FVPF eJournal
Futures Without Violence eJournal
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Working at the Crossroads: Domestic Violence, Poverty, Substance Abuse, and Mental Health

In this plenary session, leading experts in the fields of domestic violence, poverty, substance abuse, and mental health examined the intersections between co-occurring issues and offered strategies for developing a more trauma-informed, integrated health care response.  To achieve this goal, the health care paradigm must shift toward patient-centered care that meets the individual needs of each patient by allowing their own values to guide decisions about their health care.  Central themes to this approach are choice, control, and making connections between these issues to provide health care that is timely, efficient, and equitable.

“The Pernicious Three”

Katya Fels Symth, Founder of the Full Frame Initiative, emphasized how poverty increases vulnerability to abuse and reduces options for change.  Noting first that household income is one of the most significant correlates of domestic violence, she also commented that almost all homeless women with mental health problems have been abused.  Ms. Symth referred to the following concerns as the “pernicious three” factors known to compound violence and oppression:


Acute stress occurs in response to a specific event such as an eviction or the loss of services.  Stress can also occur chronically in response to ongoing problems such as the inability to pay the rent or bills.  Chronic stress is linked to adverse health outcomes.


Powerlessness occurs when the intensity of the stress becomes overwhelming and/or is sustained over long periods of time.  Health care practitioners can reinforce a sense of powerlessness if a patient feels that they do not believe her.


Assessing social support based solely on the number of people in a person’s network can be misleading.  How useful those people are to a person influences how isolated or supported a person is.  Looking only at the numbers can lead to misperceptions about the utility of social support for people in impoverished communities.

While people cope with these adversities, our societal focus on external change can be unrealistic and even dangerous for women experiencing domestic violence.  Ms. Symth recommends an alternative approach that is survival-focused.  Using this approach, women take small, micro-steps to minimize harm as they survive from day-to-day.  Ms. Symth pointed out that survivors are often moving forward in ways that we do not recognize or expect.  By taking the following small steps, health care and services providers can help to reduce the negative impact of the “pernicious three:”

  • When you ask a client a question, wait for the answer
  • Know the resources within your institution and community that address the “pernicious three
  • Remember something personal about a client that is not related to her problems
  • Encourage clients to be part of something this is not related to her issues/problems
  • Have one staff person at your institution be a community liaison to community organizations and neighborhood events

Filling Gaps and Unmet Needs

Dr. Carole Warshaw, Director of the National Center on Domestic Violence, Trauma, & Mental Health, described how the mental health system has lagged behind health care in responding to domestic violence.  She noted the mutually reinforcing relationship between mental health issues and domestic violence; victimization increases the risk of mental health consequences while mental health problems increase the risk of victimization. Social stigmas about victimization and mental health enable batterers to use partners’ mental health issues to control them.  Dr. Warshaw identified several critical intersections between domestic violence, trauma, substance abuse, and mental health.  These intersections included:

  • Trauma can affect survivors’ access to services
  • Trauma can affect our response as service providers
  • Without a trauma-informed framework, services can be retraumatizing

Dr. Warshaw stressed the importance of addressing domestic violence within the context of life trauma, noting that trauma theory can be the bridge to understanding the cumulative effects of lifetime trauma and the implications of co-occurring problems.  Her vision for developing collaborative models and building system capacity entails a shift in our thinking from asking “what’s wrong with you?” to asking “what’s happened to you?”

Leading for Change

Imani Walker is the Co-founder and Director of the Rebecca Project for Human Rights.  She shared her life story of being in an abusive relationship, experiencing depression, and self-medicating that led to addiction.  Her words, “I could not parent with dignity,” conveyed the pain and struggles of abused women who cannot find the support they so desperately need.  She went in and out of treatment programs that were not trauma-informed or gender-specific.  The turning point in her life came when a social worker referred her to a comprehensive, family-based treatment center when she was pregnant.

Ms. Walker has become an advocate leader for vulnerable women experiencing violence, substance abuse, poverty, and mental health issues.  Through the Rebecca Project, she does policy advocacy work to end demeaning and destructive practices, such as the shackling of female prisoners during childbirth, that jeopardize the welfare and dignity of women and girls.

The Substance Abuse Connection

Patti Bland, the statewide training project coordinator for the Alaska Network on Domestic Violence and Sexual Assault, provided insight into the complex relationship between chemical dependency and domestic violence.  Substance abuse can be a tool of control for batterers.  Strategies used by batterers include:

  • Forcing their partner to use substances
  • Isolating her from recovery services and resources
  • Coercing her to engage in illegal activities such as stealing and prostitution
  • Sabotaging recovery efforts
  • Using drug use history as a threat
  • Blaming the abuse on a partner’s substance use

The lack of services for abused women with substance abuse problems and societal beliefs about women and addiction are ongoing barriers to survivors’ recovery.