Building Bridges by jennyyingdi


									     Building Bridges:

Exploring the Links Between Woman
Abuse, Substance Use and Mental Ill
BC Women’s Hospital and Health
Woman Abuse Response Program:
Jill Cory     
Louise Godard 
Amber Hay     
Academic Partners:
Dr. Amy Salmon
Dr. Marina Morrow
    We Started Through Dialogue
• Invited anti-violence partners for 2 days to talk
  about what they were observing on the
  frontlines related to woman abuse, substance
  use and mental ill health
• Lead to a report of recommendations,
  development of a provincial Building Bridges
  Steering Committee and a successful proposal
  funded by Vancouver Foundation for
         Project Methodology
• BC Province-wide workshop/consultation with
  N=460 service providers representing mental
  health, substance use and anti-violence
  sectors from 82 communities
• 15 Focus groups with N=100 women affected
  by woman abuse, substance use and mental ill
• 9 interviews with policy leaders
• Self-identify as a women
• Be 19 years old or greater
• Have past or current experience(s) of abuse
• Have past or current experience(s) of either
  substance use or mental health issues or
• Have received support, currently or in the
  past, for their experience(s) of abuse
• Focus groups were facilitated using a semi-
  structured interview schedule
  • How they experienced the links between abuse,
    substance use and mental health issues?
  • How they experienced accessing anti-violence,
    addictions and mental health services?
  • What kinds of improvements would they
    recommend to better support women?
                DATA ANALYSIS
• Located all data related to service experiences, needs,
  gaps, outcomes
• Identified repeated observations
• Collated those observations into themes and
• Made comparisons and connections between themes
  and subthemes
• Applied coding labels
• Selected quotations to illustrate key points
Women’s Experiences of Abuse
    Woman abuse is most commonly
            defined as:
•   Any act of gender-based violence that
    results in, or is likely to result in, physical,
    sexual, or psychological harm or suffering to
    women, including threats of acts, coercion
    or arbitrary deprivation of liberty, whether
    occurring in public or in private life (United
    Nations, 1993, p. 3).
             What women say…
“There has been several times especially in [     ]. My
  hip was broken. My partner had broken my hip and I
  chose not to go until I was out of the situation. He
  had refused to take me. He had basically stopped me
  from going. I heard people say that you make your
  own choices you can do whatever you want. And to
  an extent I agree but when you make that choice,
  you and your children could be killed if you do it, so
  you choose not to. To an extent that choice is made
  for you.” - Natalie


          What women say…
“A lot of it was just verbal, but I wished he
  would have hit me instead of said what he
  said. The words were just as bad as, they
  hurt more than probably any being could
  have. And they did more damage for the
  long term.” – DJ
       Connecting health issues
"When I did finally get out of the relationship, I
 didn’t feel good about anything. I was a failure
 as a mother, I was a drug addict. I was in
 horrible shape. I’d lost so much weight. I was
 old and haggard looking. I’d lost all my friends.
 I was nothing. I didn’t think I was going to
 make it. It’s pretty tormenting. And to think
 that somebody can brainwash you to that
 extreme, or beat the hell out of you to that
 extreme. If it wasn’t for my son constantly
 saying ‘I love you Mommy. I need you,
 Mommy’ I would have given up and just died."
 - Dot
           Health Impacts of Abuse
• Exhaustion, trouble         • Bruises, lacerations, burns,
  sleeping, insomnia,           sprains, back pain, fractured
  nightmares or repetitive      bones, broken teeth,
  dreams                        choking, head or abdominal
• Stomach pain, anorexia,       injuries
  bulimia, GI pain            • Hearing loss, visual
• Fainting, seizures, chest     impairment, disfigurement,
  pain, hypertension,           brain damage, or paralysis
  headaches, back pain,       • Substance use, mental
  palpitations, dizziness and   health issues
• STIs, HIV/AIDS, forced      • Eberhard-Gran, J Gen Intern Med,
  pregnancies, menstrual pain
           Health Impacts of Abuse
• Women impacted by physical and/or sexual
  abuse reported 6.0 somatic symptoms and 1.5
  diseases (mean)
• Compared to women not experiencing abuse,
  who reported 1.8 and 0.5

• Eberhard-Gran, J Gen Intern Med, 10.2007
       Not taking women’s (health)
            concerns seriously
• “I agree, my abuse was 18 years ago and no one
  believed me and [I thought] it was my fault. The
  things that happened were my fault and it didn’t
  happen the way I said they did. And my ex was good
  ‘cause he knew how to beat me so that I didn’t have
  any visible bruises. And they didn’t believe me. And I
  would go to the hospital, and I wasn’t even doing
  drugs at the time, and they would say ‘you are just
  trying to get drugs for a pain that was non-existent’.
  Meanwhile he had beaten me and raped me… And I
  didn’t get any help. And it was my fault. And maybe if
  you were a good little girl and sat back and be quiet
  that wouldn’t happen to you.”
Violence against women and
       mental health
     Linking Woman Abuse and
          Mental Ill Health
• There is evidence that many mental health
  problems post-date experiences of abuse

“Mental health issues should be treated as
    effects of abuse and not as mental
             disorders per se.”
                         - Flitcraft
        Women, Violence and
         Mental ill Health

“I don’t call it mental health, I call it symptoms
    of abuse, because to me that is what it is.”

                       - Gail, woman abuse survivor

              Cathy Humphreys, Mental Health and Domestic Violence: a research overview.
                      Conference Presentation for Making Research Count, Coventry, 2003
          Women, Violence and
           Mental ill Health
• 70% of women in psychiatric in-patients
  and 80% of those in secure settings have
  histories of physical or sexual abuse (Phillips,

• More than 70% of those with post-traumatic
  stress disorder (PTSD) are women (Kessler, ‘95).
• “It’s just taken a toll on me. I don’t know where
  to turn. I thought I was going mentally insane.”
          Women, Violence and
           Mental ill Health
• Between 35 – 73% of abused women
  experience depression or anxiety, which is at
  least 3x as great as for the general female
  population. (Golding, 1999, Fikree & Bhatti, 1999)
“In the end, I ended up doing self harm to my
  wrists. It was superficial…It was a way to get
  out of that relationship after two years of
  physical and mental abuse.” - Kathy
            Women, Violence and
             Mental ill Health
• Generally rates were 2 x greater than in the
  control group in different sectors across the
  study. eg. In-patients - prevalence of depression
  was 32% in exposed and 17% in unexposed
  women (Cascardi, 1999)
• Primary care - prevalence of depression was
  69.9% in ‘exposed’ and 31.9% in ‘unexposed’
  women (McCauley, 1995)
• Domestic Violence intervention services -
  prevalence of depression was 83% (Campbell,
            Women, Violence and
             Mental ill Health
• Demonstrated that rates of depression in women
  leaving a refuge fell from 83% to 41% in 6 months
  if no recurrence of abuse occurred but only fell to
  71% if women were re-abused in the 6 month
  follow-up. (Campbell, 1995)
             Women, Violence and
              Mental ill Health
• Rates of female suicide attempts are as high as
  44% for women who have lived in refuges (Golding, 1999)
• 30% of female suicide attempts presenting at
  accident and emergency were the subject of
  woman abuse (Stark and Flitcraft, 1995)
• Risk ratio for suicide was 20.9 in women diagnosed
  with personality disorders, one of the highest risks
  of any category studied (Baxter and Appleby, 1999)
          Women, Violence and
           Mental ill Health
• Psychological impact of woman abuse not
  determined by the severity or frequency of physical
  assault, but by exposure to dominance

• “Whether it was verbal abuse or physical
  abuse. The physical abuse actually was a
  little better because the bruises go away. But
  the mental and verbal abuse really sticks
  with a person for a long time.”
                       - Cheryl
       Women, Violence and
        Mental ill Health
“What appears to be a constellation of
 symptoms or disorders may reflect a
 normal response to abuse and trauma
 and the social realities of continued
 isolation and danger.”
                         - Warshaw, 1997
          What women say…
     Perpetrators Grooming Others
“I used to get, “Oh, your crazy?!” He always presented
   himself in a good way. Most of them do and you’d
   never know…People don’t know what goes on
   behind closed doors.” – Maggie

“And that’s what he was going out and tell everyone,
  ‘well the reason I’m like this [abusive] to her is
  because [she drinks]’” - Janet
Abusers may exploit a woman’s
• Keep medications from her, give her too much
  medication, demand she takes medication
• Take advantage of changes in her symptoms and
  moods (eg. encouraging suicidal feelings)
• Threaten to take her children away and tell child
  protection authorities or the court of her illness
• Minimize her credibility
            What women say…
“Because he always participated. This is another
barrier. He always participated in my sessions with my
mental health worker. He had them believe, for the little
while, that he was Mr. Support. Hugely. He couldn’t do
that with the Stopping the Violence Program. He
insisted. And they agreed, “OK”. My partner insisted and
allowed him to. So I could never speak completely freely
or anywhere freely about the relationship. All that was
being dealt with was the mental health issue. But the
mental health issue had so much to do with the
relationship issues.” - Vivian
          What women say…
“Mine was happy that I was getting mental health
care. Because I was in an extremely low depressive
state. But I had to sneak around to get the type of
help that I really need in order to be able to climb
out of that hole. He wanted mental health and
addictions to fix me so that I would be his mould.
And that I could go back to living in the bedroom of
the RV and not coming out and bugging him and just
doing what he told me to do when he told me to do
it. That would be his idea of fixing me.” - Emma
           What women say…
“Whereas my first encounter with the social
 worker was after I attempted suicide and so he
 put himself out there like he could help. So he
 was welcome.” - Sam
Violence against women and
       substance use
    Violence against women and
           substance use
• Partner may be the primary or sole supplier
  of drugs, increasing her dependence on him
  by exploiting her dependence on drugs
• “He wouldn’t let me not drink, he would bring
  alcohol over, or you had to drink just to be
  near him. He would put a glass under my face,
  he knew I didn’t want to drink.”
    Violence against women and
           substance use
• Substance use may begin or escalate as a
  response to victimization/ woman abuse
“My addiction was the solution- my problem is
  abusive relationships and molestation when I
  was 6 or 7 years old” - Stella
“It went from mental abuse to physical to
  emotional. The way I dealt with it was by
  drinking all the time. That’s the only way I
  could cope.” – Naomi
          What women say…
• Between 60-80% of women in treatment have
  experienced sexual or physical abuse at some
  point in their lives.
• Alcohol dependency is 15 times more
  prevalent among women impacted by abuse
  than the general public.
        Violence against women and
               substance use
• Between 55 and 99% of women who have
  substance abuse issues have been victimized
  at some point in their lives (Moses, 2003)
• Between 67 and 80% of women in substance
  abuse treatment are IPV victims (Cohen et;al,
  2003;Downs, 2001).
• Between a quarter and a half of the women receiving
  victim services for IPV have SA problems (Bennett and
  Lawson, 1994; Downs, 2001; Ogle and Baer, 2003)
           Violence against women and
                  substance use
• 60% of substance abusing females were victims of
  domestic violence and 42% of women who were
  victims of violence and receiving domestic violence
  treatment were substance abusers. (Bennett and Lawson,
• The prevalence of domestic abuse within the
  substance treatment population is reported to be
  between 60-80% range but rises to between 90-
  100% when psychological abuse is accounted for
  (Downs 1999, Stringer, 1998)
    Violence against women and
           substance use
• Efforts to stop using substances may
  precipitate abusive partners' use of
  increased violence or other control tactics.
• “I went from a mentally abusive household to
  a husband who physically abused me and did
  drugs. And my home was so full of drugs, I had
  no control over what he was selling in the
  house, what he was doing in the house or
  doing to me.” - Amy
    Violence against women and
           substance use
• Some women drink alcohol or use other
  substances to numb or escape the emotional
  and physical trauma of violence/abuse
“One starts with one- the abuse and then you
  have the abuse and then you start with
  alcohol and then a bit of coke and carry on
  from there and keep going. Just trying to be
  numb...” – Alice
          What women say…
• “With drugs it’s not really a means of
  addiction, it’s more a means of survival. You
  do them to sell them and to get away from the
  guy you’re with you go to a house and do
  drugs instead of sit at home and be abused. “
  And that’s been my life history. My brothers,
  my father, my forefather.” - Willie
          What women say…
• Substance use can placate her abusive partner
  and create temporary safety for her

“We use the drugs to try and mask the abuse.
 And once you stop using them flashbacks
 come. It’s just a constant. We just self-
 medicate. Trying to push those memories
 out.” - Christine
  Medicating Impacts of Abuse
• Women in abusive relationships may be
  addicted to medications prescribed by health
  care providers for health concerns related to
  abuse. For example:
      • Chronic pain
      • Chronic headaches
      • abdominal pain
      • joint and muscle pain
      • anxiety and depression
      • sleep disorders
    Medicating Impacts of Abuse
• “I don’t understand. Oh, ‘we’ll help you, we’ll
  help you’. Whatcha going to do, give me a
  teddy bear? Basically, that’s what it was.
  Doctors, they give me medication I’ve never
  had before. So I’m walking around like
  gumbie. So I can suppress it.”
      Medicating Impacts of Abuse
• I was thrown down by my partner a couple of
  years ago… went to the DTES clinic for T3s.
  And they never asked me what happened.
  Never asked me what I wanted to do about it.
  I told them what happened.”
     Medicating Impacts of Abuse
• “A person might think ‘how did you all of a sudden
  start get involved in drugs when you were married
  and never done them before?’ How it started for me
  was I started with prescriptions. Sleeping pills, and
  anti-depressants and valiums. That was the way my
  doctor tried to help me deal with my loss. From there
  you need more pills and you go find people who you
  think can get you something and that leads to other
  things. So that’s how it happened to me.”
Linking Woman Abuse, Substance
    Use and Mental Ill Health
            What women say…
“The abuse part… I think sometimes times the
  abuse comes first, for some of us, and then I think
  the abuse continues because of the drugs and
  alcohol. It changes your personality… especially
  if you have mental health. Mental health, get
  some crack in there and some meth in there…
  you’re a different person.” - Kathy
 Linking Woman Abuse, Substance
     Use and Mental Ill Health
• Not an equal triad
• Links to woman abuse are often missed in
• Language of co-occuring, concurrent disorders
  conceal root causes
• Conflating trauma and woman abuse leads to
  inappropriate and sometimes unsafe practices
 Linking Woman Abuse, Substance
     Use and Mental Ill Health
• The largest contributions to the burden of
  disease associated with woman abuse are
  mental health and substance use issues,
  accounting for 73% and 22% of the total
  disease burden, respectively (Vos et al., 2006).
 Linking Woman Abuse, Substance
     Use and Mental Ill Health
• When services address only one problem-
  either abuse or substance use or mental
  health issues- at anytime, one or the other
  issue(s) becomes secondary and the
  opportunity to address all three issues
  together is lost (Humpreys, Regan et al., 2005;
  Humphreys, Thiara, et al., 2005).
 Linking Woman Abuse, Substance
     Use and Mental Ill Health
• Women who remain in services are often
  forced to enter settings that focus on narrowly
  defined problems, rather than being able to
  address themselves as a whole (Stenius & Veysey,
           What women say…
“It’s totally inter-related. Because abuse in
  relationships, depression, guilt, and then
  anxiety reducers, whether it’s ups or downs in
  your emotional state or whether it’s drugs or
  whatever it is I need today so I can forget
  about my pain or feel pretty or whatever. So,
  it’s all connected.” - Carrie
    More Complexity
Systems and Social Conditions
      Conditions of Women’s Lives
•   Housing         • “Understanding the
                     context in which
•   Mothering        women live also
•   Poverty          means understanding
•   Geography        the impact these
                     issues have in many
•   Racism           areas of women’s
•   Isolation        lives.”
         “You have to be broken
           and down and out”
• “You have to be broken and down and out before
  you get anything. At the bottom. I had to go to the
  extreme of living in poverty to get any help. It’s
  devastating. I mean I used to support my family and
  my kids had everything they needed. I mean my 11
  year old had been living with her dad for the last year
  and she was living in a $500,000 house and has
  everything she needs and now I have to take her and
  move into second stage living, which is not bad, but I
  mean it’s a big huge drop in what she had to take her
  away from that and it’s almost like I don’t want to. ..
 “You have to be broken and down
         and out“(con’t)
• …I mean she’s my daughter and I’ve raised her for ten years
  and her dad for one, but I want my baby back and she wants
  to come back, but then we’re stuck in the place… and it’s
  hard. And for food-wise, it’s not just the home, it’s food and
  clothes and her baseball, and having the things she already
  had. And the necessities too, going to the food bank, I mean
  thank God for those kinds of places, but to have to do that
  and to have to be in that position to get help… I mean it’s
  hard. And yea if I wasn’t pregnant I’d be out there and get a
  job, but having him (her infant baby) just brings you back. The
  worst I feel is for my daughter… trying to give her things that
  she used to have and I don’t have. We tell each other “okay
  we’re going to make it, we’re going to move forward.”
Service Encounters Can
 Increase/Cause Harm
           Service Encounters Can
            Increase/Cause Harm
• Services can retraumatize women by
  replicating the events or dynamics of women's
  primary trauma (Markoff et al., 2005; Elliot et al., 2005;
  Warshaw, 1997).

• Retraumatization occurs when services are
  unable to recognize and validate the trauma/
  abuse in women's lives, thus making services
  emotionally unsafe, disempowering and often
  devastating (Markoff et al., 2005; Elliot et al., 2005; Warshaw,
        Service Encounters Can
         Increase/Cause Harm
• “Drugs. I mean after all you said, who
  wouldn’t turn to drugs or alcohol with all that?
  Every time you turn around another obstacle,
  another mountain to climb. Who wouldn’t give
  up? That’s so much work. And on your own.
  Nobody telling you ‘you’re doing the right
  thing and here’s another resource.’ Yeah, with
  no support. None.”
        Service Encounters Can
         Increase/Cause Harm
• “When women present with all 3, it prevents
  them from getting services because no one
  wants to touch these women.” – service
• “It doesn’t seem like systems want to make the
  extra effort to assist the most vulnerable
  women.” – service provider
           Service Encounters Can
            Increase/Cause Harm
• Retraumatization can occur in numerous ways
  - use of seclusion, restraints or involuntary
  medication (Markoff et al., 2005).
• Can also occur in more subtle ways -
  confrontational or aggressive techniques that
  may be used to break down a women's denial
  of her substance use can be retraumatizing in
  that such an approach parallels the
  interpersonal dynamics of a women's abusive
  relationship (Markoff et al., 2005; Warshaw, 1997; Swan et al.,
        Service Encounters Can
         Increase/Cause Harm
• “Denial and minimization of experiences of
  abuse are used as tactics of psychological
  control in abusive relationships and these can
  be inadvertently repeated in clinical
  encounters if the clinician is unable to apply an
  approach that is framed by the need for
  safety, whether we are aware of the context of
  abuse or not.” – Dr. Carole Warshaw ‘97
     Minimizing Women’s Safety
• “A lot of doctors don’t want to talk about it or
  deal with it [violence/abuse]. So they just give
  you what you need or what they think you
  need and they push you out of the way…They
  just want to keep you medicated.”
      Services can increase harm:
       substance use approaches
• “The focus on the woman sends the message that
  the responsibility is on women to correct situation,
  no accountability for the abuser.” (service provider)
• Focus on single issues, often without recognizing
  social conditions
     Minimizing Women’s Safety
• Treatment length and lack of options for non-
  residential support
• Mandates that don’t support women staying
  in treatment: mixed gender, male dominated
  and male oriented services
• Services without childcare
• Lack of focus on safety after Rx completion
• MI, Stages of Change,12 Step, Trauma/PTSD
• “There’s still only around 7 detox beds. Can’t
  smoke in there now. But it’s pretty harsh
  because a lot of people are leaving because of
  the cigarette thing. My partner got kicked out
  last week for smoking a cigarette. Having to
  quit smoking while you’re detoxing. I think it’s
  too much…. They can’t take everything away
  at the same time.”
• “They say ‘well we give you the patch’ and I
  was like ‘you can’t smoke the patch’!”
• “What works for one doesn’t work for others...
  there’s so many people leaving because of
  cigarettes. It’s a big thing going on now.”
  Services can increase harm:
   substance use approaches
“I watched a lot of women get kicked out
of the recovery house for getting loaded.
And I think it’s ridiculous. I can
understand those women are dangerous.
But give them somewhere else to go.
Give them a detox bed.” - Manny
Services can increase harm: mental
     health treatment models
•   Mental health practices can retraumatize.
•   Confinement or isolation,
•   Removing autonomy
•   Intensive therapy
•   CBT
•   Enforcing medication
             Get to Know Me
• “CBT is good in some ways but it doesn’t really
  help you tap into your feelings. So she
  recommended me to someone else and right
  away she wanted me to jump in and I’m going
  like…excuse me shouldn’t you know
  better…rapport building or something. This is
  my first day with you so I didn’t go back.” -
         Unmet treatment needs
• Among women receiving substance use treatment,
  only 25% state that their experiences of abuse were
  adequately addressed (Swan et al., 2001).
• Providers may be reluctant to acknowledge women's
  experiences of abuse, either viewing it as a distinct
  issue in itself or may diminish its significance due to
  fear or misperceptions, concerns that addressing
  abuse is counter-therapeutic, lack of appropriate and
  specialized programs, or insufficient knowledge or
  training (Morrow, 2002).
            Trauma Interventions
               Can Cause Harm
•   Self Regulation
•   Self Soothing
•   Self Esteem
•   Self Trust
•   Limit Setting and Assertiveness
•   Clear Express of Needs and Desires
•   Clear Communication
•   Accurate Perception of Others and Honest labeling
•   Appreciating Mutuality and Reciprocity
          Service Encounters Can
           Increase/Cause Harm
• For those who do successfully enter services,
  research has shown that in comparison to
  women with either condition alone, women
  who have experiences of abuse, substance use
  and mental health issues have worse
  treatment outcomes (Swan et al., 2001; Thompson &
  Kingree, 1998; Comfort & Kaltenbach, 2000).
        Service Encounters Can
         Increase/Cause Harm
• Women living within an abusive relationship
  were significantly less likely to complete
  substance use treatment; only 41% of women
  who were currently in an abusive relationship
  completed treatment, compared to 77% of
  women who were not in an abusive
  relationship. (Swan et al.2001)
        Service Encounters Can
         Increase/Cause Harm
• “And when I left they said, ‘take these. They
  are anti-depressants. But don’t drink. Don’t
  drink more than 6 drinks per week.’ I
  thought, I’m not taking them because I drink
  more than 6 drinks per day. So, I just didn’t
  take them.”
      Services Can Increase Harm
• Most transition houses won’t accept women
  who are substance using
• Must be clean 7 to 10 days
• Have medications controlled by staff
• Have belongings searched
• “Our mandate can set women up to think that
  ‘clean’ is right or that they must fit our
  mandate. Limits service availability.” –provider
• “When you’re talking about women getting
  kicked out. It depends on the situation. []
  house is OK because it’s low barrier and you
  can come in there. But at the women’s shelter,
  where there are kids there, I do believe you
  have to be clean and sober.”
• “My doctor is my drug dealer… I tell her that I have someone
  else that deals with my health… you’re just my drug dealer.”
• My own doctor even… I can’t believe he wanted to write me a
  prescription for morphine, and that was I wanted to get on
  methadone because I wanted to get off the morphine… He
  said well I don’t know what you’re asking for and I said well I
  want something for the pain but not Tylenol not something
  that’s just going to just dull the pain. I said “quite frankly I’m
  surprised you offered morphine because you know I’m an ex-
  morphine addict- or user I should say, because I’m still
  addicted, up here (pointing to her head). Now I’m just on
  straight codeine.
     Services Can Increase Harm
• “Well, I stayed at some shelters. I had a
  really bad experience at a shelter. The first
  night I was there, the woman in the next bed
  to me OD’ed. And I felt really unsafe in
  shelters. That’s why I stayed in my car the
  majority of the time.”
     Help Can be Retraumatizing
• “Same with storage. Everything I do have.
  You can take a box of things that you love and
  treasure to a transition house. You can bring
  clothes. What happens to your stuff?”
• “Hard to live in a transition house with my
  kids—it was traumatic for all of us.”
                Homeless Shelters
• “He lived there, he said, ‘it’s great, you get breakfast’. I’m
  thinking you get bacon and eggs! A little different. I was
  hungry. It was overwhelming. You drive up, there’s about a
  gazillion people waiting for their beds. I thought, ‘What am I
  doing here?’ … they said, ‘You need to rest, we’d like you to
  stay here [drop-in centre] for a couple of days.’ I only stayed
  there for one night and that was enough. But it was an
  experience. I thought I was suffering! You sleep in a dorm with
  150 women, and they’re all so very tired. They know, they’ve
  been there before. … They’re just so tired. Then you see one
  woman in a wheelchair going around and stealing other
  people’s purses in the middle of the night…So I stayed up and I
  cried all night. It was sad. This is a whole different world for
  me. I’ve never experienced something like that. You go into
  the washroom and there’s a great big jar of condoms. This
  was all so new. They come in with this great big hose and they
  hose down the bathroom.”
 Jumping through hoops to stay in
• “I’m out of the shelter for stuff that I did so I’ve been
  asked to leave. ..And it is was difficult for me to
  understand, for me to come here and not be able to
  leave at four o’clock in the afternoon and I can’t go
  anywhere. I can’t phone somebody. Like I don’t have
  a person after me. And if I can’t leave, can I phone?
  Not that I have anyone that I need to phone or want
  to phone, I just want to know I can phone. It’s very
  difficult.” - Jose
And there are many!!
           Gaps and Barriers
• Compartmentalizing Issues
• “Mental health issues are construed as
  separate from abuse – now that’s crazy!” –
  service provider
            Gaps and Barriers
• Gaps between Services – “Substance use
  counselling is sometimes in conflict with
  mental health counselling, and neither support
  women’s safety and other impacts of abuse.”
  – service provider
            Gaps and Barriers
• Lack of Integration –”These three things are
  impacting women’s lives at the same time and
  makes it difficult to access services because of
  ‘silos’ and turf issues.” – service provider
   Attitudes of Professionals Reduce
• “I don’t feel comfortable if it’s a certain
  person. There’s somebody there that makes
  you feel like you’re a burden. And I’ve been a
  burden all my life. I don’t need to feel that.
  You need people to love you when you can’t
  love yourself.. Not feel like they are just there
  for a pay cheque.” - Wendy
     Attitudes of Professionals Reduce
• Some service providers are ill-informed and
  stigmatize/punish women.
• “Not all service providers see women survivors as
  survivors.” – service provider
• “The ‘oh. it’s you again’ mindset in ALL services.
  Women’s history follows them, but shouldn’t.”- Meg
• “Attitude of ‘what will you do differently this time?’
  instead of ‘what do you need from us this time that
  we didn’t provide you last time?’” – service provider
   Attitudes of Professionals Reduce
• “I’m always seeing judging eyes. Judging ears.
  It feels like they don’t want to hear your story.
  Or maybe, you’re fabricating some of your
  story? This is how it was. This is how I present
  it, because it’s the only way I know how to.
  It’s judging eyes. That’s the barrier I face every
  day when I leave the door. Which people are
  going to have those judging eyes?” - Hanna
 Labelling Women Reduces Access
• “It’s the labels too. Once they label you…
  either you use coke, or you’re in an abusive
  relationship, or alcohol or whatever. It’s there.
  It’s like a red flag. ‘Hey! You’re an addict’.”
                                           - Del
Rules, Hoops, Doors, Circles…
         Jumping through Hoops
• I just got so overwhelmed at the beginning. Ok, start
  at the transition house. Then welfare, then family
  resources, then mental health. I went through
  mental health, they couldn’t help me out. The family
  resource centre, no, they don’t do it here. I went to
  the health unit. No, they can’t help you here. So I did
  a big circle and ended back with [original counsellor].
  By then, you don’t want it anymore. I’ll do it on my
  own. I’ll do it on my own with the one counsellor I
  connect with…”. - Isabelle
    Closed Doors: Bouncing from
         service to service
• “When you make that first step and walk into
  a transition house. You tell your story. They
  start a file on you. Then they send you to the
  next place. You have to tell your story again.
  By the time you get to the 6th place of the day
  you say ‘f… this man’.” - Suki
            Service Saturation
• “From my point of view, I had been with a
  marriage counselor and I had already been in
  Mental Health and I was going through NA
  AA, whatever. From my point of view, I was
  already saturated with, ‘You’ve got to do this,
  you’ve got to do this’. I don’t need another
         Mandates that Exclude
• “But I ended up phoning one, and it was in
  [community], and they had decided not to take
  anymore bipolar patients. So, yah, just that
  afternoon. They said, ‘we’ve had some problems with
  bipolar people and we had a team meeting and we
  decided that were not going to take anymore’. So are
  there shelters out there for people that are bipolar
  specifically? No. There’s not out there. Because
  there’s a lot of women that I have run into. Lots.”
              Access to Care
• “Next to impossible to get a psychiatrist
  here—and once they find out you’re an addict
  they assume they know exactly what to do:
  here are your pills, take methadone and I’ll see
  you in 3 weeks. Yeah, they label you.”
             Limited Services
• “I don’t agree with the 30 days at the T house.
  You’re only allowed to stay 30 days and I don’t
  agree. For some women, 30 days is not
  enough. Then you boot them out the door and
  they go back.”
Limited Services
        Obstacles to Mothering
• “I’ve seen this tons living in [treatment
  centre], a women is not allowed to have her
  children for a certain amount of time. She has
  to have so many days clean. She has to prove
  herself. So what happens is she either has to
  stay in transition or she has to bunk up with a
        Obstacles to Mothering
• “My barrier is having [my daughter] taken
  care of when I go somewhere, or being able to
  take her with me.”
• “The reality is you can’t really trust someone
  with your child. You know you can trust
  yourself. You always have a little doubt.”
         Obstacles to Mothering
• “If I was to be sexually abused today and needed to
  go to a safe house, there isn’t one. My son is 16
  years old and they would not take my son in.”
• “When that all happened I went into rehab. They
  didn’t want the kids there. But then I went into a
  house for women and children. And that helped me
  out. It’s recovery. It was where I could live until I
  could get a job and afford to move out.“
          Obstacles to Mothering
• “But you shouldn’t have to go through those obstacles. I don’t
  know what you have to do to help women today so they don’t
  have to go through all those obstacles and be able to get the
  resources. I took my kids to mental health 3 times a week for
  3 years… How do you go to work when you have to go to
  counseling 3 days a week? How do you go to work when your
  kids are screaming at 3 am with bad, bad dreams and you
  can’t get the answers because they’re 3 and 5 years old. You
  know, where do you reach out? I mean I was lucky enough
  because I guess I had a career behind me and I knew how to
  dig up the resources on my own, but what about the women
  who don’t have that? Where do they go?”
        Women without Children:
           Another Barrier
• “Can I also say that I think, that as much as a
  lot of us have children, those who don’t have
  children still need the same help…Just because
  you don’t have kids doesn’t mean you haven’t
  been abused. Doesn’t mean that you don’t
  need help too. And there’s resources for
  women who have kids but I don’t see a lot of
  resources for women without kids.”
         Women without Children:
            Another Barrier
• “Like [ ], you can only come here if you have a kid 2
  years and under.”
• “What about a women who don’t have kids? They
  can’t come here and they’re just as traumatized as
  we are. They still have to go through the same stuff
  as we do and do the doors open for them? Probably
  even slower because they don’t have children that
  depend on them, but they still have to go through the
  same thing.”
     Women, pets and obstacles
• “This may not apply to the majority, but when
  I was on the streets of Vancouver, I had a dog.
  That was my connection to staying sane. And I
  had her till she was 15. But I had no where to
  go. I was in [    ] when they did a women’s
  shelter and I fought for them to put kennels in
  because a lot of women had dogs, cats,
  whatever. I think there needs to be. I’ll stay
  outside. I won’t leave my animal.”
         Lack of Compassion/
         Relationship Building
• “There are too many people that are there for
  their paycheck and not with their heart. When
  you work in mental health, you need to be a
  kind, caring and giving person to be in that
  area. There should be some kind of test for
  that. You don’t got the guts for this.”
         Lack of Compassion/
         Relationship Building
• “My violence worker, that’s who I went
  through [for counselling]...It was just very
  cognitive. I mean, I would share information
  and then she would give me more and I would
  walk out of there, you know, my head this big,
  ….I felt even more overwhelmed. …and it just
  keep going like that…”
      Not taking women’s (health)
           concerns seriously
• “A couple of years ago I was at [ ] hospital
  (Psychiatric Emergency Service), I told them I
  was going to kill myself and they sent me
  home... They just switched a couple of meds
  and sent me home.”
    Not taking women’s (health)
         concerns seriously
• “That’s the same when I was beat up… I
  couldn’t walk. They wouldn’t take x rays or
  anything. I went back 5 times and there was a
  crack in my spine. I couldn’t walk. They made
  me wait in the waiting room for 18 hours.
  They take forever.”

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