Safety and Sobriety Manual
Best Practices in Domestic Violence and Substance Abuse
Lessons Learned from Successful Collaborations
The purpose of this section is to provide an overview of successful collaborations between substance abuse and domestic violence programs. These collaborations target services for women with substance abuse problems who are also victims of domestic violence. The guiding assumptions, key program components, challenges, and lessons learned are briefly discussed.
The information in this section is based on staff interviews at eight Illinois collaborations between domestic violence and substance abuse service providers. Some of the collaborations are between different programs within a single agency, but most are the product of interagency agreements. The interviews were conducted in 2001 and 2002 by DHS staff. Four of the collaborations are DHS-funded pilot projects that have been formally evaluated1 and four collaborations are independent, community-based efforts. The agencies participating in the interviews were: (1) Constance Morris House, and Pillars, Summit; (2) PhaseNVAVE, Rockford; (3) Gateway, and Violence Prevention Center, Belleville; (4) Healthcare Alternative Systems, and Rainbow House, Chicago; (5) Leyden Family Service and Mental Health Center and The Share Program, Hoffman Estates, Family Shelter Services, Wheaton, and Prevent Child Abuse Illinois; (6) Ben Gordon Mental Health Center, and Safe Passage, DeKalb; (7) South Suburban Council on Alcoholism and Substance Abuse, East Hazel Crest, and South Suburban Family Shelter, Homewood; (8) Haymarket Center, Chicago Abused Women Coalition, and West Side Domestic Abuse Program, Chicago.
Guiding Assumptions Behind Collaborations
Successful collaborations share a number of assumptions which are summarized below:
Women with co-occurring issues need both substance abuse treatment and domestic violence advocacy services. Providers articulate that substance abuse and domestic violence are two distinct but interrelated problems which need both substance abuse and domestic violence services. Neither service is an add-on to the other, and addressing only one problem is not viewed as sufficient. Furthermore, services are offered concurrently rather than sequentially.
Safety is prioritized. Whether in domestic violence or substance abuse treatment services, a woman's safety is paramount. Safety is incorporated into the substance abuse treatment plan, and is considered in how all services are provided.
Interagency collaboration is the norm. Agencies promote interagency collaboration when possible because each agency brings a full range of services and resources (e.g., treatment, advocacy, children's programs, ancillary services) to bear on its problem focus. Collaboration ensures a balanced focus built on the expertise of both fields. Collaboration allows women to be identified and served at their agency of choice or at the agency from which they first seek services. Grounded in the principle of empowerment, women decide what services they want and when they are ready to utilize them.
Services may be integrated or coordinated. Collaborative models differ, and agencies/services may be either coordinated or integrated, rather than sequenced. Sequenced services traditionally require the client to complete one service before receiving the other. For example, domestic violence shelters have traditionally required women to be clean and sober before entering shelter. Coordinated services are parallel services offered in tandem, but are independent in content. These services are coordinated so that the client can attend both. Each service may be offered at the host agency. lntegrated services bring the services together to the client, with programs that have been designed specifically to address both domestic violence and substance abuse issues. lntegrated services are not simply blended services, but a mixture of joint services complemented by the full range of resources and programs offered by both domestic violence and substance abuse agencies. lntegrated services enhance consistency of message, a holistic approach, and a focus on both safety and sobriety across services.
Key Services in Collaborations
Ongoing Domestic Violence and Substance Abuse Screening. The traditional approach to addressing the co-occurrence of domestic violence and substance abuse has been to refer women with the cross issue, when that issue surfaces, to an agency with whom the host agency has a linkage agreement. Concerns about that approach include:
- Without universal screening, staff will probably not identify the majority of cases. Staff only identify those cases in the most extreme crisis situations;
- Referrals are often not followed by clients, who may be overwhelmed, or may not recognize the connection between the violence and abuse and their substance use;
- Lack of service coordination makes attendance difficult, setting up clients for failure;
- Lack of staff education and cross-training leads to a fragmented approach at best, and a conflicting approach at worst.
The most likely result of this traditional approach is service failure, which may include relapse, being asked to leave shelter, or revictimization.
The initial plan of most collaborating partners, therefore, was to implement a universal screening at intake or soon after intake. If a woman screened positive for the cross issue, she was referred to another agency. However, it became clear that many women do not disclose the cross issue at intake, for a multitude of reasons. These reasons may include shame, fear of stigma, lack of a culturally supportive service approach, fear of being rejected for service, fear of DCFS or other sanction, denial or minimization, or simply a lack of trust in the service provider. Often, however, as the issue was raised throughout services, women would self-disclose. This led collaborating partners to recognize the need for ongoing screening. This approach suggests that screening is never complete. Staff are always alert for signs and disclosure, integrating issues of domestic violence and substance abuse into their programs. The need for ongoing screening also led to the development of an early intervention/education component.
Early Intervention/Education. Called early intervention by substance abuse providers and domestic violence education by domestic violence advocates, this group-based service approach is provided by each agency for all clients at the partner agency. Women do not have to screen positive to be in this group, which uses an educational approach to deliver information about, for example, the cycle of violence, power and control tactics of abusers, and the continuum from use to addiction. These groups not only educate all clients, but they serve as a de facto screening process, with many women subsequently identifying a need for services.
Co-location of Staff. Even with enhanced screening and early intervention/education, many women do not make the connection to the partner agency for services. Out of this common experience, projects often realized that the solution lay in co-located services; in other words, bring the services to the client. Staff from one agency are based at the partner site, either full or part time. Women tend to be most comfortable at the agency they initially chose for services and their chance of receiving the cross service is greater if that service is provided at the agency they have selected. Colocated staff increase buy-in of all staff, raise awareness, provide educational opportunities for all staff, build relationships across agencies, and reduce turf issues. Co-located staff lead to truly coordinated services where both agencies feel a joint responsibility to the client.
Individual and Group Services. The range of services offered through co-located collaborations include assessment, counseling, safety planning, and substance abuse treatment. Services usually include both individual and group programs. Both substance abuse treatment and domestic violence services traditionally emphasize group-based assistance, but pilot projects found that many women preferred individual services for a variety of reasons, so that became part of the pilot program. Individual counseling allows confidentiality for both issues, reduces stigma and discomfort, and builds a relationship with a personal counselor. Groups are co-facilitated by a domestic violence advocate/counselor and a substance abuse counselor. The group integrates the two issues; this is not a single-issue group with a guest speaker.
Case Management. Case management is an approach to human services which emphasizes the use of individualized assessment, matching assessment to service, advocacy for needed services, provision of both counseling and concrete services as needed, and ongoing evaluation of both process and outcome. Case management is a core service of most domestic violence agencies and a required service in most substance abuse settings. Case management is a wonderful resource for collaborating projects. The more complex the client's issues, the more necessary case management becomes. This is especially true for women who are receiving services at both agencies.
Consultation. As individual relationships develop among staff at both agencies, case consultation develops naturally. Staff have a cross-problem contact person to call with questions or for feedback. This has been especially helpful in crisis situations. An example of how relationships facilitate consultation and support was observed at a shelter working with an addicted woman. The woman overdosed one night, and the shelter staff were understandably terrified. After calling an ambulance, they called their substance abuse treatment partner, who told them exactly what to do, what was happening, and what to expect. She drove straight to the shelter, and stayed with the staff and woman, riding in the ambulance to the hospital with the woman. Shelter staff reported a profound sense of relief and comfort in the assistance provided by the partnering agency's counselor.
Key Program Supports
Training. Training and education of staff is crucial for program implementation and staff support. Collaborating partners find that training is an ongoing effort. Training may include both in-house and cross training programs, and it may be either informal or structured. Initial "101" training often helps staff recognize their own belief systems and become familiar with the other system's culture. Training and discussion address unspoken expectations of what each partner can and cannot do, and begin to address myths and provide basic education
Joint Staffing. Joint staffing is critical to coordinating services. Both staff are in the room talking about the same woman. This allows them to serve women better and more consistently. Often, each side has a very different picture of the woman. Also, joint staffing builds relationships among staff; as they learn to appreciate each other's expertise, mutual trust and respect begin to develop. Teachable moments provide informal training opportunities. Collaboration is a big-time commitment, and the payoff is equally big. Collaborating agencies comment that there is no shortcut to developing trust and building relationships.
Coordinated Administration. Coordinated project administration is needed to address issues of confidentiality, policy changes, staff roles and responsibilities, information sharing, record keeping, and program management. Time must be devoted to developing a program plan that encompasses all these issues, in addition to service content.
Monitoring Performance. One program manager found that staff implemented new screening tools for about a week, then stopped using them. She stresses the importance of supervision and monitoring of program implementation. When staff were assured that management was committed to the collaboration, and that staff would be evaluated and recognized for implementing the new tools, then the new project became firmly institutionalized within the agency.
Supervision. Staff supervision, both programmatic and clinical, is needed to ensure quality services. Domestic violence and substance abuse collaborations open new territory for most staff, and often raise personal issues that need to be addressed. Issues may be related to the staff members' personal or family experience, beliefs and attitudes toward cross-problem populations or cross-problem agencies, clinical issues which emerge during assessment and intervention, or resource management.
A number of barriers to collaboration were noted in our interviews and these barriers are noted elsewhere in this manual. Issues of conflicting philosophy (e.g. medical model v. social justice perspective, personal choice v. abusive control, treatment v. advocacy), language (e.g. powerless v. empowering, enabling v. being coerced), and misunderstanding (e.g., addiction and abuse, funding, and confidentiality). Barriers to collaboration such as these are not ignored by partnered agency staff. Experience demonstrates that, as staff talk to and educate one other, they identify more common ground and common goals than common conflicts. Such identification motivates staff to develop joint programming.
Keys to Success
A number of elements emerged in the interviews which appear to be associated with more successful collaborations.
Program Champions. Successful programs often have program champions. The program champion is a staff person who sees the big picture, who will push to make the collaboration happen, who is open-minded and willing to listen, and who is willing to adapt the approach. The program champion is deeply committed to addressing both issues, and inspires others to see the connections and the essential need for the collaboration.
Vision, Commitment, Common Goal. Successful collaborations are characterized by the ability of program partners to recognize their common goals, which engenders a commitment to keep working at the collaboration when challenges arise. They have a sense of purpose about what they are doing, and a feeling of unity and teamwork among program staff. Many projects have developed their own name, adding to their sense of cohesion. Out of the common purpose and common goals, trust develops among partners.
Openness to Flexibility, Learning, and Changing the Model. Collaboration transforms participants. No collaborative project looks the same at the end as it did at the beginning. Successful collaborations are characterized by a high level of flexibility and openness to solving problems as they arose. Each had an initial program plan and vision of how the collaboration would work, and each evolved and changed with experience. Successful collaborations all required patience, openness and time commitment to develop the program plan and to build relationships. Open and frequent communication is essential.
Co-located Services. Co-location means that an agency's services are offered not only at the host agency, but at the cross-problem agency as well. Every collaboration found its way to co-located services, which are seen to be the foundation of a strong program.
Empowerment Models and Women-Specific Treatment. Domestic violence agencies are characterized by their use of an empowerment approach. Substance abuse treatment, however, has a range of models and approaches. It appears that substance abuse treatment agencies with women-specific treatment models are the most appropriate partners for this type of collaboration. Women-specific substance abuse treatment staff are more likely to be nonconfrontational, and usually recognize the significant impact of violence and abuse on their clients' lives. These agencies are developmentally and temperamentally in the best position to develop a collaborative project with domestic violence agencies.
Resources Dedicated to the Project. In an ever-changing climate of staff, clients, and organizations, sustainability of collaboration is key. As both a sign of management's investment in the project and as necessary concrete support, resources must be dedicated to the project and sustained over time. Resources include staff time, staff supervision, training, program management, and program materials. Project oversight and accountability are key to success. Collaborations of this nature do not run themselves; they require management and ongoing monitoring.
Conclusion: Co-location, Cross-Training, and Commitment
Collaboration between community-based substance abuse agencies and domestic violence agencies are underway, and are expected to increase in number. The advantages of these coordinated efforts far outweigh the inevitable differences between staff and philosophies. Participating staff and participating clients notice the difference. Moreover, preliminary program evaluation increases our confidence in coordination, co-location, cross-training, and commitment.
While we have learned much from the eight collaborations described here, there is much more to learn. We do not know, for example, whether the highly overseen pilot projects performed better than, the same as, or poorer than the autonomous collaborations. It is not clear how much collaborations cost, nor exactly what their benefits might be. We do not know whether integrated or coordinated programs work best, or for whom they work best. Despite this lack of knowledge, we are increasingly confident that, for women who are abused by their intimate partners and also abuse alcohol or drugs themselves, a woman-specific substance abuse program co-located with an empowerment-oriented domestic violence program offers the best opportunity for safety and sobriety.
1 The results of the evaluation by Dr. Patricia O'Brien are in the previous chapter.