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.

Poverty and Trauma - A Paper by Jennifer Frechette, Skidmore College

Dr. Ruby Payne states that the definition of poverty is “the extent to which an individual does without resources.” Payne (2005) states that the resources needed include financial, emotional, spiritual, physical, social support systems, and relationship resources, as well as the knowledge of unspoken social norms (p. 7). Without these, Payne states, people are at higher risk of becoming impoverished and homeless. If these resources and supports are in place the individual is more likely to find stability in others and therefore have support in times of need.


According to the National Child Traumatic Stress Network (NCTSN), homelessness results from severe poverty, the inability to find housing that is affordable, single parenthood, and lack of social supports (2005, p. 1). Those who experience homelessness have an increased susceptibility to trauma, loss of community, family, and security. Families who live in shelters are confronted by many problems such as “the need to reestablish a home, interpersonal difficulties, mental and physical problems” (NCTSN, 2005, p. 1). Homelessness makes families more likely to experience various traumas including physical and sexual assault as well as increased anxiety due to feelings of being overwhelmed and hyper vigilance pertaining to maintaining personal safety (NCTSN, 2005, p. 1). Payne (1996) outlines important things to know about poverty. Firstly, poverty is relative; meaning that it depends on your surroundings and community. Second, poverty occurs everywhere in the world. Third, economic class is ever changing. Fourth, there are different types of poverty, those being generational and situational. Generational, as defined by Payne, is “being in poverty for two generations or longer” whereas situational poverty is caused by circumstances and generally lasts a shorter amount of time. Fifth, society as a whole operates under middle class norms and finally, Payne states that in order to move from “poverty to middle class or middle class to wealth, an individual must give up relationships for achievement.”

The NCTSN ( 2005) states that children bear the most trauma from homelessness stating that homeless children get sick “ twice the rate of other children” and that they “suffer twice as many ear infections, have four times the rate of asthma, and have five times more diarrhea and stomach problems” ( p. 2) . Among these statistics homeless children go hungry twice as often as non-homeless children and are twice as more likely to have difficulty completing each grade of school, as well as are more likely to have difficulties emotionally and behaviorally in school (NCTSN, 2005, p. 2). The NCTSN (2005) states that, “half of school-age homeless children experience anxiety, depression, or withdrawal” (p. 2).

It is important for children in poverty to receive assistance from those around them, including shelter staff. But what is essential is that those that choose to support homeless families provide a safe environment which includes positive role models, positive social interaction, and equality. The NCTSN (2005) states that

By making families co-participants in establishing rules and regulations, and by housing caregivers and children together, programs can help prevent re-traumatization. Programs can also empower families by maximizing their choice and control, thereby ensuring that they constructively use services to attain personal stability and heal emotional hurt (p. 2).

Shelters are the primary safe zone for homeless families in the United States. Many shelters work closely with community health agencies as trauma specific care givers to homeless families (NCTSN, 2005, p. 2). It is important to restore stability, assess trauma within the family, and create a safe net to understand and address the trauma between family members in order to best address and assist each individual family members needs. NCTSN (2005) states that it is important to train shelter staff to understand the link of homelessness and traumatic experience by “promoting wider awareness of the role of trauma in precipitating and extending family homelessness” (p. 2). Collins et al (2010) cite Figley (1988) state that,

"Trauma can impact the family system through several distinct pathways: simultaneous exposure when all members of the family are exposed to the same event; vicarious traumatization or contagion of trauma from an exposed family member to others in the family; intrafamilial trauma when one family member is the perpetrator of the trauma; and secondary stress when traumatic distress symptoms disrupt family functioning (30).Balancing these various pathways for and of trauma can many times distance supports from the

purpose of working with family members who have been exposed to traumatic experiences. Validating each individual in the family’s experience with trauma while balancing the family’s impact or possible perpetration of that event can be difficult. However, what is important to keep in mind is that each family member has a right to be heard and each one is likely to have experienced victimization at some time or another. Balancing the various traumatizations and homelessness of families can be cumbersome; however, there are multiple other factors that play a key role in family functioning. "

Families living in poverty are at risk of facing a number of stressors including conflict within family, violence, various abuses, and neglect from society and are vulnerable to homelessness, financial disparity, and substance abuse (Collins, K., Connors, K., Davis, S., Donohue, A., Gardner, S., Goldblatt, E., Hayward, A., Kiser, L., Strieder, F.& Thompson, E. , 2010, p. 30). Putnam and Tricett (1993), as cited in Collins (2010) state that there is a concern, among impoverished, about physical safety which is found among multiple generations (p. 30).

Psychological trauma is likely among the homeless for three reasons, (1) The sudden or gradual loss of one's home, (2) the conditions in a shelter and (3) the occurrence of past sexual or physical abuse history previous to homelessness (Goodman, Saxe, and Harvey,1991, p. 1219). Goodman et al( 1991) state that learned helplessness is a potential effect of homelessness that can be prevented by creating an empowering environment around post trauma living and a rebuilding of expectations and norms within the individuals social constructs (p. 1219).

The event of losing one’s home is traumatic enough. What accompanies loss of home is loss of neighbors, community, and places the family that is in this transition in a state of perpetual stress. Goodman et al (1991) cite Shinn, Knickman, & Weitzman (1989, 1991) and Sosin, Pihavin, & Westerfelt (1991), as stating that the transition from being housed to being homeless lasts days, weeks, months, or even longer. Most people living on the street or in shelters have already spent time living with friends or relatives and may have experienced previous episodes of homelessness (p. 1219).

Collins et al ( 2010) cite Wethington et al (2008) as stating that “Although exposure to the social ecology of urban poverty carries significant risk, most children continue to function well and do not develop PTSD” (p. 13). Through supportive relationships with family and friends, these children learn and use coping and problem-solving skills that encourage positive adaptation. Problem solving, coping skills, trauma history, intelligence, supports, poor attachments, and gender of the child are some of the risks and protective factors that children living in poverty can either benefit from or limit children’s ability to adapt and grow (Collins et al, 2010, p. 13) .

Children are the most susceptible to traumatic experience and this susceptibility only increases when they are faced with displacement of home. Goodman et al (1991) state that those that are homeless experience trauma from the process of being homeless but also are traumatized by lack of safety and loss of control in the shelter system (p. 1219) . For many children, stability means going to school each day where their friends are and going home at the end of the day to their family to their bedroom and their space.

One of the most traumatizing experiences that the homeless have is that of leaving the societal norm of what is considered normal for housing and entering into something that is viewed as less than desirable by society. (Goodman et al, 1991, p. 1220). Bowlby ( 1969, 1973) as cited in Goodman et al (1991) states that humans need intimate and long lasting attachments and for homeless children the loss of safety and autonomy makes creating secure emotional attachments difficult (p. 1220). Van der Kolk( 1987) as cited in Goodman et al ( 1991) proposes that “psychological trauma is the perceived severance of secure affiliative bonds, which damages the psychological sense of trust, safety, and security” (p. 1220). Trauma victims that are placed in an unknown and perceivably unsafe living situation often exacerbate their trauma and this often causes distrust and isolation from the social supports of the traumatized, homeless victim ( Goodman et al, 1991, p. 1220). Goodman et al (1991) state that homeless individuals who are able to enter into shelters in their own communities are better off because they can maintain already established connections; otherwise, those made to move out of their neighborhoods many times experience difficulty maintaining ties to that community. Goodman et al (1991) states that, “Physical distance may engender a sense of psychological distance that increases the sense of isolation. Shelter providers should encourage and help homeless residents maintain social networks, thereby building on strengths rather than focusing on deficits” (p. 1222).

By becoming homeless, the individual can often no longer continue their normal routine or functioning extending to work, friends, and otherwise. They lose control over their personal space and their needs which they are forced to rely on others for. Goodman, Saxe, and Harvey (1991) state that the homeless, “may depend on help from others to fulfill their most basic needs, such as eating, sleeping, keeping clean, guarding personal belongings, and caring for children” (1221) . Many shelters separate families, women and children go into one shelter and men in another making what is a stressful situation even worse by further fragmenting families and taking away natural supports put in place within the family as well as removing a potential “safe person” for each individual in the family.

The victimization experienced by homeless women in New York City ranged from 43% being raped by a member of their family, 74% reporting physical abuse, and 25% were robbed (D'Ercole & Struening, 1990 as cited in Goodman et al, 1991, p. 1222). Bassuk and Rosenberg (1988) compared homeless and housed mothers in Boston and found 41% of homeless compared to 5% of housed experienced physical abuse during childhood, and 41% of homeless and 20% of housed had experienced intimate partner violence in their adult lives (Goodman et al, 1991, p. 1222). Collins et al (2010) found in a national study that “50% to 90% of adults in the United States have experienced one or more traumatic events; and 10% to 20% of those exposed will develop all of the symptoms necessary to establish a diagnosis of PTSD” ( p. 21) . Wilson( 2005) cited Newmann and Sallman’s ( 2004) finding that women who experience child abuse are at much higher risk to develop disorders such as anxiety, and substance abuse than women who did not experience child abuse. It was also found that women who experienced sexual abuse as a child ran a higher risk of developing mental health problems such as depression, anxiety, posttraumatic stress disorder among others.

Many of us, when thinking about the poor, automatically turn to third world countries; however, the statistics regarding American children are astounding. According to Collins et al (2010), “49% of American children in urban areas live in low-income families” and that “Families constitute two-fifths of the U.S. homeless population.” (p. 4). 83% of inner city teens have experienced at least one traumatic even and that in that same population, 59%- 92% who are involved in the mental health system report traumatic experiences and urban females are four times more likely to develop severe traumatic stress (Collins et al, 2010, p. 4).

In order to assist those traumatized by and in the homeless and poor communities it is important to keep in mind the family system and structure as a whole. What is important, is treating the family as a whole while recognizing past, present, and future traumas as a whole as well as the various trauma modes experienced by each individual and how that impacted each individual in the collective. Evans & English (2002) and Esposito ( 1999) as cited in Collins et al (2010) state that “There are few well-developed, standardized and empirically supported family therapies for treating family systems impacted by trauma” ( p. 2), meaning those treating family systems in impoverished communities face even a more difficult time finding a successful treatment regime. It is important to understand the effects of trauma and poverty on different family members and among familial relationships, as well as understanding the full range of family members’ responses to trauma and poverty, is critical to improving outcomes.

Collins et al (2010) states that the traumatic context of urban poverty has pervasive effects that slowly erode parent and family function and affect outcomes. Contextual risks of urban poverty (meager resources, crowded conditions, trauma, etc.) affect everyone exposed, but effects on children are exaggerated by reduced parental well-being and family functioning (p. 6).

Understanding the risks of poverty and supporting families, children and parents alike, is essential for actions by parents on children’s problem behaviors (Collins et al, 2010, p. 6).

Goodman et al (1991) states that by viewing homelessness as a psychologically traumatic experience has a number of implications for psychologists and other mental health practitioners. Given that the presence and severity of psychological trauma depends in large part on community response to victims and the overall environment in which they function (see, e.g., Green et al., 1985), improving the psychosocial conditions of shelter life could mitigate or even prevent the development or exacerbation of psychological trauma (p. 1222).

Homelessness in of itself is traumatic. The relief that supports in shelters and social services can provide victims of homelessness is insurmountable.

Homeless children and families experience trauma by virtue of losing their home, community, and stability. Homeless and impoverished people are more likely to experience other forms of trauma as well, such as physical and sexual abuse. What the homeless and impoverished need is support in finding stable employment and housing as well as assistance in addressing their past traumatic experiences. What can assist with decreasing trauma caused by homelessness is support from the surrounding communities and a willingness from society to accept poverty as a reality while breaking down barriers caused by economic status. These actions need to be taken to fully address the trauma the homeless and impoverished experience daily in the United States.


Works Cited:
Collins, K., Connors, K., Davis, S., Donohue, A., Gardner, S., Goldblatt, E., Hayward,

A., Kiser, L., Strieder, F. Thompson, E. (2010). Understanding the impact of trauma and urban poverty on family systems: Risks, resilience, and interventions. Baltimore, MD: Family Informed Trauma Treatment Center.

http://nctsn.org/nccts/nav.do?pid=ctr_rsch_prod_ar or

http://fittcenter.umaryland.edu/WhitePaper.aspx

Goodman, L., Saxe, L., & Harvey, M. ( 1991). Homelessness as psychological trauma: Broadening perspectives. American Psychologist, 46( 11), 1219- 1225.

National Child Traumatic Stress Network: Homelessness and Extreme Poverty Working Group

( 2005) . Facts on trauma and homeless children . www. NCTSNET. org.

Payne, R.K. (1996). Understanding and working with students and adults from poverty. Instructional Leader 4(2).

Payne, R.K. (2005). A framework for understanding poverty.Highlands, Tx : AHA! Process inc.

Wilson, D. ( 2005). Poverty and child welfare: Understanding the connection. Northwest Institute for Children and Familes.

Sexual assault, domestic violence can damage long-term mental health

(Health.com) -- Women are drastically more likely to develop a mental disorder at some point in their lives if they have been the victim of rape, sexual assault, stalking, or intimate-partner violence, according to a new study in the Journal of the American Medical Association.


While the connection between these harrowing experiences and poor mental health is hardly surprising, experts say the new findings highlight just how strongly the two problems are intertwined -- and how important it is for doctors and other health-care workers to ask women about past episodes of violence, even if they happened years ago.

"When professionals are treating women with depression or mental health issues, it's best to be clued in to the fact that violence might be behind [it]," says Andrea Gielen, Sc.D., director for the Center for Injury Research and Policy at Johns Hopkins University, in Baltimore, who was not involved in the study.

Researchers in Australia analyzed health data from a nationally representative sample of Australian women between the ages of 16 and 85. Episodes of sexual assault, stalking, and other "gender-based violence" were all too common, with 27% of the group reporting at least one episode of abuse.

Fifty-seven percent of the women with a history of abuse also had a history of depression, bipolar disorder, post-traumatic stress, substance abuse, or anxiety (including panic disorder and obsessive-compulsive disorder), versus 28% of the women who had not experienced gender-based violence.

Among women who had been exposed to at least three different types of violence, the rate of mental disorders or substance abuse rose to 89%.

"The extent and strength of the association we found was surprising and very concerning," says lead author Susan Rees, Ph.D., a senior research fellow in psychiatry at the University of New South Wales, in Sydney.

Rees and her colleagues can't say for sure whether the mental health problems in the study were triggered by the violence, or whether women with preexisting mental health issues were more likely to experience violence. (They did, however, control for a range of potential mitigating factors, including socioeconomic status and a family history of psychiatric problems.)

But there is "ample evidence" that traumatic events -- especially interpersonal traumatic events, such as domestic abuse -- can trigger mental problems, Rees says.

Moreover, she adds, episodes of gender-based violence often occur very early in life, whereas mental disorders often don't surface until years later.

Rates of gender-based violence in the U.S. and Australia are comparable, so a study of this kind conducted in the U.S. would likely yield similar results, Rees says. Roughly one-fifth of women in the U.S. say they have experienced intimate-partner violence (which includes domestic abuse), stalking, or both, and 17% say they have been victims of rape or attempted rape, according to the study.

The findings drive home that violence against women is a major public health concern.

"It underscores the impact on society as more than just the immediate consequences, more than just treating women in an emergency department for a violent injury," Gielen says.

Mental health specialists and providers of women's health services should collaborate and develop a unified approach to more effectively screen and treat mental health problems in women who have experienced violence, Rees and her colleagues say.

The U.S. has already taken a promising step in this direction, Gielen says. On Monday, the U.S. Department of Health and Human Services issued new guidelines for preventive care for women that, among other things, require all new health plans to offer no-cost domestic-violence screenings to women beginning in August 2012.

"Almost every public health organization in the country recommends screening for violence, so we're in a really good situation to really move forward," Gielen says. "The big challenge, though, is to work toward what happens after screening: How do we make [screenings] maximally effective, to make sure they really help women?"

Those questions may soon be addressed in the federal Violence Against Women Act, which is up for reauthorization this year. The renewal of the law may provide opportunities for grants, community interventions, and training programs for mental health professionals, Gielen says.

"I think this study really sets up a very hopeful future for providing help to these women who really need it," she says.

Copyright Health Magazine 2010

Generational Poverty and Trauma

  NOTE: Please be aware that for the sake of creating an understanding of some of the issues that pertain to trauma survivors who have grown up in poverty, I will be making some generalized statements. It is very important to know the survivor as an individual with specific issues that may be due to growing up in a specific culture and may not necessarily meet all the characteristics of that culture.


Many of the survivors who seek shelter from domestic violence programs have grown up in generational poverty. Ruby Payne, author of “A Framework for Understanding Poverty” defines generational poverty as families who have lived in poverty for at least two generations, meaning children of parents in poverty grow up to live in poverty themselves. By contrast, families in situational poverty have fallen into poverty because of a traumatic event such as illness or divorce. She writes that families in generational poverty form their own culture with different values, habits and lifestyles from families in the middle class.

Persons who grow up in generational poverty have different values regarding money, different communication styles, and perceive the world based on their own experience. Someone who has grown up in pervasive poverty may not have had resources available with which to develop skills with which they could move out of poverty. These resources include financial means and support systems that can assist the person in moving out of poverty. Trauma also impacts the ability of a person to move out of poverty. Those skills which are necessary in order to maintain safety and survive in a culture of poverty and trauma are primary, while other developmental milestones or skills may not be nurtured and enhanced.

In the following chart I present information based on Ruby Payne’s work but also add in the component of growing up with trauma. It shows the values involved in decision making, conflict resolution, financial decision, and meeting new people and describes the world view of people who have grown up in generation poverty, middle class, wealth, and/or a culture of trauma.

Generational Poverty
Decision Making - Decisions made based on needs of entertainment and relationships


Conflict Resolution - Ability to fight or have someone who is willing to fight for you.

Money - Money is for entertainment and relationships.

World View - The world is what is locally around you.

Meeting New People - Comments are usually made about you before you are introduced to others.


Middle Class

Decision Making - Decisions are made related to work and achievement.


Conflict Resolution - Able to use words as tools to negotiate conflict.

Money - Money is for security and is saved. .

World View - The world is your own nation.

Meeting New People - You introduce yourself to others.

Wealth

Decision Making - Ramifications of the financial, social, and political connections are important to decision making.


Money - Money is for security and is usually invested.

World View - The world is international.

Meeting New People - Someone in the group formally introduces you.

Trauma

Decision Making - Decisions are based on safety


Conflict Resolution - Fight, flight or freeze

Money - The future is improbable. Much has been lost in the past and it is anticipated that loss will occur again. Spending decisions are based on anticipated loss.

World View - The world is unpredictable and limited.

Meeting New People - If I don’t trust you, I won’t talk to you unless I need something from you.



When working with someone who has experienced trauma and poverty it is important not to judge them or have the expectation that they will make decisions the same way that you would if you have not grown up in poverty or with trauma. For example, given that a person has grown up in poverty and trauma she may make a decision to spend an income tax return on entertainment or items needed at this moment rather than saving for the future. For a trauma survivor, given that so much has been lost in the past and that the victim has often felt she is living on borrowed time, saving for a future that may not occur is not considered. By imposing our values on the person we are at risk of alienating her.  It is best to recognize the difference in values and understand that as a domestic violence advocate you need to work within the values of the person for whom you are advocating.

I invite you to have discussions at your workplace that take into consideration the impact of generational poverty and trauma and work toward a greater understanding of the dynamics that occur in the decision making process and communication styles for persons who have not had the resources to be able to move beyond poverty and trauma.

"Working the System"

A couple of months ago I was at a conference where a speaker was discussing children and trauma. He told a story to illustrate the resourcefulness and resiliency of a 15 year old girl whose mother was a prostitute and a drug addict. This young girl also had four brothers and sisters and they were all left to their own devises, basically raising themselves. The gentleman had asked the young girl what she was doing for food. She responded that she was having a hot meal every night of the week. He was surprised. “How do you do that?” he asked. “Well, I know if I go to my friend’s house on Tuesday nights and am hanging around there between 5 and 5:30 that her mom will ask me to stay for dinner. I like that because Tuesday is spaghetti night at her house. On Friday night the Congregational Church as a free dinner and there are other places that serve meal on other nights. I’ve got it covered most nights” she told him. The speaker went on to talk about how resourceful this young girl was. I raised my hand and asked him, “What happens between the age of 15 and 25? Why is it that we can call her resourceful at 15 and at 25 we accuse her of working the system?”

That is the question I want to ask of people. If someone grows up in poverty and is living under the rules of a welfare system, this is the system in which their skill base is built. In fact, there may have been few if any opportunities to learn other skills with which to build a life. Many of us judge people in poverty from our middle class viewpoint, expecting people to have had the same level of support and education that we have had. Unfortunately, this is not true. People who grew up in poverty and trauma have many skills that have served to help them survive. These include knowing where to get a hot meal, how to manage on food stamps, how to keep the landlord at bay, where to sleep in order to stay warm, and what to say or do in order to get needs met. This may mean “lying,”, “manipulating,” and “working the system” in order to have these needs met, because they have learned in the past that telling the truth did not always get needs met and the system is set up in a way that it requires someone to “work it.”

As advocates, we can provide opportunities to learn new survival skills once the person feels safe and stable. Safety and stability means being treated with non-judgment and with recognition of the resiliency and resourcefulness that has gotten her to your door. If she continues to use old skills even after learning new skills, then remember how long it has taken you to learn something new and apply it, or to break an old habit, or just remember that she may not feel safe enough to change yet.

Building relationships based on trust is a key to recovering from trauma. Knowing that you are emotionally safe from judgment is a key component in building that trust.

Book Review – The Boy Who Was Raised as a Dog and other stories from a child psychiatrist’s notebook by Bruce D. Perry, M.D., PhD., and Maia Szalavitz

I have had a number of survivors ask me questions about what trauma has done to their children and how they can help them recover from the impact of witnessing domestic violence or suffering from sexual abuse. Amidst the stories of children who experienced extreme abuse and neglect, Dr. Perry and Ms. Szalavitz, in their book, The Boy Who Was Raised as a Dog, provide hope and encouragement for parents and those who work with traumatized children.

First of all, let me warn you, this book is not for bedtime reading or for reading in large doses. It is hard to put down, but the reader should take breaks, practice self-care, and not focus solely on the horrific stories, but also on the successes that have occurred by providing nurturing, healing environments for children.

Included are the stories of the children of the Branch Davidian cult in Waco, Texas, the effects of living in extreme neglect (a child from a eastern European orphanage, a baby left alone for 8 hours a day by a babysitter who only returned to the house to change his diaper), and children who had suffered from sexual abuse. There is also the story of the children in Gilmer, TX who were the focus in an investigation which led to hysteria and accusations of ritual Satanic abuse.

In addition to describing how trauma affects the brain of a developing child, Dr. Perry also describes how treating the child as if they were still at the age during which the abuse occurred results in the brain being able to get back on track developmentally. The writer’s tell the story of Mama P. who taught a young mother how to nurture her child after the doctors had learned from Mama P the importance of cuddles and hugs. This is not the story of doctors in labs studying rats, but the story of a doctor willing to learn from children and parents about what is best for the child. Dr. Perry spent many hours on the floor with the child, paper and a box of crayons, letting the child lead the way rather than forcing therapy on a child who did not feel safe.

According to the authors, “The human brain develops sequentially in roughly the same order in which its regions evolved. The most primitive, central areas, starting with the brainstem, develop first. As a child grows, each successive brain region, in turn, undergoes important changes and growth. But in order to develop properly each area requires appropriately timed, patterned, repetitive experiences. The neurosequential approach to helping traumatized and maltreated children first examines which regions and functions are underdeveloped or poorly functioning and then works to provide the missing stimulation to help the grain resume a more normal development.” Basically, if a child missed out on a lot of play, nurturing, etc, the then need to have those experiences to be able to develop into full functional adult.

In the last chapter, the authors reiterate what we have also learned from Judith Herman’s book, Trauma & Recovery; healing from trauma occurs best in communities of healthy and nurturing adults. The implications of living in a transient society with less and less money available for safe and stimulating child care, and schools that focus more on cognitive development than on a child’s emotional and physical needs are also discussed, leaving the reader wondering how the recent cuts in many needed programs will affect the next generation.

I highly recommend this book for anyone who is working with traumatized and abused children.