Nisa Hussain
Program Associate, Workforce and Leadership Development
Association of Maternal & Child Health Programs

Dr. Carole Warshaw, MD
Director, National Center on Domestic Violence, Trauma & Mental Health

As the opioid epidemic continues to grow and gain national attention, it is important to shed light on the connections between substance abuse, mental health and intimate partner violence (IPV). While there is nothing quite “new” about the devastating impacts that these three issues have on families among all demographics in the United States, several recent studies on their interaction together create an emerging perspective for Maternal and Child Health  (MCH) workforces to consider.

On May 2nd, the National Health Collaborative on Violence and Abuse (NHCVA) and Futures Without Violence hosted a briefing in Washington D.C., “Public Health Crisis: Solutions to Violence and Abuse.” One panelist spoke of the impact of intimate partner violence among people with substance use and mental health disorders. Carole Warshaw, M.D., of The National Center on Domestic Violence, Trauma, and Mental Health (NCDVTMH), presented on “Mental Health and Substance Use Coercion: Prevalence and Implications for Mental Health and Substance Use Policy.” While there are studies demonstrating the complex interplay between mental health and substance abuse, she is among the few who have talked about the compounding influence of IPV among its survivors.

Dr. Warshaw explained that IPV plays a critical role in the development and the exacerbation of mental health and substance use disorders. According to research, domestic violence survivors face a greater risk of experiencing a range of mental health conditions, including depression, PTSD, substance use disorders, and suicidality. In addition, research indicates there are high rates of domestic violence among women receiving services in mental health and substance use disorder treatment settings. In 2012, the National Domestic Violence Hotline (NDVH), in collaboration with NCDVTMH, conducted a pair of surveys to further explore these connections, specifically to investigate tactics of coercion by abusive partners targeting their partner’s mental health and/or substance use.

Dr. Warshaw described the survey results to demonstrate how common it is for abusers to engage in behaviors designed to undermine their partners’ sanity and sobriety, control their partner’s ability to engage in treatment, and discredit them with potential sources of protection and support. While survivors of domestic violence may use substances to cope with emotional trauma or chronic pain, they may also be coerced into using by an abusive partner, who then sabotages their recovery and uses their substance use condition to further his or her control.

Some 5,989 adult women who experienced domestic violence and were not in immediate crisis voluntarily participated in the two NDVH-NCDVTMH surveys after hotline staff explained the topics and guaranteed their anonymity. Among the findings:

Substance Use Coercion Survey (3,248 participants)

• 26 percent reported using alcohol or other drugs as a way to reduce the pain of their partner or ex-partner’s abuse.
• 27 percent said a partner or ex-partner had pressured or forced them to use alcohol or other drugs or made them use more than they wanted.
• 15.2 percent reported that in the last few years, they had tried to get help for their use of alcohol or other drugs. Of those individuals, 60.1 percent said that a partner or ex-partner had tried to prevent or discourage them from getting that help.
• 37.5 percent said a partner or ex-partner had threatened to report their alcohol or drug use to someone in authority to keep them from getting something they wanted or needed (e.g., custody of their children, a job, benefits or a protective order).

Mental Health Coercion Survey (2,741 participants)

• 85.6 percent said a partner or ex-partner had called them “crazy” or accused them of being “crazy.”
• 73.8 percent said a partner or ex-partner had deliberately done things to make them feel like they were going crazy or losing their mind.
• 53.5 percent said that in the last few years, they had gone to see someone such as a counselor, social worker, therapist or doctor to get help with feeling upset or depressed, and of those, 49.8 percent said that a partner or ex‐partner tried to prevent or discourage them from getting that help or taking medication they were prescribed for their feelings.
• 50.2 percent said that a partner or ex‐partner threatened to report to authorities that they are “crazy” to keep them from getting something they wanted or needed (e.g., custody of their children, medication or a protective order).

The results showed that experiences of mental health and substance use coercion were common among hotline callers. Particularly salient for MCH providers is that over 50 percent of those who sought help for their mental health and over 60 percent of those who sought help for substance use said their partners tried to interfere with their treatment.

These forms of abuse not only jeopardize the well-being of survivors and their children, but also compromise the effectiveness of treatment and prevention efforts. For example, MCH providers are aware of the risks posed by postpartum depression and opioid use during pregnancy, but might not  consider the role that mental health and substance use coercion might be playing in the lives of women who are dealing with these conditions nor be aware of interventions that could help support their engagement in treatment.

The findings underscore the importance of ensuring that the MCH workforce is trained to recognize and respond to the ways that IPV can impact women’s mental health and substance use and to institute policies and practices that support attention to these issues. MCH providers can ask about mental health and substance use coercion as part of their routine behavioral health history intakes and/or as part of their screening and assessment for IPV. Including questions about the connection between a person’s relationship with their partner, their mental health and use of substances creates an opportunity for someone who is experiencing IPV to think about how these issues might be connected for them and to develop strategies to navigate more safely. It also allows clinicians to provide more appropriately tailored counseling, treatment and referrals.

NCDVTMH recommends federal, state and local agencies responding to the opioid epidemic to incorporate strategies that drill down on the interplay between coercion, IPV and substance abuse. They also recommend that strategies are included in trainings for opioid treatment providers, treatment programs and broader prevention initiatives and in the development of policies and practice standards. Additionally, improving collaboration between treatment providers and local domestic violence programs is critical to addressing the challenges of treating addiction.

Keeping signs of substance use coercion, mental health coercion and domestic violence in mind is one step toward protecting those individuals and families affected by more than one of these abusive factors.

For more information visit the NCDVTMH at www.nationalcenterdvtraumamh.org. See the PDF of the survey results.