few programs providing separate, distinct services for women impacted by multiple abuse issues including domestic violence, sexual assault, trauma and substance use problems.* Women impacted by multiple abuse issues are often invisible when in our progams or perceived as disruptive when their substance use or mental health issues becomes evident or unmanageable. Many times women with co-occurring or multiple abuse issues are missing from community programs altogether. Yet battered women and survivors of sexual assault who struggle with substance abuse, chemical dependence or trauma issues often need our services the most. Every program has strengths and challenges impacting our ability to provide services. Unfortunately many advocacy programs are under-equipped to address co-occurring substance use or mental health issues impacting women’s safety and health. Similarly, chemical dependency treatment services and mental health providers often struggle when addressing domestic violence, sexual assault and stalking. In order to better extend services and advocacy to battered women with separate issues of trauma, substance misuse or chemical dependence we must expand our current practices and explore new strategies to address safety and support wellness. The co-occurrence of domestic violence and alcohol use (or misuse) is well documented and associated with increased lethality rates and greater severity of injuries for women impacted by these public health risks. Additionally, studies indicate domestic violence, alcohol, nicotine and other drug use are all factors associated with low birth weight and other negative health outcomes for both women and their children. *(See glossary of definitions associated with substance use problems at the end of this article). BACKGROUND While most women who have experienced intimate partner violence do not experience chemical dependence or mental illness, it is important to acknowledge many women receiving services from domestic violence/sexual assault programs are dealing with chemical dependence and recovery issues as well as mental health concerns stemming from trauma. One study of Illinois domestic violence shelters reveals that as many as 42% of service recipients abuse alcohol or other drugs (Bennett & Lawson, 1994). Researcher William Downs reports findings indicating one in four women in an Iowa shelter/safe home sample had a lifetime diagnosis of alcohol dependence and another one in four had alcohol or other drug problems (Downs, 2002). The Women’s Action Alliance’s experience with a domestic violence shelter program over a fifteen-month period of time indicated 60-75% of the women seeking shelter services had developed problems with their original coping mechanisms, alcohol and drugs (Roth, 1991). Preliminary data from a National Institute on Drug Abuse study noted 90% of women in drug treatment had experienced severe domestic violence from a partner during their lifetime (Miller, 1994). Similar findings have been noted on monthly client service reports from the Alcohol/Drug Help Line Domestic Violence Outreach Project in Washington State (Bland, 2003). Clearly, a significant number of women and children seen in domestic violence agencies and sexual assault victim service programs suffer from substance abuse problems (Kubbs, 2000). As recently as fifteen years ago, Finkelstein reported alcoholism and drug abuse were still viewed primarily as “men’s diseases” (Finkelstein, 1994). Substance abuse and chemical dependence are women’s issues. According to the Washington State Coalition on Women’s Substance Issues, the physiological impact of substance abuse on women needs more attention. Women have higher blood alcohol levels than do males after consuming equal amounts of alcohol (LaGrange, 1994; Lieber, 1993). Research has documented women have a higher prevalence and greater severity of alcohol-related liver disease with shorter duration of alcohol use and lower consumption levels than men (Kubbs, 2000). Women also have higher death rates from alcohol-related damage (CSAT, 1994). While using substances can initially serve as a survival strategy or coping mechanism anyone might use, studies indicate women are more likely to begin substance misuse in response to trauma. Women are likely to use prescription medication much more often than men. Seventy percent of prescriptions for tranquilizers, sedatives and stimulants are written for women (Roth, 1991). The Minnesota Coalition for Battered Women (1992) states that psychotropic medication is over-prescribed for battered women. They also note that women who have been abused may also use alcohol or drugs for a variety of other reasons, including: coercion by an abusive partner, chemical dependence, cultural oppression, or—for women recently leaving a battering relationship—a new sense of freedom. Unfortunately, using substances for any reason becomes problematic when misuse occurs or chemical dependence is indicated. A significant number of battered women and survivors of sexual assault with substance misuse or chemical dependence issues, typically experience discrimination and barriers to services. Similarly, battered women with mental health concerns also face barriers and stigma. Ability to maintain employment, housing, health insurance or child custody may be threatened by public disclosure of current or past substance abuse or mental health problems. Societal attitudes tend to view chemical dependence and mental illness as moral failings rather than as health problems. This can lead to isolation and shame, which may be compounded when domestic violence and/or sexual assault co-occur. Most alarming of all is the impact of multiple abuse issues on safety. Safety is strongly compromised when domestic violence and chemical dependence co-occur. While these problems frequently co-occur, there is little evidence that either problem causes the other. Individually, each can be chronic, progressive and lethal. Together, severity of injuries and lethality rates climb for women who experience both chemical dependence and battering (Dutton, 1992). These problems are compounded when perpetrators include sexual assault and other forms of sexual abuse in their arsenal of violence. RATIONALE While there is little credible evidence supporting a direct cause-and-effect link, substance misuse, trauma and violence against women are correlated. For women in substance abuse treatment, failure to address current or past victimization can interfere with treatment effectiveness and can lead to relapse. For victims of violence or abuse, problematic alcohol or drug use can often make it harder to safety plan or access safety, harder to maintain autonomy and harder to receive justice due to bias. Multiple abuse issues also pose serious public health consequences for women and their children. The following are a few of the many reasons an individual who experiences domestic violence and/or sexual abuse or stalking and who also has a substance use problem, may be at increased risk for harm (Bland, 1997; Illinois Department of Human Services, 2000). Mental health concerns may also pose risks as well: • Acute and chronic effects of alcohol and other drug use may prevent one from accurately assessing the level of danger posed by a perpetrator. Accurate assessment of danger may also be impacted by thought disorder symptoms as well. • Under the influence or during a manic episode, one may feel a sense of increased power. Individuals may erroneously believe they can defend themselves against physical assaults and may not realize the impact of substances on their gross motor functioning and reflexes. • Traumatic brain injury, mental health symptoms and substance use 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 as a mechanism of control. Abstinence and recovery efforts may be sabotaged. For example, a domestic violence/sexual assault victim receiving methadone on a daily basis could easily be stalked. • There may be reluctance on the part of the individuals with mental health or chemical dependence symptoms to seek assistance stemming from fear of being labeled, institutionalized or medicated. • There may also be reluctance on the part of the crime victim to seek assistance or contact police for fear of arrest, deportation or referral to the Office of Children’s Services. • The compulsion to use and withdrawal symptoms may make it difficult for victims of domestic violence/sexual assault who are actively substance-abusing and chemically dependent to access services such as shelter, advocacy, or other forms of help. • Additionally, woman in recovery may find the stress of securing safety leads to relapse. Behaviors stemming from trauma, self-harming actions such as cutting or suicidal threats may make group living challenging. Alcohol or other drug overdose or suicide threats/attempts, etc. are indicators immediate intervention is required. • If she is using or has used in the past, or if she has ever disclosed mental health concerns, she may not be believed. RECOMMENDATIONS Advocates and their community partners should have training and skills to ensure service capacity to: • Recognize signs of Intimate Partner Violence (IPV), substance use problems, trauma, and other mental health concerns (e.g. anxiety, depression, suicidal ideation, thought disorders, etc.) and understand their impact on safety, autonomy and justice. • Provide resources to help women impacted by domestic violence, sexual assault or stalking as well as by substance use problems or chemical dependence, trauma and other mental health issues to develop options to better ensure personal safety, autonomy and justice. • Develop policies and procedures to ensure program accessibility and non-judgmental, non-punitive service provision for women impacted by multiple abuse issues. • Integrate the philosophies employed by many substance abuse counselors, mental health providers and women’s advocates, to ensure women coping with substance use problems, trauma and IPV (e.g. domestic violence, sexual assault, stalking) can use services safely and without confusion. • Develop community partnerships or work groups to address these issues together. CONCLUSION We can support women seeking safety, sobriety and wellness by reducing program service barriers and ending isolation for women impacted by multiple abuse issues and their children. Training for advocates and community partners such as substance abuse professionals and mental health providers is critical. Policies and procedures to ensure culturally competent, appropriate, non-punitive and non-judgmental accessible services are critical. Because women impacted by trauma and substance use, misuse or dependence may be at greater risk for injury and lethality, support groups addressing mental health and substance use as a safety issue are essential for women impacted by trauma such as intimate partner or other interpersonal violence. DEFINITIONS (Compiled by Patti Bland, and Hoog, Cathy. 2001. Enough and Yet Not Enough: An Educational Resource Manual On Domestic Violence Advocacy For Persons With Disabilities In Washington State. Seattle, WA: Washington State Coalition Against Domestic Violence. Definitions noted with asterisk are from Inaba, D.S. and W.E. Cohen. 2000. Uppers, Downers, All Arounders: Physical and Mental Effects of Psychoactive Drugs, 4th Edition, Ashland, OR: CNS Publications.) 12 Step Program – a self help group that is often used as an adjunct to treatment but which is NOT treatment. 12 step programs can support lifetime recovery and can be extremely useful however battered women will also benefit from referrals to gender specific groups and battered women’s advocacy programs for safety planning as a recovery issue (Bland, 6/2001). Addiction/Chemical or Substance Dependence/ Substance Use Disorder (SUD’s) - are characterized by continuous or periodic impaired control over drinking alcohol or using other drugs, preoccupation with use, use despite adverse consequences and distortions in thinking, (e.g. denial). The neurochemical dysfunction in addiction/dependence/SUD’s is best described as a chemical deficiency in pathways of the brain. (Above definitions developed by APA & ASAM adapted by DV/SA Task Force of IL DHS, 7/2000) Addict-phobia – includes fear of people with substance use problems, disorders or dependence) and addiction (chemical dependence or substance use disorders), holding negative stereotypes pertaining to people suffering from substance use problems; refraining from offering services, support or respect. Addict-phobia creates barriers for those who are afraid of getting labeled and fearful about seeking help. Additionally, addict-phobia negatively impacts people struggling to recover daily. Examples of addict-phobia include mistaken belief systems about addiction/dependence, failure to understand triggers, unrealistic expectations, lack of knowledge about brain chemistry, liver function, relapse processes, resources and recovery options as well as failure to understand appropriate role of accountability, consistency and structure. Addict-phobia makes it possible for individuals and systems to establish (overly rigid or overly permeable) criteria which can limit or prohibit access to services or successful outcomes to an entire class of people. Addict-phobia is a form of oppression in our society. (Bland, 6/2001). Alcoholism – a treatable illness brought on by harmful dependence upon alcohol which is physically and psychologically addictive. As a disease, alcoholism is primary, chronic progressive and fatal. (CSAT/ACF Seminar Series Substance Abuse Lexicon, 5/2001). *Binge – using large amounts of alcohol or other drugs in a short period of time. Binge drinking for women may be defined as four or more drinks in one drinking session at least once every two weeks but being abstinent in between those times. Blackout - an amnesia like period often associated with heavy drinking While blackouts impact memory, there is no evidence to support contention that blackouts alter judgment or behavior at the time of occurrence (Kinney & Leaton, 1991). *Cocaine psychosis – a drug-induced mental illness; symptoms include extreme paranoia and hallucinations. Similar psychosis is associated with amphetamine use. *Coke bugs – imaginary insects a long-term cocaine abuser thinks are crawling under the skin. They often cause substance abusers to scratch themselves bloody. Similar activity is associated with amphetamine use. Cognitive Impairments – disruptions in thinking skills such as inattention, memory problems, disruptions in communication, spatial disorientation, problems with sequencing (the ability to follow a set of steps in order to accomplish a task), misperception of time, and perseveration (constant repetition of meaningless or inappropriate words or phrases). (This and the following definitions are from CSAT/ACF Seminar Series Substance Abuse Lexicon, 5/2001). *Craving – the powerful desire to use a psychoactive drug or engage in compulsive behavior. It is manifested in physiological changes such as change in heart rate, sweating, anxiety, drop in body temperature, pupil dilation and stomach muscle movements. Endogenous craving is caused by neurochemical changes in the brain, such as depletion of dopamine resulting from cocaine use. Other cravings are caused by environmental triggers (cue cravings). *Cross-dependence – occurs when an individual becomes addicted to or tissue dependent on one drug, resulting in biochemical and cellular changes that support addiction to other drugs. *Cross-tolerance – the development of tolerance to other drugs by the continued exposure to a drug that affects body mechanisms to tolerate other drugs (e.g., tolerance to heroin translates to morphine, alcohol and barbiturates). Delirium Tremens (DT’s) – When the level of alcohol in the blood drops suddenly and the person becomes delirious as well as tremulous and suffers from hallucinations that are primarily visual but also may be tactile. Detoxification – The process of providing medical care during the removal of dependence producing substances from the body so that withdrawal symptoms are minimized and physiological function is safely restored. Treatment includes medication, rest, diet, fluids and nursing care. Dual Diagnosis /Co-Occurring Disorder – Clinical terms referring specifically to patients who meet the diagnostic criteria for a substance use disorder as well as meeting the diagnostic criteria for: 1.) An organic mental or developmental disorder 2.) A major psychiatric disorder with or without current symptomology 3.) A personality disorder or 4.) A compulsive disorder such as an eating or pathological gambling disorder. Euphoric Recall - memories formed under the influence that may be used as inappropriate excuse to minimize, rationalize or deny behavior (Johnson, 1980). *Harm Reduction – a tertiary prevention and treatment technique that tries to minimize the medical and social problems associated with drug use rather than making abstinence the primary goal (e.g., needle exchange and methadone maintenance Mentally Ill Chemical Abusers (MICA) – A term used to designate people who have an AOD (alcohol or other drug) disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. Methadone – A synthetic narcotic. It may be used as a substitute for heroin, producing less socially disabling addiction or aiding in withdrawal from heroin. Relapse – Is common in recovery from addiction and not considered treatment failure. As with other chronic illnesses, significant improvement is considered successful treatment even if complete remission or absolute cure is not achieved. Substance abuse/substance misuse - a destructive pattern of drug use including alcohol (alcohol = ETOH) which leads to clinically significant impairment or distress. Often the substance abuse/substance misuse continues despite significant life problems. When a person exhibits tolerance and withdrawal the person has progressed from abuse to Addiction (a disease consisting of a number of brain chemistry disorders). Tolerance - the need for significantly larger amounts of substance to achieve intoxication. Drug effects decrease if the usual amount is taken. Withdrawal - adverse reaction after a reduction of substance. RESOURCES Alaska Network on Domestic Violence and Sexual Assault Model Protocol for Working with Women Impacted by DVSA and Substance Abuse (2004). Bennett, L. and M. Lawson. 1994. 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Roth, P., ed. 1991. Alcohol and Drugs Are Women’s Issues, Volume Two, The Model Program Guide. New Jersey: Women’s Action Alliance and Scarecrow Press. Getting Safe and Sober: Real Tools You Can Use 1 Alaska Network on Domestic Violence and Sexual Assault