Transcript Open Doors Project

-- Participant Slides --
Open Doors
Bringing an Inclusive Service
Model to your work
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 01
INTRODUCTION AND OVERVIEW
Open Doors
An Inclusive Service Model
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Introduction
Welcome
Territory acknowledgement
About the trainer/facilitator …
Open Doors
An Inclusive Service Model
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Impetus for Open Doors
• Women who have experienced violence and
who have mental health and substance use
issues often face restricted access to
Transition Houses & Safe Homes.
• As a result they are at increased risk of
homelessness/further violence.
• Homeless shelters report many of the women
using their services have experienced
violence.
Open Doors
An Inclusive Service Model
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Project background
• Lead by the YWCA Canada
• Project partners:
o Canadian Network of Women’s Shelters and
Transitional Houses (CNWSTH)
o BC Society of Transition Houses (BCSTH)
o The Canadian Women’s Foundation
• Aims to increase access for women fleeing
violence and are coping with trauma, mental
wellness and substance use to VAW shelters and
transition houses.
Open Doors
An Inclusive Service Model
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Project background
• The goal of the project is to foster national systemic
change by implementing an inclusive service model in
communities and supporting broad use of the model
• This 3-year project is training and supporting 50
Community Service Leaders with the aim of changing
the standard of service in each of their 50 communities
• Additional supports provided to support systemic
change:
o Website – opendoorsproject.ca
o Webinars & learning community
Open Doors
An Inclusive Service Model
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Inclusive service model development
• YWCA Saying Ye: Effective Practices in Sheltering
Abused Women with Mental Health and
Addiction Issues
• BCSTH Reducing Barriers to Support Women
Fleeing Violence Toolkit.
• CNWSTH Practice Implementation Manual
• Gap analysis of non-VAW focused shelter serving
abused women online survey.
• Needs assessment thought focus groups with
abused women in non-VAW focused shelters.
Open Doors
An Inclusive Service Model
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Inclusive service model in a nutshell
• Working in a ‘grey’ zone guided by the
circumstances and needs of women and their
children.
• Recognising that one size does not fit all.
• Working from strengths.
• Incorporating Feminist Trauma-informed
practice.
• Using a harm reduction approach.
Open Doors
An Inclusive Service Model
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Agenda
Day 1
• Introduction
• Connecting the
dots
• Foundational
principles
• Understanding
trauma
• PTSD
• Vicarious trauma
• Self care
Day 2
Day 3
• Mental wellness
• Supporting women
with mental health
issues
• Self harm
• Suicide
• Substance use
• Supporting women
with substance use
issues
• Records
management
• Debriefing practice
• Revisioning
services
• Sharing ideas
Open Doors
An Inclusive Service Model
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To sum it all up …
Saying ‘yes’ more
than ‘no’ as often as
possible
Open Doors
An Inclusive Service Model
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Module 02
GROUP AGREEMENT
HOPES AND FEARS
Open Doors
An Inclusive Service Model
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Group Agreement
• How can we make the
most out of our time
together?
• What do we need to
establish to make this
space safe for
everyone?
Open Doors
An Inclusive Service Model
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Hopes and fears
• What does the group
hope to get out of this
workshop?
• What are some of our
shared fears?
Open Doors
An Inclusive Service Model
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You get to decide where you
would like to go …
And the best
way to get
there!
Open Doors
An Inclusive Service Model
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Module 03
MAKING THE CONNECTIONS
Open Doors
An Inclusive Service Model
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Social Context
Genderbased
Violence
“A women’s experiences with
violence often precede her
mental wellness and/or
substance use concerns”
•
(Gatz et al., 2005; Humphreys et
al., 2005; Humphreys, 2007)
1
Substance
Use
Mental
Wellness
Social Location
Open Doors
An Inclusive Service Model
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Many “symptoms” that women exhibit
represent their attempts to cope with
and adapt to traumatic stress … [yet we
often] focus on what is ‘wrong’ with this
person, rather than on what horrible
things have happened to this person.
- Lori Haskell, Bridging Response: A front-line worker’s guide
to supporting women who have post-traumatic stress
Open Doors
An Inclusive Service Model
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Video: For Her Own Good
• Things to keep in mind as you watch the
video:
o What are the key messages the women want us to
hear?
o What did the women find useful in their healing
journey?
o What are the links between violence, mental
wellness and substance use?
Video is produced by the Ontario Association of Interval & Transition Houses
Open Doors
An Inclusive Service Model
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Remember – no one expects you to be a drug and
alcohol expert – you just need to be able and willing
to have conversations with women about their
substance use and relate these conversations to the
risks women are exposed to, their safety and
ongoing physical, mental, emotional and spiritual
needs.
- Tessa Parkes, Freedom From Violence Toolkit
Open Doors
An Inclusive Service Model
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Module 04
FOUNDATIONAL PRINCIPLES
Open Doors
An Inclusive Service Model
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Foundational Principles for supporting women
Holistic &
Integrated
Harm
Reduction
WomanCentred
Relational
AntiOppression
Responsive
Adapted from Reducing Barriers to Support for Women Fleeing Violence: A Toolkit for Supporting Women with
Varying Levels of Mental Wellness and Substance Use (BC Society of Transition Houses, 2011)
Open Doors
An Inclusive Service Model
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Woman-centred
• Take into account the various social factors
and contexts that shape women’s lives.
• Intersectionality = various inequities/forms of
oppression are interconnected and impact
different women differently.
• Each woman’s experience is unique. They are
the experts of their own lives.
Open Doors
An Inclusive Service Model
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Woman-centred
• Focus on women’s strength and resistance
(strength-based and response-based
approach)
• Provide non-judgemental information about
all options available to women, and respect
and support their decisions
• Recognizing women are competent at making
decisions that are best for them.
Open Doors
An Inclusive Service Model
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Anti-oppression
• We are all impacted, to
some extent, various
forms of discrimination.
• Recognize and make
conscious efforts to
NOT replicate power
structures that foster
inequality and bias.
Open Doors
An Inclusive Service Model
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Thinking about language
Instead of …
Consider …
Crazy/Psychotic/Insane/Bipolar
Women living with …
Junkie/Addict/Druggie
Women struggling with substance use
Clean
Not using substance/cutting
back/abstinent
Relapse
Lapse
Off her meds
Choosing not to take her prescription
due to …
Open Doors
An Inclusive Service Model
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Deficit-based language
Adapted from: Royal College of Nursing, Informed Gender Practice: Mental health acute care that works
for women, 2008, National Institute for Mental Health: London, UK.
Open Doors
An Inclusive Service Model
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Relational
• Supportive, respectful, non-judgmental
relationship is the foundation of healing.
• Includes relationships between worker &
women and women & women
Open Doors
An Inclusive Service Model
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Holistic & integrated
• Women are often asked to separate and
compartmentalize each issue when seeking
services.
• The distress she presents is only a small part
of how she is in the world.
• Collaborate with local agencies, formally and
informally, to better serve women.
Open Doors
An Inclusive Service Model
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Challenges of access to services
• Women may bounce back and
forth between offices being told
they need to deal with their
‘other’ issues first.
• Services may be piecemeal
or located far away from
each other.
• Funding may be narrow and
restrictive.
Open Doors
An Inclusive Service Model
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Responsive
• Constantly adapting how
we work with women and
how we do the work.
• Need for clear program
policies, procedures and
practices that are
consistent across shifts
and staff.
Open Doors
An Inclusive Service Model
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Harm reduction
• Reducing the harmful
effects of behaviours
that a person is not able
to stop.
• Recognizing that
ignoring or condemning
the behaviour will not
make it go away.
• Respecting decisions.
Open Doors
An Inclusive Service Model
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The reduction of harmful consequences of
substance (ab)use without necessarily requiring
any reduction in use. These harms may be
related to health, social or economic factors
that affect the individual, community and
society as a whole. Harm reduction seeks to
reduce the more immediate and tangible harms
an individual may face.
- Centre for Addiction & Mental health
Open Doors
An Inclusive Service Model
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Walking in her shoes
• What are some of the barriers the women
experienced?
• How may her experience influence her
behaviours when she contacts you?
Open Doors
An Inclusive Service Model
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Module 06
FEMINIST TRAUMA-INFORMED
APPROACH
Open Doors
An Inclusive Service Model
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Feminist trauma-informed practice
• Locating the “problems” within the systems of
oppressions, not pathologizing the women.
• Understanding that men’s violence against
women can cause trauma.
• Recognising the ways in which trauma can
show up in our bodies/minds/belief
systems/behaviours.
• Coming from a strength-based approach.
Open Doors
An Inclusive Service Model
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Trauma-informed work
• Does not necessarily require disclosure of
trauma.
• More about the overall essence of the approach,
or way of being in the relationship, than a specific
strategy or method.
• Focus on safety and engagement.
• Creates an environment where there is not
further traumatization or re-traumatization
(events that reflect earlier experiences of
powerlessness and loss of control) and where
they can make decisions at a pace that feels safe.
Open Doors
An Inclusive Service Model
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Trauma-specialized work
• Work in a trauma-informed environment that
is focused on treating trauma through
therapeutic interventions involving
practitioners with specialist skills.
Open Doors
An Inclusive Service Model
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Trauma-informed work
• Work at the client, staff, agency, and system
levels from the core principles of:
o Trauma awareness
o Safety
o Trustworthiness
o Choice and collaboration
o Building of strengths and skills
Open Doors
An Inclusive Service Model
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Key messages for
trauma-informed practice
• Normalize the experience, reduce stigma.
• Emphasize resilience and hope.
• Communicate that what happened is not their
fault.
• Reassure them that they don’t need to ‘go it
alone’.
Open Doors
An Inclusive Service Model
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Honouring Women’s Resistance to
Violence and Oppression
Open Doors
An Inclusive Service Model
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Module 07
SUPPORTING WOMEN WHO
EXPERIENCED TRAUMA
Open Doors
An Inclusive Service Model
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Understanding trauma
• DSM V: Experience an event that involves
actual or threatened danger such as serious
injury or death to self or others.
• “An inescapably stressful event that
overwhelms people’s coping mechanisms”.
• What is considered ‘traumatic’ depends on
subjective perspective and social responses.
Open Doors
An Inclusive Service Model
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Simple PTSD vs. Complex PTSD
Simple PTSD
Complex PTSD
• Results from a one-time
event
• Examples: natural
disaster, accident, an
assault
• Compounding effects of
multiple trauma
• Possibly perpetrated by
someone the survivor
trusted
• Examples: childhood
abuse, domestic violence,
residential schools,
prisoners of war camps,
human trafficking
Open Doors
An Inclusive Service Model
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… there is a shift from a brain (and
body) focused on learning to a brain
(and body) focused in survival. … the
survival brain seeks to anticipate,
prevent, or protect against the damage
caused by potential or actual dangers.
- Julian Ford, Neurobiological and Developmental
Research: Clinical Implications
Open Doors
An Inclusive Service Model
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Trauma & memory
Open Doors
An Inclusive Service Model
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Window of tolerance
Open Doors
An Inclusive Service Model
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Impact of trauma
Spiritual/
Belief
System
Biological
Social/
Interpersonal
Psychological
Open Doors
An Inclusive Service Model
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Signs & symptoms of trauma
•
•
•
•
•
•
Nightmares, flashbacks & intrusive thoughts
Fear, helplessness, despair, anger…
Avoidance behaviours
Emotional numbing & heightened emotion
Hypervigilance
Altered perception of self, perpetrator, belief
system
• Altered relationships including isolation
Open Doors
An Inclusive Service Model
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Practical tools
•
•
•
•
•
Assistance to identify triggers
Assistance to recognise early warning signs
Suggestions for self-soothing/grounding
Suggestions for ways to prioritise self care
Connection with self and others
Open Doors
An Inclusive Service Model
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Module 08
VICARIOUS TRAUMA
Open Doors
An Inclusive Service Model
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Vicarious Trauma
• Exposure to traumatic stories day in and day
out can put workers at risk of vicarious
trauma.
• Effects are cumulative.
• Impact varies for each individual.
• Can lead to burn out and resentment.
Open Doors
An Inclusive Service Model
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[Vicarious trauma] is the result of
absorbing the sight, smell, sound,
touch and feel of the stories told in
detail by victims searching for a way
to release their own pain.
- Guidebook on Vicarious trauma: Recommended
Solutions for Anti-Violence Workers
Open Doors
An Inclusive Service Model
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Beyond the Cliff
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An Inclusive Service Model
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Impact of Vicarious Trauma on Workers
•
•
•
•
•
Personal
Job Performance
Morale
Interpersonal
Behavioural
Open Doors
An Inclusive Service Model
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Possible indications of vicarious trauma
Open Doors
An Inclusive Service Model
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Protective factors against
vicarious trauma
• Countering isolation
• Developing mindful selfawareness
• Consciously expanding
perspective to embrace
complexity
• Active optimism
• Holistic self-care
• Maintaining clear
boundaries and
honouring limits
• Exquisite Empathy
• Professional Satisfaction
• Creating Meaning
Harrison, R.L. and M.J. Westwood, Preventing vicarious traumatization of mental health therapists: Identifying
protective practices. Psychotherapy: Theory, Research, Practice, Training, 2009. 46(2): p. 203-219.
Open Doors
An Inclusive Service Model
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Module 09
SELF-CARE
Open Doors
An Inclusive Service Model
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Resisting “burnout” in Feminist Activism
• Relying on “self care” is not enough – it
blames our clients for harming us and does
not address the root cause of the “spiritual
pain.”
• Puts the burden of working in unjust contexts
onto the backs of us as individual workers.
• Radio interview with Dr. Vikki Reynolds –
Resisting Burnout in Feminist Activism
http://rabble.ca/podcasts/shows/f-word/2011/08/resisting-burnout-feminist-activism
Open Doors
An Inclusive Service Model
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The people I work alongside don't burn me
out and they don't hurt me, they transform
me, challenge me and inspire me. What is
trying to blow me up is the injustice they live
with and my frustrating inability to
personally change the problems that they
wrestle with and live in.
- Dr. Vikki Reynolds, Unpacking burnout: We're not
burning out - we're resisting being blown (2013)
Open Doors
An Inclusive Service Model
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Self Care
• What are you already
doing to practice self
care?
• Any practices you would
like to try out?
• Any practices you have
done before and
stopped? Why is that?
Open Doors
An Inclusive Service Model
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Module 10
MENTAL WELLNESS AND VIOLENCE
DSM-V & MEDICAL MODEL
Open Doors
An Inclusive Service Model
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Good Mental Health
Minimal
mental illness
symptoms &
good mental
wellness
No
diagnosable
mental illness
& good mental
wellness
Detectable
Symptoms
No Symptoms
Severe mental
illness
symptoms &
poor mental
wellness
No
diagnosable
mental illness
& poor mental
wellness
Poor Mental Health
Mental Wellness Continuum
(Adapted from K. Tudor, ‘Mental Health Promotion: Paradigms and Practice’, 1996)
Open Doors
An Inclusive Service Model
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How is mental health exploited?
• Women struggling with mental health illness
are vulnerable to exploitation by their
abusers.
1. How might it be used?
2. How might we incorporate this knowledge
into our work?
Open Doors
An Inclusive Service Model
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How is mental health exploited?
•
•
•
•
Over or under medicate her
Threaten to report her as unfit mother
Minimize her credibility (e.g. she’s crazy)
Exacerbate her symptoms (e.g. encourage
suicidal ideation)
• Erode her sense of self worth and self esteem
• Rationalize his violence (e.g. she deserves it)
Open Doors
An Inclusive Service Model
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Rethinking ‘normal’
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• How do we come to
understand what are
considered ‘normal
behaviours’?
• Who gets to say
what is ‘normal’?
• What does it mean
to be ‘abnormal’?
Open Doors
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The Myth of “Normal”
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DSM-V & ‘Disorders’
• DSM-V is a tool used by psychiatrists to
diagnosis patients.
• Diagnosis is a best-guess based on a
combination of symptoms.
• Disorders are “clinically significant pattern of
thinking, feeling and/or behaving that is
associated with distress or impairment”
Open Doors
An Inclusive Service Model
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Some drawbacks of the medical model
• Focus on the symptoms of individuals
o Less emphasis on looking at or addressing the
causes and the social contexts
• Lack of training
o Discomfort with discussing issues of violence or
trauma with the women
• Clinicians are seen as experts
o Little space for women to direct service received
Open Doors
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Pros & cons of diagnosis
Useful
• May be able to access
services
• Gives a common
understanding to
patients and care
providers about
symptoms
• Treatment plans
Harmful
• Being “screened out”
for services
• Reduce identity to a
label
• Conflicting diagnosis
and/ or multiple
diagnosis
Open Doors
An Inclusive Service Model
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About medications
• Medications are often prescribed to people who
seek medical support for their mental wellness
and is diagnosis with a disorder.
o What do you think/believe about medication in
general?
o What has influenced your thinking about
medications?
o How have these beliefs affected your work with
survivors who are taking medications in the shelter?
Open Doors
An Inclusive Service Model
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Module 11
STARTING THE CONVERSATION AND
SAFETY PLANNING FOR MENTAL WELLNESS
Open Doors
An Inclusive Service Model
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I wanted to drink and use that day
because of what was going on in my life
and I was honest with [the support
worker]… but if you are honest and tell
them this is what is going on … [they tell
you to] get out of here.
- Woman in Women Abuse Response Program Groups
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An Inclusive Service Model
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Starting the conversation
• Women are often reluctant to talk about their
mental health for many reasons.
• What might some of these reasons be?
• With these in mind, how can we start the
conversation?
Open Doors
An Inclusive Service Model
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Responding to disclosure
• Acknowledge the trust it takes to disclose.
• Affirm autonomy and support her in making
her own decisions.
• Ask about her needs and how to support her.
• Be curious about what does mental illness or
substance use means to her.
Open Doors
An Inclusive Service Model
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Safety planning for mental wellness
• How can we tell if she is experiencing
symptoms?
• What can we do to support her when she is
experiencing symptoms?
• Does she see her mental wellness connected
to her experiences with violence?
Open Doors
An Inclusive Service Model
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Module 12
SUPPORTING WOMEN WHO EXPERIENCE
MENTAL ILLNESS SYMPTOMS
Open Doors
An Inclusive Service Model
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Depressive symptoms
• What are some of the indicators of
“depression”?
• How may some of the depressive symptoms
bump up against the house rules?
Open Doors
An Inclusive Service Model
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Supporting women
who are feeling ‘depressed’
•
•
•
•
•
•
Active listening
Ask her how she would like to be supported
Assess harm and/or suicide risk
Check our own bias & assumptions
Validate and normalize her feelings
Ask her to rate her mood on a scale of 1 to 10
to help gauge her feelings
Open Doors
An Inclusive Service Model
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Practical tools
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•
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•
•
•
Keep a mood journey/diary
Divide up the day – check list & routines
Set realistic goals & ask for help
Identify thinking patterns that are not helpful
Set aside time for self care
Explore how negative thoughts may be tied to
the abuse
Open Doors
An Inclusive Service Model
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Anxiety
• What are the signs and symptoms of anxiety?
• How may anxiety symptoms show up as a
challenge in the work?
Open Doors
An Inclusive Service Model
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Supporting women
who are feeling anxious
• Active listening
• Validate and normalize feelings of anxiety
• Plan and/or remind the woman about her
safety plans
• Share practical and accurate information such
as protection orders, court procedures, child
protection act, etc.
Open Doors
An Inclusive Service Model
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Practical tools
•
•
•
•
•
Identify triggers
Breathing & grounding exercises
Practice relaxation
Coping statements
Replacing negative thoughts with realistic
statements
Open Doors
An Inclusive Service Model
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Psychotic disorders
• Schizophrenia is the most common type of
psychotic disorders.
• Psychotic break - lose touch with reality and
sometimes makes it difficult for people to
think and speak in an organized way
• Delusion – thoughts and beliefs that cannot
be true.
• Hallucination – experiences things that are
not there, can be any of our senses
Open Doors
An Inclusive Service Model
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Supporting women with
psychotic disorders
Responding to a psychotic break:
• Reduce distractions (i.e. TV, radio, people)
• DO NOT confirm or argue about
hallucinations/delusions
• Instead, state what you can observe
o i.e. I can see that you are really upset/ scared/
frightened.
Open Doors
An Inclusive Service Model
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Safety planning with women with
psychotic disorders
• Be transparent about policies and behaviours
to help reduce paranoia.
• Check for self-harm or thoughts of suicide.
• Identify triggers & early warning signs and
know how to deal with them.
Open Doors
An Inclusive Service Model
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Practical tools
• Daily journal to keep track of triggers & early
warning signs
• Create a safety plan and let others know how
to help you during an episode
• Identify support person(s) to do reality check
with and reach out when feeling unsafe
• Reduce substance use
• Seek medical support
Open Doors
An Inclusive Service Model
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Module 13
SUPPORTING WOMEN WHO SELF-HARM
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An Inclusive Service Model
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Self harm
• Express and/or deal with emotional pain.
• Deal with overwhelming feeling of emptiness
or numbness.
• Self-punish
• To regain control of their body.
• To cope and avoid suicide.
• Self harm can look very different between
people.
Open Doors
An Inclusive Service Model
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Supporting women who self harm
•
•
•
•
Active listening
Create a safe space to talk about self harm
Be patient and non-judgemental
Ask the women how self harm is useful for her
and normalize the feelings
• Explore and encourage other coping
mechanisms
Open Doors
An Inclusive Service Model
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Module 14
SUPPORTING WOMEN WITH
SUICIDE IDEATION
Open Doors
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Suicide
•
•
•
•
It is about ending the pain.
Overwhelming sense of no other way out.
It has to be taken seriously every time.
What are some signs that a person may be
thinking about suicide?
Open Doors
An Inclusive Service Model
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Changing how we talk
about suicide
• “Committed” is used to describe criminal
offence. Not long ago suicide was also
considered a criminal offense.
• “Attempt” suggests suicide that does not
result in death is a “failure.”
• Use “completed suicide” or “ uncompleted
suicide”
Open Doors
An Inclusive Service Model
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Starting the conversation
• What may be some of the ways you can begin
the conversation about suicide?
• When would be a good time to talk about it?
• What are some of ways you can prepare
yourself for the conversation?
Open Doors
An Inclusive Service Model
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Risk assessment
• Are you thinking about suicide/killing
yourself?
• Do you have a plan? What is it?
• When are you planning to do it?
• Do you have the means to carry out the plan
(i.e. have the pills/knife)?
• Have you thought about this before? If so,
what stopped you from doing it? What
happened?
Open Doors
An Inclusive Service Model
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Practical tools
•
•
•
•
•
•
Create a contract with someone you trust
Reminders for reasons to live
Future planning
Keep a “grateful” diary
Positive self talk
Call the crisis line
Open Doors
An Inclusive Service Model
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Module 15
SUBSTANCE USE AND VIOLENCE
Open Doors
An Inclusive Service Model
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Remember – no one expects you to be a drug and
alcohol expert – you just need to be able and willing
to have conversations with women about their
substance use and relate these conversations to the
risks women are exposed to, their safety and
ongoing physical, mental, emotional and spiritual
needs.
- Tessa Parkes, Freedom From Violence Toolkit
Open Doors
An Inclusive Service Model
-- Participant Slides --
Violence and Substance use
• Why might women use substances?
• How could substance use be exploited by
abusers?
• How might we incorporate this knowledge
into our work?
Open Doors
An Inclusive Service Model
-- Participant Slides --
How do abusers exploit substances?
• Encourage or forced substance use to develop
dependency
• Shame her for substance use
• Threaten to report her as unfit mother
• Withhold substances and force her into
withdrawal
• Use substances to alter her mental wellness
Open Doors
An Inclusive Service Model
-- Participant Slides --
How do survivors use substances?
•
•
•
•
•
Cope with effects of trauma
Self medicate for mental health issues
Numb or escape temporary from pain
Appease the abuser
Cope with chaotic lifestyle (e.g. use before
engaging with survival sex work)
• Control withdrawal symptoms
Open Doors
An Inclusive Service Model
-- Participant Slides --
Spectrum of substance use
Beneficial use
• Use that has
positive health,
spiritual or social
impact
Casual/Nonproblematic use
• Recreational,
casual or other use
that has negligible
health or social
effects
Problematic use
Dependence
• Use that begins to
have negative
consequences for
individual,
friends/family or
society
• Use that has
become habitual
and compulsive
despite negative
health and social
effects
(Adapted from Health Officers Council of British Columbia, 2005)
Open Doors
An Inclusive Service Model
-- Participant Slides --
Think-Pair-Share
• What are some of the coping
mechanisms you use?
• Are any of them healthier than
others?
• Are any of them more easily
accessible than others?
• How hard would it be to give
any of them up tomorrow?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Risks of stopping substance use
• Cut back or stopping substance use may put
women at risk through:
o Increased violence from abuser
o Absence of other coping mechanisms
o Severe withdrawal
o Intense emotional reactions
o Mental health illness symptoms
o Termination of services (i.e. doctor refuses to see
the woman anymore)
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 16
UNDERSTANDING SUBSTANCE USE
Open Doors
An Inclusive Service Model
-- Participant Slides --
The Rat Park experiment
• How does dependence on substances
develop?
• Are you surprised about the findings?
• What are the ‘cages’ in real life?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Zero-tolerance
• What are we ACTUALLY asking from women
when we say we have ‘zero-tolerance’ for
substance use?
• Women who use substances are already
accessing transition houses and they will
continue to do so.
• Shifting the focus on how to make their
experience more positive.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Assumptions about substance use
• What are some of the
assumptions we may
have of people that use
substances?
• Are some substances
more acceptable than
others?
• Where do those ideas
come from?
Open Doors
An Inclusive Service Model
-- Participant Slides --
What are substances?
Legal
• Coffee
• Alcohol
• Tobacco
• Over the counter drugs
• Prescription drugs
• Methadone, methadose &
Suboxone
• Medical marijuana
Illegal
• Marijuana
• Cocaine
• Heroin
• Crystal Meth
• Ecstasy
 What social values may be
attached to the legality of
the substance?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Open Doors
An Inclusive Service Model
-- Participant Slides --
Types of substances
Depressants
• Slowing down of the central
nervous system
• Low dose – feeling of calm,
drowsiness and well-being
• Higher dose – intoxication,
unconsciousness, coma and
death
Stimulants
• Excite or speed up the
central nervous system
• Low dose – feeling alert and
awake, decrease appetite,
feeling euphoric and sense
of well-being
• Higher dose – Irritability,
paranoia, agitation, rapid
/irregular heart rate, and
delirium
Open Doors
An Inclusive Service Model
-- Participant Slides --
Types of substances
Hallucinogens
• “Psychedelic” drugs
• Distort the senses and can
cause hallucinations and
confusions
• Can cause “bad trips”
similar to nightmares
Cannabis
• Most widely used illegal
drug
• Has both properties as
hallucinogens and
depressants
Open Doors
An Inclusive Service Model
-- Participant Slides --
Video: Safe for All
• What are the messages this video is trying to
convey to the viewers?
• How did the video response to the following
arguments to exclude women who use
substances?
o It’s for the safety of the other women and children.
o If she choose that lifestyle, she is not ready for
healing.
o Having harm reduction supplies available will
encourage drug use.
o She is not being “productive” or working on her goals.
Video is produced by the Ontario Association of Interval & Transition Houses
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 17
SUPPORTING WOMEN WHO USE
SUBSTANCE AND SAFETY PLANNING
Open Doors
An Inclusive Service Model
-- Participant Slides --
Some signs of intoxication
•
•
•
•
•
•
Slurred or rapid speech
Difficulty focusing
Grumpy & irritable
Anxious
Mood swings
Unable to sleep or
sleepy all the time
•
•
•
•
•
•
No appetite
Aggressive or angry
Paranoia & suspicious
Grandiose thinking
Sudden movements
Flat affects
Open Doors
An Inclusive Service Model
-- Participant Slides --
Supporting women who are intoxicated
• Create a safe environment.
• Be patient and non-judgemental.
• Consider having harm reduction supplies (e.g.
clean needles, crack pipes, sharp boxes)
available.
• Offer her food and water.
• Normalize the use of substances at this time
and identify potential safety concerns.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Some useful questions
•
•
•
•
•
What do you use?
What is/is not an issue for you?
What does substance use mean for you?
How do you use it?
Are there any harm reduction practices you
are using?
• Does substance use affect your safety?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Brainstorm!
•
•
•
•
What to do the next day?
What are your current practices?
What are the goals of your current practices?
Are there any unintentional consequences?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Some signs of withdrawal
• Sweaty, hot and then
cold, goosebumps
• Grumpy & irritable
• Anxious
• Tired/lethargic
• Mood swings
• Unable to sleep or
sleepy all the time
•
•
•
•
•
•
•
Aggressive or angry
Aches & pains
Trouble concentrating
Tense muscles
Upset stomach
Cravings
Paranoia & suspicious
Open Doors
An Inclusive Service Model
-- Participant Slides --
Understanding withdrawal
• Withdrawal from some substances can be very
dangerous and may require medical
interventions.
• Withdrawal can be very painful physically.
• Length can vary from hours to days.
• Most vulnerable time to use again.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Supporting women in withdrawal
• Keep her as comfortable as possible.
o Food & water
o Quiet room with dimmed light
o Warm blankets
• Remind her why she wants to stop using in the
first place.
• Be patient and non-judgemental.
• Call for help if required.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Some signs of overdose
• Breathing rapidly,
erratic or stopping
completely
• Heart rate is rapid,
erratic or very slow
• Nausea and vomiting
• Shaking
• Seizures
• Unable to talk/
incoherent
• Drifting in and out
• Unconscious
• Limp body or rigid
muscles
• Change in body
temperature
Open Doors
An Inclusive Service Model
-- Participant Slides --
Supporting women who are overdosing
• Call for help – ask someone to call 911.
• Talk to the woman and let her know you are
here to help her.
• Ask her (if you can) what she has taken.
• AVOID giving her food and water.
• Have her sit on the ground or lie in recovery
position until help arrives.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Policies for substances
• What are your current policies for substances?
• When and how do you discuss drug policy
with the women?
• Is there a different policy for smoking tobacco
and prescription marijuana?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Safety planning for substance use
• Ask about previous experiences on cutting
back or stopping use.
• Discuss withdrawal symptoms that are
dangerous and plans for addressing them.
• Discuss harm reduction supplies and practices.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Harm Reduction Resources
• Toward the Heart:
http://towardtheheart.com/
• BC Harm Reduction Strategies and Services:
http://www.bccdc.ca/prevention/HarmReduct
ion/default.htm
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 18
RECORD MANAGEMENT
CASE NOTES
Open Doors
An Inclusive Service Model
-- Participant Slides --
Records Can Include:
• Intake forms and
demographic data
• Informed consent form
• Release of Information
forms
• Service plans
• Case Notes
• Third party reports if
necessary
• Correspondence
regarding women/child
if necessary
• Court and legal
documents
• Referrals
• Safety plans
• Closing report
Open Doors
An Inclusive Service Model
-- Participant Slides --
Benefits of record keeping
Documents that you have informed consent
Documents that the limitations of
confidentiality have been explained.
Supports accountability.
Helps develop and implement a safety plan.
Helps with consistency of service.
Risks - any records we make can be
subpoenaed and potentially be used against
her interests and for the abuser.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Privacy Principles
• Safety, confidentiality, privacy and well-being
of women and children is primary.
• Women and children have the right to be
informed of services, documentation process
and have access to their records.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Agencies Should:
• Determine what privacy legislation guides your
agency’s record keeping practices: PIPEDA, PIPA,
FIOPPA
• Develop a privacy policy and have a privacy officer.
• Determine the scope of the information for collection.
• Decide if you are going to keep files or not.
• Set limits on the use of the information you have
collected.
• Provide women/child access to their records.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Agencies Should:
• Develop standard retention and destruction process.
o How long will you keep the records for and why?
o How will you destroy them in a secure way?
o Schedule a set time to go through and destroy unneeded
records.
• Only disclose to board members in exceptional
circumstances.
o ED can provide Board with general overview of any incidence
of crisis.
o Board members who support staff for supervision may need
access or information.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Agencies Should:
• Develop clear system of sharing information within the
agency.
o Do you have a “Consent to Sharing Information” policy?
• Determine who needs to have access to records in
order to carry out their work.
o Tiered system access to records
• Keep online and paper records secure.
o How do you make sure that only the authorized persons can
access the records?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Consent
• Obtain consent (written/oral) for collecting,
using and disclosing personal information.
• If the woman/child has not consented to
release their personal information, do not
disclose it unless there is a legal obligation to
release.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Before obtaining consent
•
•
•
•
•
•
Explain services, the benefits and risks of care.
Satisfy yourself that woman/child understands
what they are consenting to.
Make reasonable effort to determine that the
care is in best interests of the child/woman.
Ensure the consent is voluntary.
Inform woman/child about limits to
confidentiality at the time they request service.
Explain the records management practice.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Before recording information,
ask yourself:
• What is the purpose of collecting the
information?
• Is this information necessary to
deliver/determine services?
• Will what I write improve services for her?
• Is this fact based?
• What will I do with this information?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Before recording information,
ask yourself:
• Could the information I collect be harmful to
the woman and her children in terms of:
o Her access to services?
o Current or future legal actions?
o Being accessed by a third party (e.g. the abuser,
her employer, other family members)?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Content of File Notes
• Develop a common format and write legibly.
• Session-by-session basis, up to date, dated.
• Only include information that is necessary to
deliver services or is needed by other staff.
• Consider flagging entries with legal
significance.
• Indicate information provided by a third party
and consider whether it is necessary to be
included in the file.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Content of File Notes
• Files are not meant to document historical or
legal facts.
• Counselling records contain observations (not
speculation).
• Make objective notes about the session.
• Language used should reflect her experience.
• Be brief: note major topic areas discussed.
• Avoid verbatim accounts.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Information Sharing
• Determine if collaborating with other
programs will increase her (child’s) safety.
• Include her in the process of sharing her
information.
• Balance the need for confidentiality and
impact of retelling the story.
• Release of Information form.
• How do you determine what information
needs to be shared?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 19
SUPPORTING MOTHERS
Open Doors
An Inclusive Service Model
-- Participant Slides --
Open Doors
An Inclusive Service Model
-- Participant Slides --
Open Doors
An Inclusive Service Model
-- Participant Slides --
Supporting mothers
• Protecting and supporting mothers is one of the
more effective ways to protect and support
children.
• Using substance or struggling with mental
wellness do not automatically means she is not a
good parent.
o She has a glass of wine after she put the kids to sleep.
o She sends her kids to school, comes home and sleeps
until she needs to pick them up.
Open Doors
An Inclusive Service Model
-- Participant Slides --
She is good enough
• Tremendous pressure on mothers to be
perfect.
• Working with her from her strength.
• Collaborate with her and support her:
o Child care
o Harm reduction supplies and practices
o Accurate information
o Referrals and connecting to community services
Open Doors
An Inclusive Service Model
-- Participant Slides --
Pregnancy and substance use
• Many women will be reluctant to access
healthcare for themselves or their children
because of fears that they will be judged,
treated poorly, or lose custody of their
children.
• Stigmatizing her substance use negates the
other determinants of health, focussing the
"blame" solely on the woman and erasing the
systems of oppression.
Open Doors
An Inclusive Service Model
-- Participant Slides --
If child protection is needed…
• Follow your program’s policies, procedures
and practices for engaging with child
protection agency.
• Whenever possible, speak to the women first
and talk about your concerns for her children.
• Encourage her to make contact herself.
• Provide support through the process if she
wants you to do so.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 20
REVISITING HOUSE RULES,
ELIGIBILITY AND INTAKE
Open Doors
An Inclusive Service Model
-- Participant Slides --
Let’s take a closer look at house ‘rules’
• House rules may have good intentions but
they may become barriers for women.
• Rules may be enforced inconsistently
depending on the worker.
• House rules may also reinforce the dominant
assumed “norm” and shame or punish those
who do not fall within that category.
• Consider switching to the language of
‘guidelines’…
Open Doors
An Inclusive Service Model
-- Participant Slides --
Source: The North West
Territories Health and Social
Services
Invisibility of these
cultural practices which
allows them to be subtle
and hidden because they
are no longer questioned.
Staff Belief that her own
cultural practices are
better and more desirable
than others.
Systemic
Oppression
within a
Transition
House
Formally: appearance of the ‘better
and more desirable’ cultural
practices in organizations, laws,
programs and policies.
Informally: those whose practices
are different are judged and
criticized.
Staff Belief that other
cultural practices are not
as good as her own.
Staff has the power to influence
others and impose their beliefs
on other people.
Open Doors
An Inclusive Service Model
-- Participant Slides --
Source: The North West
Territories Health and Social
Services
Dish washing directly
after eating is ‘just the
way it is’ – assumed this is
the best way to do things
with no questioning why
or if the rule is really
necessary.
Worker believes washing
the dishes is best done
right after eating.
Example: The
curious case
of the dish
washing rule
Formally - Directive to wash dishes
directly after eating is put into
house rules and will result in a
formal warning if not followed.
Informally – women who do not
wash their dishes directly after
eating seen as lazy.
Worker believes not
washing dishes right after
eating is a sign of
laziness.
Worker persuades other staff &
managers about need to make
sure women are cleaning their
dishes directly after eating.
Open Doors
An Inclusive Service Model
-- Participant Slides --
House rules & guidelines
• Does this guideline benefit women or increase
barriers for women we are supporting?
• Does this guideline reflect the Foundational
Principles?
• How might you review your policies,
procedures and practices for barriers or
systemic oppression?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Critical Incident reporting
• A critical incident is a serious or unusual
event.
• Powerful tool to help us review policy and
prevent similar incidents.
• Identify follow-up procedures and increase
safety.
• What is the current practice for critical
incident reporting?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Eligibility and suitability
• Eligibility:
o Has the woman experienced violence?
• Suitability:
o Does the woman feel your program is a good fit
for her?
o Can our program accommodate the woman (and
her children) at this moment?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Intake
• What information do we need immediately?
• Are there any questions you can ask after the
woman arrived?
• How does the information change the way we
provide services to a woman?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 21
DEBRIEFING PRACTICES
Open Doors
An Inclusive Service Model
-- Participant Slides --
Reality & challenges for staff
•
•
•
•
•
•
Single-staff shifts/understaffed
Lack of crossover times
Limited rooms/spaces
Concerns for other residents
No clear guidelines/policies
Lack of training and professional development
Open Doors
An Inclusive Service Model
-- Participant Slides --
Supporting Each Other
• We may not approach each situation exactly
the same way.
• Conflicts can be an opportunity for creative
problem solving.
• Part of the learning process and consciousness
raising for ourselves and colleagues
Open Doors
An Inclusive Service Model
-- Participant Slides --
How our feelings influence our work
• What may influence how we feel about a
particular resident?
• What are some of the ways that have been
useful for you to keep your feelings from
influencing your interaction with a resident?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Venting is not debriefing
• It is natural to "vent" our negative feelings
about a woman with coworkers.
• Justify our feelings rather than challenge our
feelings, learn, grow and make conscious
choices to improve our practices.
• Reflecting on our frustration can lead us to
“what is going on?” and steer us away from
“what is wrong with her?”
Open Doors
An Inclusive Service Model
-- Participant Slides --
Debriefing practice
• Steps of debriefing:
1.
2.
3.
4.
Venting
Personal Context/Reframing
Social Context
Action
Open Doors
An Inclusive Service Model
-- Participant Slides --
Debriefing practice
• Venting:
o Very important and the first step to debriefing – but
not the only step.
o As the listener, ask your coworker if they would prefer
you listen in silence or listen actively.
• Personal Context/Reframing
o Ask your coworker what she thinks might be
happening for the resident she is debriefing about.
o Changing the narrative from “What’s wrong with
her?” to “What’s happening for her?”.
o Reframing any assumptions you might have heard in
the venting stage
Open Doors
An Inclusive Service Model
-- Participant Slides --
Debriefing practice
• Social Context:
o Move from the personal feelings into the
social/political context
o Recognizing and naming the social injustice that
contribute to the woman’s response
• Action:
o Consider together what, if anything, could have made
the experience of working with the resident(s)
different for your coworker. What got in the way of a
better experience? This is the most important step in
the process for both your coworker and for bringing
social change
Open Doors
An Inclusive Service Model
-- Participant Slides --
Making time & space for debriefing
• It can be very tricky to find the time and space
for debriefing.
• Useful to have a debrief when feelings like
these creep up:
o She doesn’t deserve X
o She’s too demanding
o She’s unappreciative
• What is the current practice for debriefing?
Open Doors
An Inclusive Service Model
-- Participant Slides --
Module 22
APPLYING FOUNDATIONAL PRINCIPLES
AND REVISITING POLICIES
Open Doors
An Inclusive Service Model
-- Participant Slides --
Foundations Principles for supporting women
Holistic &
Integrated
Harm
Reduction
WomanCentred
Relational
AntiOppression
Responsive
Adapted from Reducing Barriers to Support for Women Fleeing Violence: A Toolkit for Supporting Women with
Varying Levels of Mental Wellness and Substance Use (BC Society of Transition Houses, 2011)
Open Doors
An Inclusive Service Model
-- Participant Slides --
Procedure and practice review
• Policies and procedures should be seen as
living documents
• Review, adapt and update regularly
What is
water?
Open Doors
An Inclusive Service Model