Thursday, June 25, 2015

The Origins of Addiction - from Dr. Vincent Felitti and the Adverse Childhood Study

In this film,  Dr Vincent Felitti, from Kaiser Permanente presents information from the ongoing 17,000 person Adverse Childhood Experiences (ACE) Study to challenge the conventional view that certain chemicals are intrinsically addicting.  He presents the evidence gathered in the ACE study to show that “addiction is not a disease, but is an unconsciously attempted response to minimize the effects of abnormal life experiences. Addiction can be seen as the unconscious, compulsive use of psychoactive materials in response to the stress of life experiences, typically dating back to childhood.”
Dr. Felitti discusses patients, including the woman who was the first person to draw his attention to the issue of using substances (in her case food), who are engaging in behaviors normally considered harmful in order to alleviate and protect from the pain of childhood experiences.  He primarily addresses food, alcohol, nicotine, methamphetamines and heroin addiction.  They are a few of the things that may be seen as public health problems but may often be “personal solutions to long-concealed adverse childhood experiences.  Describing bad habits as self-destructive behaviors hides their functionality in the life of a trauma survivor.”
As I think about how we try to address substance abuse, the heroin crisis, and human trafficking, I am drawn to the conclusion that we will fail in our attempts to resolve the crises until we begin to talk about the long held private conditions that lead to the public problems.  “These life experiences are very likely to be lost in time, and protected by shame, by secrecy, and by social taboos against exploring certain aspects of human experience.”  So many of us were raised in families and cultures where we did not discuss shameful family secrets.  As we grew up we were seen as the problem when the legacy of adverse childhood experiences presented as addictions and mental illness.
At this point in time treatment options are few and far between and minimally address the origins of the addiction.  By failing to address the adversity experience in childhood by so many people, we fail in our attempts to treat.  When treatment fails, we blame the person instead of recognizing that by “treating someone’s attempted solution, we may be threatening and causing flight from treatment” or forcing them to find another, possibly life-threatening, solution.
When these childhood experiences are named and validated as the source of long term difficulties in adolescence and adulthood we are removing the stigma and helping persons understand that it is not about having something wrong with them, but that something was done to them.  The next steps are to assist in finding healthier solutions and recognizing the strength and resiliency that helped them find solutions in the first place and survive in the midst of extremely adverse experiences. 



Monday, June 22, 2015

Mental Health and Substance Use Coercion Surveys Report from the National Center on DV, Trauma and Mental Health

The National Center on Domestic Violence Trauma and Mental Health has done a study on batterers' efforts to undermine victims' sanity and sobriety, to control their medication and treatment, or to sabotage their recovery and access to resources and support. This is considered to be another element of coercive control and can often lead to long term consequences for the victim.  Please read and disseminate the attached information to your local mental health and substance abuse agencies.

http://www.nationalcenterdvtraumamh.org/publications-products/mental-health-and-substance-use-coercion-surveys-report/

Tuesday, March 10, 2015

An Invitation to Re-consider “Failure to Protect”

I provide training to child welfare workers a few times a year about the impact of domestic violence on children and families.  During most of those sessions I heard a worker talk about a parent’s (always a mother’s) failure to protect her children from the domestic violence.  I usually try to re-direct the responsibility for the abuse back to the perpetrator, but workers seem to be at a loss as to how to address the issue and may look for other language that may still end up stigmatizing the non-offending parent and perpetuating the idea that child protection workers are adversaries.
I reviewed a few articles about failure to protect and have provided the links below.  However, I would like to take space here to paraphrase some of the important points and hope that you will take the time to read the articles in full.  I will not be addressing the issue of mothers as perpetrators and/or persons who are complicit in the child abuse.  Those areas definitely need to be addressed by the child welfare system.  I am just addressing the issue of blaming a non-offending parent for the actions of the offender.
When charging a mother with failure to protect, assumptions and stereotypes create a heightened duty on the part of the mother.  The assumption that women have a greater capacity for nurturing and therefore a heightened duty to protect produces a gender disparity between women and men.  Also, in some cases, when the woman is abused, the court and others may feel that this was sufficient to alert her to the batterer’s tendency to violence and leading her to leave him in order to protect her children.  This viewpoint on the part of the court or services may be in direct opposition to a cultural or religious belief in the keeping the family together at all costs.
In the past, Battered Woman Syndrome may have been used to explain failure to protect; however, BWS is now seen as reinforcing negative stereotypes about women’s passivity and weakness.  On the whole, though, the failure to protect seems to reflect a gender bias, and sometimes racial bias, that needs to be addressed.   
The three stereotypes that appear when someone is charged with failure to protect are:
1.       The All-Sacrificing Mother – in which the assumption is made that the mother can leave the abuser and that the threat of the charge will encourage her to act when she would not do so otherwise.  Workers or the court may not consider what steps she may have taken to leave or protect her family that did not work or if she has been blamed for any steps she did take by being told the actions were “inconsistent or ineffectual.”  The lack of shelter space and permanent housing, lack of financial or other support, little protection from the court system, and fear of the batterer may not be taken into consideration.
2.       The All-Knowing (and Blamed) Mother – mothers are assumed to be all knowing and face harsher scrutiny.  Women are expected to have a greater ability to discern the causes of bumps and bruises and be able to see through their partners’ lies than would a male non-offending parent. 
3.       The Nurturing Mother/Breadwinning Father – Often, in two parent household in which the mother works there appears to be a higher expectation that she be aware of any abuse to her children and more able to prevent it than for the working father. 
Given what we know about the control an abuser has over his victims and the fear a women may have of being involved in the system, we can see that when abuse is occurring in the home she is caught between a rock and a hard place.  Trauma victims will often resort to doing what is important for the moment and do their best to protect themselves and their children; however, these efforts may not be explained and/or considered enough by workers or by the judge if the case rises to that level.  We also know that women often feel conflicted when they know that their children love the offending parent and they may choose to stay because of that bond.  Also, a history of witnessing domestic violence in her own home as a child along with victimization as a child may result in difficulty in making productive decisions for her and her family.  There also may be other issues such as poverty, homelessness, substance abuse, and mental illness that contribute to a sense of powerlessness.
When asked what could be used instead of “failure to protect” in documenting these incidents, I responded by asking the worker to identify what community and societal barriers are in place that make it difficult for the mother to make the changes necessary and to be sure that the final “blame” for the abuse is placed firmly where it needs to be.  Is there adequate, affordable housing near her family supports, daycare, and place of employment?  Is there shelter space for her and her children?  Is there a protective order in place and, if so, is it being enforced?   Is the offender being held responsible for his actions?  If the offender is the father, have protections been put in place for visitation?  If the offender violates the protective order and is back in the home, is this due to coercion on his part or need for financial assistance on her part? Is there a definite pattern of power and coercive control?  When a report needs to be filed, can another reason be used rather than “failure to protect”, such as drug exposure or medical neglect? 
According to an advocate, “if a mom is filed on for ‘failure to protect’ from domestic violence it will be very difficult for her to change that behavior or break out of the cycle of violence given the powerless over the actions of the perpetrator. If a mom is filed on for exposure to substance or anything else, those become goals she will more likely agree upon and will be more likely to constructively work towards.” 
When a situation rises to the attention of child welfare, I am strongly aware of the mandate to ensure children are protected from further harm.  Social workers are dedicated individuals who are burdened by this heavy responsibility.  By recognizing that the “failure to protect” allegation against victims may further harm, stigmatize and create resistance, workers can find other ways to partner with non-offending mothers in creating safe lives for their children. 



 Chickens at a local NH shelter. They provide fresh eggs and the children love them!

Thursday, February 5, 2015

The Four Agreements for Advocates

Back in 1997 a book written by Don Miguel Ruiz was published that one would normally pass by as another piece of pop psychology written by a supposed Toltec to litter the “self-help” section of bookstores for a short period of time.  It would then disappear into the dusty back room of used book stores.  However, the wisdom between its pages was so simple and yet so profound that it continues to endure and influence lives eighteen years later.  Whatever the origins of the wisdom, it is hard to dispute the value of applying the Four Agreements in one’s personal and professional life.  I am going to attempt to take these agreements and apply them to the work that we do as advocates for domestic and sexual assault victims.
The Four Agreements are:
Be impeccable with your word;
Don’t take anything personally;
Don’t make assumptions; and
Always do your best.

The 1st Agreement:  Be impeccable with your word
Ruiz defines the word impeccability as meaning “’without sin.  And sin is anything that you do which goes against yourself.  You go against yourself when you judge or blame yourself for anything.  When you are impeccable, you take responsibility for your actions, but you do not judge or blame yourself.”  In addition we don’t use our words against others in the same way.  Criticizing, blaming, or gossiping about the people with whom we work (other advocates and/or survivors) is not honoring the agreement to be impeccable. 
Honoring our commitments is also considered to be a part of being impeccable in our word.  When we make a commitment to a survivor or a co-worker we must make sure that we are able to follow through on that commitment.  We should not make promises we can’t keep.  It is more honorable to say “no” that to make a promise that we eventually will have to break.  It is important that we be aware of our limitations and the scope of our services so that we do not make empty promises. 
The 2nd Agreement: Don’t take anything personally
This seems to be one of the most difficult agreements for advocates, especially when they feel they are doing everything they can for someone and then the person becomes angry and seemingly ungrateful for what has been done for them.  Don Miguel Ruiz puts it very succinctly, “Nothing other people do is because of you.  It is because of them.”  So when someone is angry at you or if someone is talking bad about your agency recognize that it has more to do with them and how they are feeling than it does to do with you.  Especially if you have been keeping the 1st agreement!  The agreements build on each other. 
The other side of this is that even when someone is saying wonderful things about you and telling you that you are the best advocate in the whole world and they could never have done it without you – well, don’t take it personally.  It is still about them and how they feel about themselves.  They feel great and the whole world feels wonderful.  Just reflect back to them what an awesome job they did and let it go.  We don’t need to fill our heads with a scrapbook of all the good things that people said about us.  It is about them. 
The 3rd Agreement: Don’t make assumptions (or if you do, assume everyone is following the 4th Agreement!)
Ruiz says “the way to keep yourself from making assumptions is to ask questions.  Make sure communication is clear.  If you don’t understand, ask.  Have the courage to ask questions until you are as clear as you can be.”  Often I find advocates making assumptions about how institutions should respond to domestic violence and how survivors should be responding to their circumstances.  This creates more drama and angst.  By asking questions of other service providers we can find out what their limitations are and maybe open communication enough to be able to find out what can be done within their system or create a relationship in which change can be created.  Assumptions build walls of misunderstanding.  By communicating we can tear down those walls.
When we work with survivors we often make assumptions about how they are feeling or what they are doing based on how we would feel or what we would do.  By asking questions we learn more, we find out with what barriers they are fighting, and we learn more about their inner strengths and capabilities.  We become more victim-center when we do not make assumptions.
The 4th Agreement: Always do your best
Doing our best is what maintains our commitment to the first three agreements and keeps us focused.  Don Miguel Ruiz states:  Under any circumstance, always do your best, no more and no less.  But keep in mind that your best is never going to be the same from one moment to the next (italics mine).  Everything is alive and change all the time, so your best will sometimes be high quality, and other times it will not be as good.”  As I said above, it if we are going to assume anything about someone else, it is that they are also doing their best.
The level of our best is going to rely on self-care.  If we don’t take care of ourselves our best will not be very good and our ability to follow any of these agreements will be less than optimal.  When we find ourselves unable to follow through on our commitments, gossiping or blaming, taking things personally, or making assumptions, there is a good chance that our personal well of compassion has run dry because we haven’t maintained good positive self-care.  And, on the other hand, following the Four Agreements is a means of self-care that doesn’t require taking a day off or backing off on commitments.  Once we stop and take a breath, focus back on where we may not be keeping the agreements, we can then move forward with integrity and focus on victim-centered services.


Tuesday, December 2, 2014

Please take the time to read another blog - Women. Healing. Violence.

This blog post came to my attention today and I am hoping that you will find it as valuable and compelling as I have.

Please note that this full piece is very powerful and can be triggering for some.  Please read slowly and take breaks if necessary.  

Here are a few excerpts from Is it possible to recover from rape and sexual abuse? Yes and No by Laura S. Kerr PhD on her blog "Women, Healing and Violence."  I hope you will take the time to read the full post at http://womenhealingviolence.wordpress.com/2014/11/23/is-it-possible-to-recover-from-rape-and-sexual-abuse-yes-and-no/

"...the process of healing from sexual violence is slow, painful, and expensive. And because I have worked hard for a peaceful mind and body, I am protective of them. I have a low tolerance of toxic attitudes and behaviors that might upend my recovery. But I am also quick to stand up to injustices that impact others, and I have witnessed this trait in people like myself who are committed to healing their wounds of violence and abuse. Unintentionally, we become warriors of the heart — the would-be Bodhisattvas and protectors of those less fortunate and vulnerable — those we imagine are like we were before we reclaimed our right to dignity and self-preservation, and those we imagine could become victims like we once were."


"After sexual violence, most women want to forget what happened, and return to the lives they led prior to the assault. The survivor desires to be the person she was before, and avoid perceiving herself as irrevocably damaged by the rape or sexual abuse. Confusion, humiliation, and hurt are common, and contribute to self-doubt and silence.
Consequently, women often choose a course of action that will protect them from the imagined judgment of others, including avoiding seeking help. And who can blame us? Throughout history, women have been held responsible for the sexual violence perpetrated against them. Remaining silent just may be an archetypal defense response to the anticipated judgment and shaming that across the millennia have been the common response to sexually violated women (along with forced prostitution, stoning to death, and abandonment)."

Monday, November 24, 2014

Book Review – The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma by Bessel Van der Kolk, MD, Penguin Group, New York, 2014

I am very excited about this recently published book by Dr. Bessel Van der Kolk.  Initially, I did not think that another book could be placed alongside Judith Herman’s Trauma and Recovery as a “go to” text on the intricacies trauma and its effects.  However, I am now going to refer to The Body Keeps the Score as the new, much needed, reference book for anyone interested in the effects of trauma and the varied ways to address its impact on people’s lives.
Not only is this book full of information but it is also written in a format that makes for interesting and engaging reading.  It is not written like a research paper, although the research is well documented.  I was able to read it for hours at a time, not something I can usually do with research articles.
In The Body Keeps the Score, Dr. Van der Kolk relates the history behind today’s current focus on trauma in veterans and survivors of interpersonal trauma.  He tells stories from his own years working for the Veteran’s Administration and finding that the psychotic episodes that veterans were being diagnosed as having (and for which they were heavily medicated) were actually flashbacks of experiences that had occurred in the jungles of Viet Nam.  This eventually led to post traumatic stress disorder being included in the Diagnostic and Statistical Manual when it first arrived in the 1980s.  Dr. Van der Kolk, however, does not tread lightly around the issues surrounding the DSM and its later iterations.  Instead, he is very critical of the process of creating the DSM and its subsequent use by insurance companies, something for which it was never designed. 
Dr. Van der Kolk also describes how after extensive research came out about childhood trauma and its long term impacts he and his colleagues came to the conclusion that a new diagnosis of Development Trauma Disorder needed to included.  This was a request that was denied by the American Psychiatric Association in 2011 even after the results of the Adverse Childhood Experience study were made an integral part of current trauma research.  This has resulted in a loss of research and funding that would assist in addressing the needs of children who have suffered from chronic trauma and continue to be misdiagnosed and heavily medicated in lieu of much needed trauma treatment.
In addition to extensively covering the effects of trauma on children, Dr. Van der Kolk also addresses the controversy surrounding repressed memories and the misguided notions still prevalent in the psychiatric world that repressed memories are not factual.  He provides anecdotal and research based evidence that validates the experiences of people who have regained memories of childhood abuse. 
The most helpful part of this book, and it is really hard to narrow down the best part, is Dr. Van der Kolk’s review of the most helpful trauma therapies.  His devotion to body based modalities is evident and he strong advises against talk therapy as it generates activation/arousal responses that are not helpful until the person is able to trust their body’s responses.  He states that it is through body based modalities that a trauma survivor will eventually gain “self-ownership of their body.”  I am sure that many survivors with whom we work would appreciate knowing that this is a possibility.

I highly encourage anyone who is interested in the field of trauma studies and/or works with survivors of trauma to add this book to their library

Wednesday, October 29, 2014

Barriers to Leaving – Looking in the Mirror at Domestic Violence Programs

I have spent a large portion of my career working with domestic violence programs both from within and as a part of the community.  There have been a lot of changes over the years that have increased access to domestic violence programs that have made big differences in the lives of survivors who seek a safe environment in which to focus on the next steps in they want to take in order to be free of abuse.
In the past, many domestic violence programs were guilty of restricting access to survivors who were using drugs or alcohol or who had a mental illness.  I remember talking to one program many years ago that had a policy that a person who had used alcohol or drugs in the past thirty days would not be allowed into shelter until she had thirty days clean and sober.  I informed them that I knew that half their staff would not be able to get into shelter if needed.  Eventually, programs realized that expecting a survivor to get clean and sober who was self- medicating the effects of trauma or living with an abuser who used drugs or alcohol as a means of control was unrealistic and was, as Patti Bland of the National Center on DV, Trauma and Mental Health puts it “actually placing the program in the position of colluding with the abuser.”
Another positive step we have taken is the realization that even though domestic violence programs are not (and should never be) clinical programs, we can provide support services to survivors who are experiencing effects of trauma that have often been seen as mental health issues.  Programs no longer ask about medications as a means of determining if a person has a mental health issue and then using that as an excuse to screen someone out of shelter.  It can’t be done and, fortunately, is not being done. 
However, I feel that some programs, after all of these positive changes, forget that we still need to be diligent in looking at the things that may still be happening that set up barriers and decrease the probability that a survivor will seek services from a domestic violence program.  Programs are often so overwhelmed by the ongoing failures and barriers within their community and society that they become complacent and forget to focus on the barriers that may be generated by the domestic violence program.  Here are a few areas that need to be considered in order to truly reduce barriers and provide victim-center services:
Comprehensive Safety Planning vs. Refusing to House Survivors Who Live in the Same Town/City as the Shelter:  Whenever a program says that they cannot house a survivor and her children because she and her abuser live in the same town as the shelter they are setting up a barrier.  The program is forcing a victim to choose between her job/home and her and her children’s local support and safety.  We are saying that in order to receive services she needs to give up even more than she already has to at the hands of the abuser.  Solutions to this issue would be to investigate the “open shelter” concept in which the community is well aware of the location of the shelter, thus encouraging neighbors to report suspicious activity, and making safety planning a high priority in order to be able to assist the survivor in being able to access local resources and maintain employment while still living in the same community as her abuser.  This will reduce transportation issues for court and visitation also.  Yes, there are times when a victim needs to leave the area for her safety, but this should be her choice.
Case Management vs. Support Services:  I am concerned about the concept of “case management.”  As the executive director of a community mental health program I once worked for said “people are not ‘cases’ to be managed.  They are to be supported.”  If we start looking at victims as cases we are in danger of limiting the services we provide to a menu rather than taking a victim-centered approach to supporting the person in the decisions she makes for her future.  We are also in danger of moving to a more clinical approach that looks at symptoms and issues rather than coping skills, victim needs, and systems of oppression and barriers in the community.
Modeling DV Programs’ Services After Homeless Programs:  When we start to provide services in the manner of homeless services we are in danger of forgetting about the issues of domestic violence and trauma.  I have seen program staff become too eager to move the survivor to housing while not addressing the issues of domestic violence and trauma.  Programs need to go back to their mission statement and review the primary purpose of the organization.
The best way to look at services in a program and determine whether or not the services are a barrier to survivors seeking safety is for staff to put themselves in the shoes of the victim.  We often do an exercise called “In Her Shoes” to point out the barriers and difficulties in the community, but we also need to do the same for our programs.  Ask yourself, “If I was a woman in danger, would this program meet my needs for safety, connection, and stability?”