Harm Reduction in the Context of Domestic Violence Services

This post was taken from Reducing Barriers to Support Women Fleeing Violence, A Toolkit for Supporting Women with Varying Levels of Mental Wellness and Substance Use, a publicaton of the British Columbia Society of Transition Houses.  This particular section of provided by Rhea Redivo of the South Okanagan Women in Need Society.

Harm reduction is a valuable philosophy in approaching women who have substance abuse and mental health issues.


Traditionally, addictions services have focused on abstinence as the primary treatment goal. Harm reduction, however, acknowledges that abstinence, like substance use itself, exists on a continuum. Instead of being a discrete event, it is seen as a progressive, non-linear journey that is unique to each individual and entails both success and failure. For many, immediate and complete abstinence is not only unlikely, but an unrealistic expectation. Relapse and/or some degree of continued use in an inherent part of the recovery journey and therefore expected. The purpose of harm reduction strategies is to reduce the medical, personal and social risks and harms associated with substance use, particularly for the individual, but also for society. Not unlike the purpose of safety planning for women remaining in abusive situation, harm reduction strives to enhance client’s safety while still using and to reduce negative repercussions. In essence, harm reduction strategies ensure clients survive the various stages of their journey with minimal negative effects until such time as they achieve their ultimate goal: abstinence.

As with anti-violence services, the primary focus is safety. Other aspects are raising awareness, respecting choice, and empowering in order to enhance motivation to change. Change is a choice that requires time and commitment to one’s best interests. It must therefore be internally motivated, not externally exposed (Bland &Edmund, 2008). To that end, service is guided by individual need, readiness and choice. Emotional safety is essential. It entails acceptance, respect and gentle honesty while providing information and education that promote women’s understanding of the impact of use on them and their lives, especially health and safety. Recognizing individual strengths and small successes provide encouragement, while acknowledging underlying positive intentions and normalizing substance use as a response to abuse reduces guilt and shame. Empowerment and respecting choice help promote and self-confidence; giving information and raising awareness help increase desire to change. Together, they enhance internal motivation and the likelihood of change.

The basic tenets of ‘harm reduction’ have long formed the basis for anti-violence practice, where the primary goal is to help women reduce, avoid or escape violence and to minimize its effects. Like abstinence, freedom from domestic violence may be the ultimate goal. However, rather than being a discrete event, it is a progressive, non-linear, process that is unique to the individual and occurs over time. Setbacks are also considered an inherent part of the journey and safety planning is standard practice.

Individual choice, education, and empowerment are likewise key practice values, as is the underlying service goal to reduce potential harm pending more substantial change. Women’s needs, readiness and choices guide service provision. Women are not told what to do; they are given information, education and resources so they can decide for themselves what to do. Applying harm reduction requires them same practice values and principles be extended to women who have substance us or mental health issues. Imposing expectations that women immediately leave their abuser or ‘do what we think only revictimizes and disempowers, which undermines, rather than promotes, internal motivation.

Degree of risk
Although domestic violence, substance use, and mental illness often appear together, causal relationships remain unclear. Individually, each can be chronic, progressive, and potentially lethal. When combined, their severity and lethality increase. Since substance use and mental health issues may increase women’s risk for violence as well as the severity of violence, women accessing anti-violence shelters who also have co-occurring substance use or mental health issues are therefore are great risk that those who do not. Mental health issues pose the additional risk of self-harm (Parkes, 2007d). Yet, service is often denied these women due to the very issues that place them at greater risk, which further compromises their safety.

The immediate danger posed by domestic violence is generally great than that posed by substance use or mental health issues, yet either can be equally as lethal as any abuser (Bland, 2008). Policies must therefore strive to balance supporting abstinence with creating safety so that women unable to remain abstinent can ask for help.

Risk reduction involves providing appropriate, effective services for women experiencing both domestic violence and substance use or mental health issues so they can increase their own and their children’s safety and well-being. A harm reduction approach ensures they receive the service they need regardless of these issues or their choices regarding treatment. Inviting women to examine their situation honestly through open, non-critical discussions that also offer information and choices is a key strategy. In addition, substance use and mental health issues must be considered in women’s overall safety plan, which may include identifying triggers for substance use or mental health behaviors, alternate responses, or skill development.

Potential Benefits

Temporary respite from violence provides a window of opportunity for women to reflect not only on violence, but also on substance use or mental health issues, and their impact on health, well-being and safety. Within the safe context of the shelter, women receive safety, support and information that allow them to consider their options. In addition to learning about resources and treatment options available to them, they may also learn alternative coping strategies. These tools allow women to make decision about what will help them on their recovery journey (Bland & Edmund, 2008).

In this way, shelters serve not only as a form of harm reduction, but also as a catalyst for change, and for women with co-occurring substance use, their stay in a shelter appears to be a first step to recovery. Whether brief or more substantive, substance use interventions within shelters appear to help women alter their substance use (Bland & Edmund, 2008). Indeed, after their stay, motivation to use and levels of stress likewise decreased, while perceived ability to face challenges increased. While decline in use is greatest among those with the highest initial level of use and the most significant intervention in the shelter, reductions occurred regardless of the degree of intervention provided (Jategaonkar & Poole, 2004).

More substantive interventions result in more substantive personal change. Incorporating harm reduction and increasing levels of intervention would reduce clients’ risks and provide the necessary support for them to achieve their goals of heal and safety for themselves and their children.

Harm Reduction in the Shelter Context

Research has shown that the most effective intervention offers integrated support nd treatment grounded in policies that recognize the overlap of violence, substance use and mental health issues as well as the context of social and structural determinants (SAMHSA as cited in Poole & the Coalescing on Women and Substance Use Virtual Community, 2007). To be effective service must be grounded in an understanding of how these various issues interact to affect women’s lives and safety.

Harm reduction values and principles must inform all aspects of policy, procedure and service provision. Approach to, and expectations of, clients must likewise reflect these values. Temporary abstinence or other limitations on behavior may be reasonable for some clients; however, for others they are unrealistic and pose a significant barrier, especially for those who still live with violence and have substance use or mental health issues. Imposing such expectations in these cases is contrary to the goals and values of anti-violence services. Encouraging reduction or safer choices may be both more reasonable and more successful.

Service provision must also recognize the potentially differing needs of women with co-occurring substance use or mental health issues. Accompanying memory distortions or cognitive deficits can affect their ability to judge safety, recall incidents, report violence, and enact safety plans. They can also affect their ability to advocate for themselves (Bland & Edmund, 2008), which in turn compromises their capacity to get the help they need or interact effectively with service providers. To accommodate their needs, it may be necessary to repeat information, provide structure, simplify goals, or advocate on their behalf with other service providers so they can access necessary resources. Reducing social stressors like housing, relationships or finances, which likewise interact reciprocally with both substance use and mental health issues, continues to be a key service goal.

Employee Expectations

Harm reduction requires that the issue be addressed. As Bland (2008) states, the “intervention is in the asking.” While shelter employees are not expected to become addictions or mental health counselors, they are expected to be aware of how substance use and mental health issue affect women’s lives and interact with violence. They must be willing and able to create emotional safety for women, to discuss substance use or mental health issues non-critically and without labeling women or judging their treatment choices, and to make links between these issues and the violence they experience or other aspects of their lives. This requires a context of emotional safety. Equally necessary is a thorough knowledge of relevant services and resources, including the degree to which they provide gender-specific services and physical or psychological safety, as well as the potential risks and benefits they present. Providing women with information and choices allows them to decide what they need and how to get it (Poole & the Coalescing on Women & Substance Use Virtual Community, 2007).

In order to admit a problem and ask for help, women need to feel emotionally safe. Emotional safety entails acceptance, sensitivity, gentle honesty and respect. Given the stigma and institutional oppression often associated with substance use or mental health issues, women may initially deny problems. Honesty requires trust, and for women who trust in others and themselves has been repeatedly violated, emotional safety may take time. Blame and moral retribution not only compromise safety, but confirm the stigma they have experience, aggravate the shame and guilt they already feel, and further alienate and disempower them while empowering their abusers.

Screening and Assessment

Given the high co-occurrence of domestic violence with substance use or mental health issues, routine screening and assessment for these issues must be universal. As with screening for violence, the primary purpose of screening for these issues is not to deny service, but to obtain information, in particular information that can help identify those women in need of specific types of support and are then given appropriate choices that help ensure their survival (Bland & Edmund, 2008). In essence, the purpose of screening and assessment to improve the service women receive and thereby enhance their chances of survival despite the challenges they face until they are ready to make larger changes. Their underlying intent is inclusion, not exclusion.

Women are unlikely to identify themselves as addicted (Bland & Edmund, 2008) or mentally ill (Parkes, 2007a) unless their safety is assured. In –depth exploration of these issues is unlikely to occur until trust and safety are established. Initial screening is therefore to be specific and brief and conducted within a context of openness and acceptance. Assessment, which is broader and more comprehensive, begins only after the immediate crisis is over and a trusting relationship has been initiated. In any case, in order to promote safety, and thus disclosure, women are to be offered choices and informed of the reasons behind any questions they are asked.

Safety and Safety Planning

Safety is always paramount, not just for the individual, but also for the group. Effective safety planning must consider individual patterns and consequences of behavior, both in terms of how they affect women personally and their potential effect on other residents. Safety planning is to follow established guidelines within a context of collaboration, sensitivity and respect for all individuals concerned.

Resident Expectations

Creating a safe environment requires consistency, yet flexibility. Rules should be unambiguous, straightforward and specific. Above all, they must be few in number with both expectations and consequences clear and consistently applied. In contrast, guidelines should be wide-ranging and flexible so that enforcement can be responsive to individual needs and circumstances. ‘Fairness,’ like equity, is governed by relativity, and the underlying principle when enforcing rules and guidelines is always a consideration of each woman’s best interests in any given situation.

For more information or to find out how to obtain the above-mentioned toolkit, please contact Linda Douglas at linda@nhcadsv.org

Healing Neen and Being a Drop in the Bucket

A few weeks ago I attended a conference held by the National Association for Infant Mental Health. One of the keynote speakers was Tonier Cain. Her story was inspiring and hopeful. It was also a testimony to the need for trauma responsive services for women.


Tonier spent nineteen years on the streets of Baltimore, using drugs, prostituting, being rape and abused, and going in and out of the correctional system. She had a total of 83 arrests and 66 convictions. She lost five children to the system because of her inability to stay clean and sober and out of jail. It wasn’t until she was able to enter a trauma-responsive treatment program for female offenders that she was able to change her life. She was pregnant and determined not to lose custody of another child and begged a judge to keep her in jail for a few more months so that she would qualify for the program. Once she entered the program she was asked “Tony, what happened to you?” and when she told her life story someone let her know that she was not responsible for all of the bad things that happened to her as a child and she believed them.

Tonier was the oldest child of a drug addict and alcoholic. When she was nine years old her mother had parties and once her mother passed out, her mother’s “guests” would go to the children’s room. Tonier would block the doorway in order to protect her brothers and sisters, sacrificing her safety for theirs. When she was a teenager, her mother signed papers for her to be married to a man who was nine years older than Tonia and who beat her if the house was not as clean as he wanted it to be. She learned that if she used cocaine she was able to find the energy to clean, but was not able to stop the beatings.

Tonier Cain is now a nationally recognized speaker with seven years clean and sober. She is a dynamic advocate for trauma-informed services and is heart wrenchingly honest when speaking about her life.

Tonier’s story is available at http://www.healingneen.org/. The 54 minute DVD is free of charge to anyone desiring a copy. I highly recommend this video as a means of learning how valuable understanding the impact of childhood trauma on a woman’s future can be and knowing that many of the women we work with are responding to the trauma. Also included in the video is a short discussion with Dr. Vincent Filletti M.D., chief researcher of the Adverse Childhood Experiences Study.

As I viewed this video today, I was reminded of a statement made by Patti Bland of the Alaska Network on Domestic Violence and Substance Abuse at a meeting I attended in late September. She stated that “each time we look for reasons not to provide shelter to a battered woman we are colluding with the abuser.” Tonier Cain does not mention it in her video or in her speech, but I can imagine a similar woman seeking services at a domestic violence program and being refused shelter because of her drug use or mental health issues. How often has an abuser used his partner’s drug use or mental illness as a means of control by saying “No one will help you. You’re just a druggie.” “No one is going to take you in. You’re crazy.” And how often is he right? Through the Open Doors to Safety program, this is certainly happening less and less here in New Hampshire. However, there are often other reasons that a woman may not be accepted into shelter that validate the messages that she has been receiving from her current or past abuser. “You’re not worth anything.” “No one will want you.” “You will never get away from me.”

If you work at a shelter program, I invite you to think about Patti Bland’s statement and consider how you can provide services that respond to the trauma that she has experienced through her life and that do not traumatize her further. If you do watch Tonia Cain’s movie, Healing Neen, take time to discuss how you could possible assist a woman who comes to you with a similar story while she is still in active addiction. What community contacts/collaborations do you have in place to assist your program in providing services?

Stephanie Covington, http://www.stephaniecovington.com/ who spoke at the Healing the Wounds of Abuse conference in Manchester and Plymouth NH last month, talked about how we are all drops in the bucket of a woman’s life. She may come and go from our services and we may feel we have failed her. However, we don’t know which drop in the bucket we are, one of the first or one of the many that follow, but eventually, hopefully, there will be enough safety, support, and information provided so that she can make changes in her life. I hope we don’t pass up chances to be a drop in a survivor’s bucket.