Download Throwing the Woman out with the Bathwater

Throwing the woman out with the
bathwater? Towards a trauma-informed,
gender responsive and empathic approach to
women
and
drug
use
{
Marguerite Woods
Trauma Informed Care Conference, SAOL
Project, 9.3.2016
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To pose some pertinent questions about
illicit drug use and trauma
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To explore a range of issues with regard to
women, drug use, parenting and trauma
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To focus on adversity
experienced by women
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To examine practice concerns
Aims of this presentation
or
trauma
What are the connections between drug
use and trauma?
What do we know about these links?
Why the relative silence and discomfort
about this issue in addiction and child
welfare services?
How should we respond?
Key Questions
Harm Reduction & Recovery
Stigma, labelling, diagnoses, ‘disorders’
Obstacles to empathy?
The search for single conceptual models as
answers, quick fixes and solutions
Beyond drug use
Re-conceptualisation
Feminism – ‘Waking the Feminists’ – a gender
sensitive response
Challenging & changing concepts
The Mad, Bad, Sad scenarios
 Victims
 Villains
 Damaged
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Structure/Agency debate – women
lured into use by “doctors, dealers
and darlings” (Ettorre, 1992)
Images of women drug users
I think that women get a harder time. I think
once they come to the attention of services,
we have ideas as to how women ought to
behave in our society and if they slip from
that, from being like the Virgin Mary, they’re
gone! They’re like the Mary Magdalenes
aren’t they? [Social Worker] (Woods, 2008)
Some ‘potentially perverse responses’
to women drug users
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Punitive Responses
Criminalisation of drug use during pregnancy
Enforced contraception, abortion, sterilisation or on
occasion the denial of these
Preconceived ideas (before full assessment of capacity
to parent) that drug use and parenting are
incompatible
Loss of custody – removal of children at birth
Limitations in terms of access and visiting to children
in alternative, even kinship care
Many studies of women and drug use have demonstrated that
significant numbers of women have experienced
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adversity in childhood
childhood sexual abuse
maltreatment or abuse
emotional and psychological abuse
neglect
witnessing violence between parents
domestic or intimate partner violence
rape, sexual assault
exposure to community and ambient violence
early bereavement, grief and loss
stigma
poverty and deprivation
(Woods, 2008; Reed & Mazelis, 2005; Millar & Stermac, 2000; Sterk, 1999; Maher, 1995; Taylor,
1993; Rosenbaum, 1981).
Adversity as trauma
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Such adverse experiences have been defined as traumatic
(Chung, 2009; Covington, 2008, 2007; Miller, 2002; Najavits et
al., 1997). Definitions of trauma vary and have changed
significantly over time. An effect of trauma may be Post
Traumatic Stress Disorder (PTSD), but not necessarily.
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Significant numbers of people who use drugs or alcohol
problematically have experienced trauma at some point in their
lives, ranging from 55% to 99% (Navajits et al, 1997).
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Those with a history of traumatic experiences are likely to have
experienced a number of traumatic events and in addition those
with drug/ alcohol and mental health issues experience more
frequent exposure to violence, violent relationships and abusive
environments and contexts (Harris, 1996).
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Involvement in drug and alcohol use, homelessness, prostitution
and imprisonment may increase vulnerability and the likelihood
of exposure to violence generally (Torchalla et al, 2012;).
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While 92% of the men and 91% of the women participants in one
US study reported experiences of lifetime trauma, women were
twice as likely to experience re-exposure and overall injecting
drug users experienced re-exposure to trauma at least once
monthly. The authors associated urban living and poverty with
exacerbating the possibility of such experiences of re-exposure
(Pierce, Kolodner, Brooner & Kidorf, 2011).
‘Keeping Mum’: A qualitative study of women
drug users’ experience of preserving motherhood
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Semi-structured interviews with forty professional workers
in the drug treatment, nursing, medical, community work
and social work fields
A series of in-depth interviews with twenty-six women drug
users
14 focus groups
Participant observation
In total contacts, interviews and focus groups with 205
women drug users at various stages of their drug-using and
motherhood careers; 100 professional workers and a number
of family members and several adult children of the women
participants
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Varying accounts of childhood years –
ranging from ‘happy childhoods’ (ten
women) or ‘fine’, ‘OK’ (five women) to
‘difficult’, or ‘painful’ (eleven women)
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‘My childhood was traumatic, I’d have to
say, traumatic’ [Katherine]
Adversity or Trauma? – ‘Unspoken
Histories’
The professional workers interviewed
believed that many women drug users had
endured unhappy childhoods with much
adversity, describing their experiences of
violence, severe punishments, physical
beatings, physical abuse, sexual abuse, rape
and neglect. In addition to professional
workers ’ accounts, 16 women interviewed
described experiences of abuse during
childhood.
Exposure to violence during childhood
Very few have actually identified a happy
childhood, and when I say that, it may not be
issues like just separation or whatever, it is
actually abuse a lot of the time that they have
experienced. (Refuge Worker)
For me, the root of drug abuse, a lot of it was
rooted in sexual abuse or serious bereavement
or trauma as children, you know, separation
from parents and sexual abuse… (Social
Worker)
Exposure to violence during childhood
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Of the twenty-six women interviewed, thirteen women
referred to their experiences of sexual abuse during
childhood/teenage years.
Thirteen women experienced physical abuse. Four
women experienced violence at the hands of their
mothers only, while five women experienced violence
from their fathers only.
Four women reported
experiencing violence at the hands of both their mother
and father. Eight mothers and 10 fathers were described
as having been violent.
Fifteen women reported experiences of emotional abuse
and some specifically mentioned forms of neglect.
Eleven women experienced all three types of abuse sexual abuse, physical violence and emotional abuse.
Fourteen of the 26 women interviewed witnessed or
experienced violence between their parents in the home
of the family of origin. Some specifically mentioned the
strain and pain of seeing parents experience violence.
Some witnessed their mothers experience of violence
while others spoke of their fathers’ experience of abuse at
the hand of their mothers.
Me Da used to beat me Ma, you know, things like that. Now I
mean, like Jesus, bangs of hatchets into the head and things
like that. [Helen]
The unemployment for generations, the drink, the violence
and the hard work of making ends meet, day in, day out, week
in week out. Getting food on the table, clothes on our back,
shoes on our feet - our Ma’s had to deal with that. [Amy]
Exposure to violence during childhood
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Almost all of the women who witnessed violence in their
families of origin experienced violence at the hands of
partners later in adolescence or adulthood.
In total, 17 women interviewed experienced physical
violence in one or more relationships.
Definitions of violence and abusive behaviour varied.
Many evidently violent incidents were not defined or
‘experienced’ as violence.
Low thresholds - lives impacted upon by verbal and
physical aggression.
Most women were reluctant to leave their violent partners
for a variety of reasons, including not wishing to rupture the
relationship between their children and their father.
When women left violent relationships, they described
doing so as being‘for the kids’
Ambient violence is widespread.
Experiences of domestic violence in
adulthood
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I was abused. Mentally, emotionally, physically,
sexually …I have vague memories around some
incidents. I remember a lot from my childhood.
… There was so much fuckin’ secrecy. Nobody
talked about anything and probably lack of
protection to, yeah obviously. [Katherine]
Childhood victimisation, however, was hardly
ever offered by the women as a reason for
teenage and adult drug use.
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I don’t think I met a woman drug user who
was an injector who hadn’t been abused or
raped somewhere in their career.
[Addiction Counsellor]
Other experiences
Adulthood
of
Violence
in
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A majority of one hundred professional
workers encountered suggested causal
relationships between women drug users’
early childhood experiences of adversity,
neglect and trauma and later drug use. They
also suggested that women’s early experiences
of having been parented impacted on their
later involvement in parenting and their
parenting styles.
Impacts in adulthood
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The word ‘trauma’ was used sparingly and
cautiously throughout the study
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It appeared rarely in the transcripts of 100
interviews, 14 focus groups and the field notes
from extensive fieldwork
Reflection
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Childhood experiences, the impact of neglect
and abuse experiences particularly, and their
impact on individuals in adulthood has been
regarded as ‘taboo for discussion’ (Klein et al.,
2007: 40)
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Viewing drug use as self-medication or a
coping strategy is controversial - a speculative
causal connection between adverse childhood
experiences and adult drug use.
Reservations about the focus
During fieldwork many women described their experiences of
interruption to the role of mother.
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15 of the 26 women interviewees
28 of the 44 focus group participants
a loosely estimated 75 of the 123 mothers encountered during
observation and fieldwork
Some had lost all contact with their children.
Three women interviewees and several focus group members
and street contacts retrieved the role, while several others
partially recovered their role.
Motherhood Interrupted
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Few people in the women’s social networks or
professional workers, however, regarded this
experience of interrupted motherhood as a loss,
bereavement, or trauma, merely viewing it as a
consequence of the women’s behaviour, as
reported by women and workers.
Loss of child custody – Motherhood
Interrupted or Terminated
Several recent Canadian studies also describe women drug
users’ experiences of mothering and their interaction with
child welfare services, highlighting ‘traumatic grief’. The
trauma experience is named explicitly, identified as central
to women’s experience of separation from their children,
and exacerbated by women’s lifetime histories of trauma.
These suggest the need for Child Protection workers’
understanding of and sensitivity towards these loss and
grief experiences.
(Kenny, Barrington & Green, 2015; Nixon, Radke & Tutty, 2013)
Loss of child custody
Do attitudes, demeanour, practice, and drug
treatment and child protection systems in
fact inadvertently traumatise or retraumatise
the women in contact with the services?
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While child protection or welfare systems are
often trauma informed and aware with regards
to children’s experiences, the lifetime trauma
exposure of parents is rarely acknowledged.
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It is suggested that the experiences of interactions
with social work services ‘can themselves be
origins and configuring forces of trauma with far
reaching implications for mothers and family ties’
and the loss of children as ‘an overlooked source
of institutionally orchestrated trauma’ is
highlighted (Kenny et al., 2015, p. 1163).
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Punitive perspectives
Confrontational approaches
Supervised urine testing
Lack of empathy
Boundaries
Safety, warmth, care
An understanding of and sensitivity towards
child custody losses as grief experiences
An understanding of social context
Drug Treatment – tough love?
Grella, C. (2008) From Generic to Gender-Responsive
Treatment. Journal of Psychoactive Drugs, p. 337
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Recognising the impact of violence and victimisation
Recovery from trauma as a primary goal
Empowerment model
Maximising women’s choices and controls over recovery
Based in a relational collaboration
Respectful of the need for safety, respect and acceptance
Emphasise strengths, highlighting adaptations over symptoms
and resilience over pathology
Minimise the possibilities of retraumatisation
Cultural competence and understanding of each woman in the
context of her life experience and cultural background
Consumer involvement in design and evaluation of services
Principles of trauma-informed care
(Eliott, Bjelajac, Fallot, Markoff, & Reed, 2005, pp. 464-469)
Adversity - Hope
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Benefits of adversity?
Post-traumatic Growth?
Strengths and coping
Resilience
Safety
‘Recovery’
Healing
Reducing Harm
Trauma proofing
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Need for research and an explicit focus on the trauma
experiences of drug-using women and their children
Caution with regard to labelling and ‘disordering’
Need for explicit links between trauma and drug and
alcohol use to be made in professional training
Workers responding to trauma and other mental health
issues need to be comfortable with and knowledgeable
about drug and alcohol issues
Workers need also to be aware of their own personal
traumatic experiences and the possibility of secondary or
vicarious traumatisation in the professional arena
Attitudes of workers generally towards drug-using women
must be challenged
Conclusions
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A trauma-informed, gender responsive and empathic response
(Covington, 2008; 2007; Grella, 2008; Elliot et al, 2005)
Integrated, integrative and pluralistic responses tailor made to
women’s preferences
To challenge the quest for single conceptual models of
understanding, response or intervention in the addiction field
generally and in response to trauma issues
A trauma-informed drug treatment system
A trauma-informed child welfare system, that not only takes
account of the trauma experiences of children in families
where drug/alcohol use are issues but also takes account of
women’s retrospective and current traumatisation and retraumatisation experiences.
A ‘trauma lens’ may allow for the integration of
understanding, practice and response.
The Future?
‘Recognition that problematic drug use is a response
to trauma, abuse, poverty, social disenfranchisement
and psychiatric distress should also be useful in
countering the cruel banalities of those who condem
both drugs and the marginalised. In using that tool,
however, we need to be aware of unintended effects.’
(valentine & Fraser, 2008, p. 415)
A caveat –
the next big thing in the addiction field?