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Health and Domestic Violence - Good Practice Guidelines

Principles of Good Practice for working with women who
use substances

Guidance for local domestic violence services

Introduction

Women's Aid refuge organisations, advice lines, outreach and other services exist for the benefit of all women and children experiencing physical, emotional, sexual or financial abuse in their relationships. No woman experiencing abuse of any kind should be turned away when she requires support or refuge. If a refuge organisation is unable to accept a woman who needs refuge, due to lack of space or other resources, and/or is unable to provide sufficient support for a woman who has complex needs, an appropriate referral should always be made to another organisation.

It is accepted that - at present - many domestic violence organisations do not have sufficient resources to offer a complete service to women with complex or multiple needs. This particularly applies to the provision of refuge accommodation. All Women's Aid organisations should, however, be working towards more inclusive provision, either within their current services, or by developing specialist service provision.

Aims of Good Practice Guidance:

To increase safe choices for women and children experiencing domestic violence where substance misuse is also an issue
To raise awareness and standards in refuge organisations, outreach and other services
To encourage partnership working between the domestic violence and the substance misuse sectors

Definition of substance misuse
Women's Aid understands "substances" to include alcohol, prescription medications, illegal drugs and other mood-altering substances; and "misuse" to refer to the use of such substances in such a way as to cause harm to the individual or to the wider community(i). Use of substances runs on a continuum from stable to problematic. Problematic or "chaotic" substance use becomes the prime factor in an individual's life; this can fundamentally affect her life skills, ability to cope and well-being(ii).

Some information on domestic violence and use of substances
There are a large number of women for whom domestic violence and substance misuse are a simultaneous concern. Many women use substances as a response to and a way of coping with abuse(iii). Many women who approach domestic violence services will therefore be using or misusing substances. Despite this co-existence there is no evidence to suggest a direct causal link between substance misuse and domestic violence: women's substance use should never be used to justify or "explain" their experiences of violence; nor should drug or alcohol use be accepted as an excuse for violent and abusive behaviour.

Women experiencing domestic violence are up to fifteen times more likely to misuse alcohol and nine times more likely to misuse other drugs than women generally(iv).
40% of Asian women who seek treatment for alcohol misuse are experiencing domestic violence(v).
Some women are introduced to substances by their abusive partners as a way of increasing control over them(vi); and when a woman's partner is also her supplier, it will be particularly difficult for her to end the relationship.
Women may not want to reduce or stop using substances at the same time as they decide to end their abusive relationships(vii).
When a woman seeks treatment for her substance misuse, her partner may become even more abusive, or may actively encourage her to leave treatment(viii).
Substance misuse professionals consistently underestimate the proportion of their clients who experience domestic violence(ix).
Women whose partners misuse substances may minimise or excuse his violence on those grounds; it is important to emphasis that even if substance use ceases, the violence and abuse usually continues(x).

Women with problematic substance use who also experience domestic violence are particularly likely to feel isolated and doubly stigmatised. They may find it even harder than other women to report or even to name their experience as domestic violence. When they do seek help, substance-using women are in a particularly vulnerable position, and may be unable to access any suitable sources of support. Women with problematic substance use who experience domestic violence deserve and need support from domestic violence services as much as, or more than, any other woman.

Legal issues

All domestic violence services must comply with legal requirements, in particular those under the Misuse of Drugs Act 1971. Section 8 of this Act states that those concerned in the management of any premises commit an offence if they allow the production, supply or use of any controlled substance on those premises(xi); however the legislation need not be a barrier to the development of services. Most refuge organisations also have rules governing the use of alcohol within their premises.

At all times, staff should ensure that the safety of themselves and other users and/or residents of the premises is paramount.

The Human Rights Act also has implications for the provision of services: it is important that these services are as inclusive as possible, and that organisations are equipped to work with a variety of clients including those from minority ethnic communities, disabled women, and those with substance misuse and mental health issues. Domestic violence organisations - whether or not they provide refuge services - need to develop policies and practices for working with survivors who use or misuse substances, including alcohol, prescription medication and other drugs.

Child Protection issues

Witnessing domestic violence is known to have a detrimental impact on children and is one indicator of risk of harm to children in the family. Substance misuse does not automatically mean that a woman is a "bad" parent, but it can be an additional source of stress. In considering the safety and support needs of a woman, those of her children must also be taken into account. Provision of protection and support to a woman may be the most effective way of also protecting and supporting her children; but children's and women's needs and experiences are different, and the children may have additional support needs. Children should feel they are listened to and are safe. Any disclosure of abuse, or any suspicion of harm needs to be responded to with discretion and in accordance with your organisation's Child Protection Policy and Women's Aid's National Policy on "Child protection and confidentiality" (Women's Aid, May 2002)(xii).

Risk assessment

It is recommended that all refuge organisations and local domestic violence services routinely employ risk assessments with their clients, particularly when considering a woman's admission to residential accommodation. A risk assessment is a tool designed to assess how a woman's current situation, experiences and lifestyle - including her drug and alcohol use, and the violence and abuse she has experienced - could impact on her or her children's safety, and to respond appropriately. Risk assessments help to identify possible problems and dangers, and provide guidance in making informed decisions about the level of support that might be needed, and how best to provide this(xiii). They can enable an understanding of a woman's needs, and allow this to be matched to the level of support your service can provide.

A central feature of any risk assessment should be the survivor's fears for her own safety: she has the most detailed knowledge of her perpetrator. Risk assessments are not, however, predictive, and there is no accurate procedure to calculate or foresee which cases will result in further harm or homicide. It should also be remembered that risk is not static: as circumstances change, so do risk levels.

Training

All staff in Women's Aid refuge organisations should have basic training in substance misuse issues. All staff members should familiarise themselves with their organisation's policies on the use of alcohol and drugs within their premises, and any good practice guidelines which apply to working with this client group. Funding should be sought for one or more specialist substance misuse workers in each organisation, or at least within each region. Alternatively, existing staff could be encouraged to develop a specialised interest in this field. These staff members should have or be given accredited substance misuse training.

Working with domestic violence survivors who have problematic substance use

All referrals should be assessed on an individual basis. Assessment criteria should include the woman's perception of her stability, safety and needs, and the needs of other service users/residents, rather than simply her use of substances. Be clear about the kinds of behaviour which are acceptable and not acceptable while a woman is on your premises or using your services.

Domestic violence organisations should be committed to and actively working towards providing an equivalent and inclusive service for all women, whatever their needs. This might be by developing specialist services, or by increasing capacity and resources in order to address complex needs within your regular services. Outreach provision and other appropriate support should be offered to women survivors who are unable, or choose not to, access refuge accommodation, particularly if they are in other, unsupported, temporary accommodation, such as bed and breakfast or a hostel for homeless people.

Regardless of existing resources, the following points may be helpful:

All domestic violence organisations should have, or develop, policies on the use of alcohol and drugs by their clients, their staff, and on or in the vicinity of their premises. These should be developed in conjunction with the legal implications of drug use and intoxication within a refuge or other premises.
Personal safety issues must be prioritised.
Encourage women clients to tell you about their use of substances (legal and illegal). This can help to ensure safety, both in their use of substances and, if applicable, to themselves, their children, and others within a refuge or other premises.
Find out what sources of support a woman has or can access.
Staff should be able to give basic harm reduction information, to enable those women who wish to continue to use substances, to do so with the minimum of risk to themselves, their children, and other users of the service.
Staff should be aware of specialist substance misuse services to which they can refer women for additional support. They should also familiarise themselves with the specialist mental health services in their local area, including emergency and rapid response services, to which they could refer women if necessary.
The point at which a woman leaves her partner or enters a refuge or other alternative accommodation may not be the right time for her to stop her substance use.
Staff should support women in making their own choices. This will include choices about staying with, leaving or returning to an abusive partner; using, reducing or ceasing use of substances; and entering or remaining in treatment.
Some of these choices will, however, have implications for the kind of support your organisation can provide, and women should be informed of this.
Staff have a duty to ensure that women who have substance use issues are not discriminated against by other users of their services.
If your organisation does not have resources to provide appropriate support to a client or potential client, try to find that support elsewhere. Do not reject a woman without finding somewhere else to refer her for the services she needs; this could include emergency accommodation, crisis support and/or help with substance use.
In order to assess needs and inform future service provision, refuge organisations should keep a record of the number of substance using women referred to their organisation, the numbers offered accommodation, and those not accepted, with reasons for those decisions.
Partnership working:
All Women's Aid refuge organisations should seek out and make links with other appropriate specialist agencies within their area, to facilitate the availability of joint support for women with complex needs. This can be facilitated by active participation in Crime and Disorder Reduction Partnerships, where local strategic agendas are addressed(1). Ensure that all information about other agencies, including referral procedures and the kind of service provided, is kept up to date and easily accessible to all staff. Such agencies should include substance misuse services, black and ethnic minority specific services, services specifically for lesbians, mental health services, and services for disabled women. Working practices should allow honest communication and information-sharing with other agencies, and thereby enable safe and appropriate cross-referrals.

Further information

Further information on substance use and domestic violence can be obtained from:

- The Stella Project, which has produced a "toolkit" for working with domestic violence, drugs and alcohol: Domestic Violence, Drugs and Alcohol: Good Practice Guidelines (2004). The Stella Project also delivers training within the London area, facilitates cross sectoral events, and produces a newsletter. Contact Michelle Newcomb, Stella Project Co-ordinator, The Greater London Domestic Violence Project, Third Floor, City Hall, The Queen's Walk, LONDON, SE1 2AA; Tel: 020 7983 4510; Email: Michelle.Newcomb@london.gov.uk

- Drugscope: www.drugscope.org.uk

- The Domestic Violence Policy Officer for Nottinghamshire Domestic Violence Forum, in partnership with Nottinghamshire Drug and Alcohol Action Team and Nottingham City Council, is developing a domestic violence and substance misuse action plan, including good practice guidelines for working with survivors and perpetrators of domestic violence who also use alcohol and drugs. Contact Linny Beaumont, Domestic Violence Policy Officer, Nottinghamshire County Council, Community Safety Team, Culture and Community Department, County Hall, West Bridgford, Nottingham NG2 7QP; Tel: 0115 977 2040;
Email: Linny.beaumont@nottscc.gov.uk

- Release, a national charity committed to informing the public about drugs, the law and human rights: www.release.org.uk

- Women's Aid website: www.womensaid.org.uk

- Department of Health (2000) Domestic Violence: A Resource Manual for Health Care Professionals

- Freephone 24 hour National Domestic Violence Helpline run in partnership between Women's Aid and Refuge: 0808 2000 247

- Respect phoneline for perpetrators: 0845 122 8609

These Principles of Good Practice are a product of the Women's Aid Mental Health, Substance Misuse and Domestic Violence Project, a three year initiative funded by the Department of Health. The first part of this project was a Survey to gather information on existing services. The Report of that Survey, Struggle to survive, is available from Women's Aid, price £10 (£8-50 for Women's Aid members).

In developing these Principles of Good Practice, I have greatly benefited from comments made on earlier drafts by Dr. Cathy Humphreys (University of Warwick), Michelle Newcomb from the Stella Project, and Jane Lewis, Nottingham City Council, as well as from others within Women's Aid.

Please send comments on these Principles of Good Practice to:

Jackie Barron
Health Project Worker
Women's Aid National Office,
Bristol, BS99 7WS
Telephone: 0117 915 7451
Email: j.barron@womensaid.org.uk

Final draft 24/1/05

Footnotes:
1. Crime and Reduction Disorder Partnerships (CDRPs) have a substantial overlap with Drug Action Teams, and now include senior representatives from the Primary Care Trusts (PCTs), which have a responsibility for commissioning health and related services in their local areas. Domestic violence and the needs of women survivors need to be promoted within this forum in order to enable access to future resources for development of services.

References:
(i) See the Stella Project (2004) Domestic violence, drugs and alcohol: Good practice guidance (London: The Stella Project, Greater London Domestic Violence Project and Greater London Alcohol and Drug Alliance) which gives this definition on p.43, and a similar definition for "problematic substance use" on p.15. Judgements as to "misuse" and "problematic" are, of course, subjective; and the woman's own views may not coincide with those of the workers in the agencies she approaches.
(ii) Several of the points which follow are taken, or adapted, from points made at the Stella Project launch seminar: Separate Issues, shared solutions, in 2002, and from earlier drafts of the Stella Project toolkit, cited above, 2004.
(iii) Raine, Pamela (2001) Women's perspectives on drugs and alcohol: The vicious circle (Aldershot: Ashgate)
op.cit.; Stark, E. and Flitcraft, A. (1996) Women at risk: Domestic violence & women's health (Thousand Oaks, California: Sage); Jacobs, John (December 1998) The links between substance misuse and domestic violence: Current knowledge and debates ed. by Mary-Ann McKibben and Fran Walker (Alcohol Concern and Institute for Study of Drug Dependence (ISDD); Ettorre, Elizabeth (1997) Women and alcohol: A private pleasure or a public problem? (London: The Women's Press.)
(iv) Stark, E. and Flitcraft, A. (1996) op.cit.; Maryland Department of Health, Journal of American Medical Association 2001, quoted in Lewis, Gwynneth, Drife, James, et al. (2001) Why mothers die 1997-1999: Report from the Confidential Enquiries into Maternal Deaths in the United Kingdom (London: RCOG Press).
(v) Shaikh, Zaibby and Nez, Farah (2000) A cultural cocktail: Asian women and alcohol misuse (Hounslow: EACH).
(vi) Swan, Suzanne, Farber, Stephanie, Campbell, Donna (2000) Violence in the lives of women in substance Abuse treatment: Service and policy implications Available from www.womensconsortium.org; the Stella Project (2004) op. cit. p.71.
(vii) Taylor, Holly (2003) Domestic violence and substance misuse: Making the links: An evaluation of the service provision in Tower Hamlets (London Borough of Tower Hamlets: Tower Hamlets Partnership and Learning Design Ltd.).
(viii) Taylor, H. (2003) op.cit.; the Stella Project (2004) op. cit. p.71 and passim.
(ix) This was evident from the Women's Aid survey on Mental Health, Substance Misuse and Domestic Violence; see Barron, J. (2004) Struggle to Survive: Challenges for delivering services on mental health, substance misuse and domestic violence (Bristol: Women's Aid)
(x) Taylor, H. (2003) op. cit.
(xi) Further information on the current legal position, and a sample Drugs Policy are available at http://www.ixion.demon.co.uk
(xii) Useful publications include: Advisory Council on Misuse of Drugs (2003) Hidden harm: Responding to the needs of children of problem drug users (ed. by Dr. Laurence Gruer); Carr, Deborah (2003) Pilot project for the provision of childcare to enhance attendance at the Iceni Project treatment Services (Suffolk Drug Action Team). The Stars project in Nottingham, supported by the Children's Society, is a potential model for a child-centred service for children of drug-using parents. (Reported in The Guardian , 31/03/04.) See also www.usingwomen.org.uk; and www.the-childrens-society.org.
(xiii) Definition adapted from that used by the Stella Project (2004, op. cit. p.16)