Mental Health and Substance Use Coercion Results of Two National Surveys

Everyone, we're going to go ahead and get started. Thank you all so much for joining us today. My name is Aaron Tinan with the National Center on Domestic Violence, Trauma, and Mental Health. Today's webinar is Mental Health and Substance Use Coercion: Results of Two National Surveys and Implications for Practice. We're excited to present this webinar today in collaboration with the National Domestic Violence Hotline.

Our trainers today will be Carol Warshaw, MD, director of the National Center on Domestic Violence, Trauma, and Mental Health; Shean Abraham, assistant director of Hot Services at the National Domestic Violence Hotline; Eleanor Lion, PhD, senior research consultant with the National Center; and Rachel White, JD, project manager with the National Center.

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Contact Aaron. Your sound is breaking up. Oh, man. Okay. Um, can you all hear me a little bit now? No. I think it's... Do you want me to go ahead and finish? Yep, go ahead. Thanks, Jen. Sorry, everyone. Okay, sorry. We've been having multiple technical difficulties today. So, um, on the right-hand side of the screen, there are multiple boxes. The second from the top is the chat feature. This feature will allow you to provide feedback and share resources with your fellow colleagues, as well as get in touch with the trainers or myself if you have questions regarding the training. Contact. You may contact me, Jennifer Curley, if you have any questions troubleshooting the WebEx software. To do this, click the down-facing arrow and select the person you would like to contact. You will see a lot of options for this session. You will want to select "all participants" if you would like to respond to a question from the trainer or contact me anytime during the session.

So, let's test this chat feature. Will everyone please go to the chat box, click "all participants," type in the program you were calling from, and then press enter? Great. Thanks so much. While folks can get a lot of the chat feature, there are times when it moves really quickly and can feel distracting, like it is now. If this is true for you, you can feel free to minimize the chat box by clicking the arrow next to where it says "chat." You can always open it again with the same arrow if you choose. We will be providing live captioning during this webinar. Below the chat box, there's a media viewer box. This will contain the captions. If you do not want to see the captions, click on the down-facing arrow next to the word "media viewer," the same way you might if you were to hide the chat box. At the end of the webinar, you will be taken to a brief evaluation. Please take a moment to let us know what was useful and what could have been better. If you get disconnected at any time, return to the email you received with the original webinar link and re-enter the training. Sometimes the sound cuts out due to internet connection, so feel free to call in if that is a problem for you. If you are experiencing technical difficulties or unable to contact me, Jennifer Curley, you may also contact WebEx Tech Support to resolve any issues. That phone number, which Aaron will post in the chat, is 1-866-229-3239. Again, thank you for joining us today, and we will now turn the training over to Carol.

Welcome. So, I'm Carol. We're really excited to be presenting this webinar today and to present the results of this important survey that was conducted by the National Domestic Violence Hotline that has really important implications for survivors of domestic violence and their children, and for all of us who work with survivors, for all the systems with which survivors and their children interact. So, let me move this forward.

So, the objectives today are to review the results of the two focused surveys on survivors' experiences of mental health and substance use coercion that were conducted by the National DV Hotline, and to talk about the implications for survivors in all of the systems that survivors seek help and redress.

So, why study these issues? We know that abuse and violence play a critical role in both the development and exacerbation of mental health and substance use disorders. And I think we're well aware of the kind of wealth of research on the traumatic effects of abuse and violence on all of our health and mental health and well-being. At the same time, there's been less research on why experiencing the traumatic effects of abuse or a substance abuse condition or a mental health condition actually places women at greater risk for being controlled by an abusive partner. And that's part of what we really want to talk about today.

One of the things that we think about is, you know, why does this work? We often think that if someone is experiencing traumatic effects of abuse or a mental health or substance use condition, that they may be more vulnerable to being abused by a partner. How many of you have thought this at some point in time? I know, I think I used to even use that language. But part of what we want to do is shift our understanding. Are we talking about the impact of abuse, or the effects of ongoing coercive and controlling behavior by an abusive partner that's deliberately designed to undermine our mental health and well-being? So, it's shifting the focus and the balance of how we think about these things.

So, we know that batterers, people who abuse their partners, use mental health and substance abuse issues to control their partners. And there are lots of ways they do this. Controlling medication, forcing a survivor to take an overdose and then having them committed, and then threatening to use that as a way to gain custody of their children, trying to control treatment, lots of ways of understanding sanity and credibility, parenting. And one of the things that we've heard a lot about was abusive partners saying, "She was out of control, and I had to restrain her," and using that as justification for choking or strangulation. So, we know that this works in large part because of stigma. Because abusers can get away with this because they are seen as more credible and they look better put together than the person that they've been abusing for years. So, knowing all of this was part of what motivated us to do these studies.

So, now I'm going to turn it over to Eleanor to talk about some research.

Hi, everyone. As the research part of this team, I'm going to be talking about the survey results. But just to let you know what our objectives were, we knew we had a hunch based on our experience that this was going on. And so it was a wonderful partnership with the hotline to provide us with an opportunity to learn more about how often this occurred among survivors who called the hotline. And that once we had that information, we wanted to be able to raise awareness about this particular form, these particular forms of coercion, and then working with advocates and others in the field to develop strategies for incorporating questions that address this form of coercion into assessments, as well as developing interventions for responding to it.

Carol, oh, okay. We do the... I think we're... we haven't practiced handing control of the slides back and forth. So, one of the things about coercion and control is that from the very beginning of doing our work, it was kind of central to our understanding of what we thought of domestic violence as being. That it is a pattern that involves both various mechanisms of control and coercion. And obviously, we always understood that domestic violence was more than just physical violence, more than hitting. And yet, when we have tried to document that through research, we have found that most surveys don't include the other forms of coercion and control that we know are going on, except for these particular forms. Some, some degree of threats and intimidation. And the recent National Survey did measure that. We have some measures of psychological abuse, which include ridicule and humiliation. And then there are new measures of economic abuse and control that Chris Sullivan and her colleagues developed. And MaryAnn Dutton has been working on a more comprehensive measure of a wide range of different kinds of coercive control, but those have not been well integrated yet. And the specific measures of substance abuse and mental health coercion that we were interested in are not included in the same way. I think we all owe a debt to Evan Stark, who wrote the first explicit book laying out the various manifestations of coercive control. And yet, there are also some new measures of reproductive control. So, we're slowly expanding in this area and our knowledge. And we know that the impact of the various forms of coercion and control that we have relatively neglected and are just now beginning to pay attention to have been profound because when we work with survivors every day, we know that that's their experience.

You want to pass to Shean? I am. Yeah. Of course. So, so y'all, just to introduce myself again, my name is Shean Abraham, and I'm the assistant director here at the National Domestic Violence Hotline. I just want to give you a little bit of background as to what the National Domestic Violence Hotline does and is, and how we participated and helped in these surveys. So, just to give you a little bit of background of the work that the advocates do, I'd like to tell you what their base training is that they start with when they begin work as a hotline advocate. So, hotline advocates, they all go through an extensive, pretty intense, as well, 40-hour training. And they also receive 15 hours of phone training before they go live and solo on their phones and on their calls. So, after this 40-hour training, they come to the table understanding the abusive dynamics of intimidation, manipulation, and coercion. But we all know that domestic violence has so many intersections that involve various communities, as well as social issues, and that makes it necessary for advocacy to expand to meet callers where they are. So, while they had a lot of knowledge as their baseline starting point, the intersection and the overlap of mental health and substance use coercion definitely needed more fleshing out for them prior to the start of these surveys.

So, there were three different steps that had to be taken. One, the amazing women who you get to listen to speaking today provided our advocates with the training on these topics. Since we are a 24-hour operation, we had three different shifts: a daytime, an evening, and an overnight shift, who all needed to receive this training. And so the questions for the survey were then formulated, and we moved into a collaborative session where the questions were reviewed to ensure that the language is going to be clear and understood by the callers. And then before we were able to begin asking callers these questions, introductions that introduced the callers to this survey were about what they were about, and before we asked them to participate, were formulated and then translated into Spanish for our callers with Spanish-speaking preferences.

So, when we look at, like, if we break it down, so what we want to do is break down the skeleton of what the methodology was. So, who were we surveying? Right? Anyone who identified as a victim and survivor of domestic violence and was not currently in an immediate crisis were the participants at the hotline. We received calls from folks in varying degrees of crisis. So, if someone was experiencing a high crisis situation, they weren't going to be a candidate for this survey. How did we conduct this survey? So, our hotline calls can range anywhere from 15 minutes to 30 minutes to 45 minutes, depending on the level of lethality and crisis and the factors involved. So, after our advocates have completed their normal service portion of their hotline call, we would then ask the caller if they would be willing to participate in the surveys. And the callers were assured that their participation would be voluntary and anonymous. And once we received that consent after the service portion, we went into the surveys. And over the course, both of these surveys were performed over the course of a six-week period, in between February and March for the mental health coercion in 2012. And for the substance use coercion one, that happened from April to June in 2012.

So, the hotline, what we do, the hotline helps facilitate many surveys throughout the year that help various organizations collect data and information. So, being in the unique position of being the national hotline, we receive calls from all over the United States, the outer-lying territories, sometimes Canada, sometimes international calls. So, the questions, once formulated, will reach a pretty broad demographic of callers from all over the United States. Every survey is limited to five questions. The collaborative process is so important here. The ability for advocates to be able to review questions and ensure for the smoother flow from the service portion of the call into the surveys is critical. And in our next slide, our next two slides, you'll get to see an example of what these introductions look like.

See, so even though most of our advocates, when they are speaking with our callers, are actually having very intimate conversations with our callers, the information that callers offer to our advocates is ultimately something that serves them in finding peace and safety, or just having a safe place to turn to. So, when introducing survey topics that will benefit either a study or a survey in something external, it's really important to phrase introductions in a way that helps them know that we're coming from a place of understanding, non-judgment, and openness. So, our phrasing is very important. I'd like to read the first portion of this slide and the next slide so you can get a feel for how we try to accomplish that. So, you can see that when we're introducing topics, we're using certain phrasing that shows the caller that we understand that their partners are the ones that hold the responsibility of instigating these feelings in an effort to control them, or, you know, with substance abuse, that the caller might use alcohol or drugs as a way to cope with the abuse being inflicted on them, and that their partner may try to blame and humiliate and maintain their power over them by using the substances in a myriad of ways.

So, the first one for their substance use coercion, it just sounds very simple. "People who experience violence from their partners may use alcohol or drugs as a way to cope and deal with the abuse, and their partners may blame or humiliate them for doing so. Many times, people who call our hotline are dealing with a partner who is trying to maintain power and control in the relationship, and sometimes they might use substances as a way to maintain power and control. So, in order to understand how this affects our callers, we're doing a voluntary survey." So, that just kind of shows you how we flow from our service portion into the survey portion. For the mental health coercion survey, something that they heard was similar to, "People who experience violence by their partner can often feel like they're going crazy or losing their mind, or just lose hope and feel down all the time. And sometimes their partners may cause these feelings deliberately or use these feelings as a way to control them." So, so, so that just kind of shows you a little bit of the terminology and the phrasing that we used. And it was just very critical to us to make sure that the callers knew that we were coming from a place where we were on their side, and it was not finger-pointing or blaming or stigmatizing.

Sarah, can you transfer to Eleanor? I am. I'm trying to find Eleanor, and I can't find Eleanor, but I will try to file transfer it to you, Miss Carol. Oh, are you on, Carol? It looks like Eleanor is not on, so you should go ahead. Okay. All right. Well, so, I'm going to talk about Eleanor's part until she gets back on. So, the, the, we're going to talk first about the mental health coercion survey, and then the substance use coercion survey. And in the middle, we changed it from substance abuse to substance use coercion, partly because the DSM has changed. So, part of it, even when someone's using, regardless of whether it's creating a problem, something that an abusive partner can use against them. So, we wanted to broaden how we think about that.

So, the first survey was conducted between February 1st and March 14th in 2012. And you can see there's a large number of callers, over 2,200 adult female callers who identified as victims or survivors of domestic violence. And there were, Eleanor talked a little more, if she, if she's able to get back on, about the demographics. There were male callers, but the numbers were so small that statistically it wasn't helpful in analyzing the data. So, we limited it to just a female caller list for the analysis for our report.

So, the questions that we asked, the first two questions we asked about mental health coercion were, first, "What has your partner or ex-partner ever called you crazy or accused you of being crazy?" So, we're trying to get it just, trying to undermine people's sense of perceptions of themselves and their sanity and well-being. And you can see the numbers are extraordinarily high. It was over 86% of callers said that their partners did that. And then we asked about whether their partners did things that are like gaslighting. Oh, Eleanor, you're back. Do you want to take over? I'm going to give this to you. I'm on to the second question.

Carol, she's still not on the audio portion yet. She will be soon. Okay. So, "Do you think your partner or ex-partner has ever deliberately done things to make you feel like you're going crazy or losing your mind?" So, it was deliberately trying to undermine their partner's sanity and make them feel like they were going crazy. And you can see over close to three-quarters of callers who participated in the survey said that this was going on.

So, we, the advocates who participated, who conducted the survey, were wonderful about documenting things that survivors said when they were talking with them. And some of the things that people talked about their partners or ex-partners doing was telling friends and family that they were unstable, trying to control their other people's perceptions of them, trying to diagnose the survivor, telling her that she had bipolar disorder, she had, you know, often a list of disorders that they were the expert on, and trying to convince the person, the caller, survivor, that she had this diagnosis. Trying to convince police and doctors that the caller had a mental illness by, you know, some would call the police and the partner would say, "She's crazy. There's, you know, she's the one with the problem. Don't believe her. I was just protecting myself. I was trying to help keep her under control or restrain her from doing something dangerous." And they would do that with doctors. They would try to, if someone went to the emergency room or even coming to treatment, trying to convince the, you know, help provider that she was the problem. They'd also call her names, you know, calling her crazy and other kinds of stigmatized names. And then the gaslighting, which we mentioned. This is for those of you who aren't familiar with the term gaslighting. It comes from an Alfred Hitchcock movie where the person in the movie is deliberately trying to make the person drive the person crazy and make them feel like they were losing their mind. So, actually changing furniture. We've heard stories not from this study, but from New York State, of a woman who started hearing voices and tucked herself into a psych unit and decided to stay a little bit longer. And a friend of hers went to her house to try to get her some clothes. And when her friend went to the house, she turned up the thermostat because it was cold, and then she started hearing voices as well. So, I think those are, for those, many of us have heard lots of stories, but it's very chilling to think about the extent to which this is happening deliberately.

So, so this was a quote from one of the survey participants. "Because I have bipolar disorder, he uses that against me. He says I have micro-psychotic episodes and jokes that he'd like to use a Taser on me. He forces meds on me, and it works, but he calls me crazy and more. When I express anger, he jokes, 'Take more pills,' and then he flirts with my friends in front of me and then tells me that I'm being irrational."

So, Carol, are you back on? Yeah, I've been able to hear you the entire time, and it didn't show any sign I was not. So, I'm sorry. Okay. So, you can take over. Frantic. Okay. Well, this is really interesting. Okay. So, you've, yeah, you've just read that. So, now I am moving forward.

So, the next question that we asked, or the first question that we asked, was, "Has your partner or ex-partner ever threatened to report to authorities that you're crazy in order to keep you from getting something that you wanted?" And we found that 50% said yes. So, that was half of them. And I realized this is not the first question, so I'm just getting up to speed. So, a full half. This is really clear, overt manipulation, coercion, and control. So, there are a wide variety of things that participants reported. They reported threat to use medication in order to court, in order to influence custody. So, custody and protective orders were the two most common kinds of things that mental health coercion was used. One caller, for example, shared that her abusive partner was in charge of taking her to her doctor's appointments and picking up her medications, and that the abuser stopped doing that and then used that to file a protective order against the survivor, saying that she had stopped taking her medication and was dangerous. So, some, some of the forms of coercion that survivors reported in the course of these surveys were really quite dramatic and elaborate.

Here is another quote from a survey participant. "Like hitting that nail on the head. Of all the things he was doing to me, he told me that if I tried to leave, he was going to take the kids, and I'd be in the psych ward." So, quite devastating forms of mental health coercion.

Then we asked them if they tried to get help, and if they did, had their partner tried to prevent or discourage them from getting that help? So, these are the two questions. Over half had tried, had gone to see someone, and of those, nearly half said that their partner tried to interfere with their getting that help. Some callers who wanted to seek help faced a lot of different kinds of barriers, and they didn't have, like, they didn't have transportation, or they were financially unable to seek support. But there were clear patterns of batterers interfering with their ability to seek help. Some were afraid to seek help. Some did seek help and then weren't allowed to return, even if they hadn't disclosed the abuse. However, most survivors who were able to seek help did so without letting their partner know that they had done so.

I'm trying to advance the slide. Okay. So, these are some of the kinds of ways in which abusive partners interfered with treatment. They engaged in direct manipulation of treatment, as in trying to influence diagnosis, trying to have the survivor committed, blaming the survivor's mental health for problems that they were experiencing, or trying to control medication, preventing them from taking it, forcing them to overmedicate, stealing it, calling the survivor addicted. You have a polling question on your screen, I believe. And so I'm going to continue talking, but hope that you will respond to the polling questions.

So, this is one survey participant. "Tells me I'm crazy all the time, and I feel insane. I have horrible anxiety attacks, can't breathe. He accuses me of cheating and sleeping around. I weigh now, weigh 98 pounds, and he calls me fat. I have a daughter my mom has to take care of because I can't function." Other examples that callers revealed showed that on one occasion, a partner would go to a survivor's doctor and tell him that she needed medication. The doctor would tell the survivor that she didn't, and then the batterer would return to convince the doctor that she did. Another caller reported, "She has a bipolar disorder, and during a depressive episode, while she was highly medicated, her abuser maxed out the credit cards in her name, threw her out of the house, and divorced her." And other examples. Sometimes an abuser would encourage medication to further the abuser's own purposes, but other times would not allow them to take a medication. So, it depended on the situation. So, it might vary within an individual relationship from occasion to occasion. And another, another caller shared that her ex-partner prevented her from calling authorities a lot of times because he told her she was crazy and no one would believe her. She tried calling the police several times, and yet he was able to manipulate the police, and they didn't listen to her or protect her.

So, we see the results here. A lot of you didn't answer the question. I, there's a time limit, so, but of those who did, the majority, just sort of eyeballing this, say "all the time" or "often." So, clearly, you're experiencing this in your own work with survivors as well. We also asked how many tactics were used, because you could see that there were three that were really overt forms of manipulation and control, and we didn't count the last one, interfering with treatment, because that was with a much smaller percentage, only based on the little over half who actually sought help. So, it was possible to have zero or three as the maximum. And you can see here that 89% of the callers had experienced at least one of the tactics, and that two or three were by far the most common. And the more tactics the survivor had experienced, the more likely she was to seek help. One thing I should say is we're using "she" to refer to survivors. We did ask both male and female callers who were adults these questions, but the percentage of male respondents was only about 4%, and so we didn't include in this analysis.

We know that, sort of to quickly summarize, that mental health coercion has, and it's clearly seen in the kinds of examples that you saw, as well as the responses, is the impact is to isolate the survivor from support, whether it's formal or informal. Has an impact on relationships with children, as well as with family and friends. Can enhance or lead a survivor to feeling depressed, anxious, even suicidal. And limits access to medication and treatment. So, and that's where I was expecting the poll to appear. I don't know whether it's possible to reopen it or not, but I'm going to continue.

So, for the substance use coercion survey, we had over 3,000, again, adult female callers who identified as survivors. And we know, partly and importantly, from the work of our former colleague Patty Bland, whom we still miss quite dearly, that there's such a range of ways in which abusive partners can use substances to exert coercion and control over survivors. These are all of the range of different kinds of ways in which abusers may do that. Some of the ones that we did not talk about, we did not ask about, include coercing a partner to engage in illegal acts, such as dealing or stealing, prostitution. It's not uncommon for survivors to find themselves holding drugs and getting arrested while their partners who are more actively engaged in dealing escape detection. So, that's a particularly important one that we did not ask in the surveys. But we, although we recognize that there are these kinds of forms of manipulation and control, we often forget. And again, we didn't measure all of them. But let's turn to the results.

And you can see that the poll question about substance use coercion is on the screen. But let's talk about the different other questions that we asked and other forms that it takes before moving on. So, we asked, "Has your partner or ex-partner ever pressured or forced you to use alcohol or drugs, or made you use more than you wanted?" 27% said yes. In response to our question, we believe that this is an undercount. They have no way of establishing that, but particularly with regard to potentially admitting to illegal substances, that's even with the assurance of confidentiality, can be a risky thing to admit. So, we think that this could is likely to be an undercount. Still, a substantial number said yes. And when they talked about it, they reported being pressured to use. Some were able to refuse, others were not, because of manipulation or threats. They might be forced to watch their partner use, or actually be drugged through injection, through putting substances in drinks, other things. So, there were a continuum of experiences, all happening in the context of power and control in the relationship.

One participant reported that her partner would order alcohol at restaurants and tell her if she didn't drink it, he wouldn't pay for the meal, which she couldn't afford to pay for. Another one reported that she doesn't remember an entire week because he drugged her with ketamine and kept feeding her more every two hours for a week, and then he told everyone she was crazy and pretended to be the supportive, heroic husband with the "crazy wife on drugs." Another caller really seemed to resonate with this survey. She shared that after she went into rehab, he would force her to watch and help him use. She became addicted again and got kicked out of college. Eventually, she relocated to another state but still relied on him. So, it took a lot of different forms. And this is just the being forced or pressured to use or use more than they wanted.

The second question, at a higher rate of positive response, they said that their partner or ex-partner threatened to report their alcohol or other drug use to someone in authority to keep them from getting something they wanted or needed. So, nearly 38% said yes in response to this question. One participant shared that she became addicted to opiates that her partner had forced on her. She was prescribed medication to get off the drugs, but her partner would claim that she was selling her prescriptions instead of using them, and he threatened to tell the judge that. So, they go to some fairly extreme lengths.

Next question: "Have you ever been afraid to call the police because your partner said that they wouldn't believe you or that you would be arrested for being under the influence?" And again, a quarter said that. One caller shared, "I'm very scared of calling the police because he lied before, and I got in trouble last time, and I didn't even do it." Another caller reported that she tried calling the police after her abuser hurt her, but disconnected after he threatened to show the police where she keeps her marijuana and pipes. So, clearly using this against them. So, interfering with their ability to get other kinds of at least legal or other authoritative help.

Participants reported that their abusive partners threatened to report to officials, made false allegations, and reported current and/or past substance use. One participant said, "I was afraid to call social services because he'd throw up in my face that I used to smoke pot. Even now, it scares me because I've never had a good relationship with social services." Another participant shared that her partner threatened to call child protective services and tell authorities about smoking weed to get her children taken away. Another caller reported her ex-partner would drug or drink and then call the police and say she was using. She reported that she had never used drugs voluntarily, but was afraid to call the police because he'd say she was using. And finally, another shared that her ex-partner has told her that no one will believe her because she sounds like she's on drugs. Her ex-partner has made up stories to protective services that she was using drugs around her children. She said she's never used drugs, except that she has used alcohol to cope.

Which gets us to our next question: "Have you ever used alcohol or other drugs as a way to reduce the pain?" And over a quarter said yes. One caller said that she was suicidal because of the physical and emotional abuse. During the past 10 years, she's been using prescription drugs to cope, and he's been stopping her from going to counseling to get help and support. Another shared, "If I knew he was coming over, I'd have a drink and a Xanax for anxiety. I'd feel nervous." Another disclosed that she takes more like about a double dose of a prescription medicine than she is prescribed to in order to tune out the abuse. So, clearly a pattern in a range of ways.

Then we asked if they had ever tried to get help. 15% said yes, and of those, over half said that their partners had tried to prevent or discourage them from getting that help, which clearly... Never mind. Here's a survey participant who said, "He threatened countless times to call the sheriff and the pastors and report my drinking. Discouraged me from getting help. After I got help, when I drank again, he would say, 'See, you failed at this too,' and he'd leave bottles all around when I was in recovery." So, lots of different ways to sabotage someone's potential recovery. Other forms that it took: they were not allowed to attend meetings, withholding transportation or other resources to get treatment, and sort of throwing substance use in their face, keeping them in the home visibly consuming them.

We asked how many kinds and how many tactics. We figured we tallied that, and 43% said they had at least one. Of those who reported having at least one, almost 60% reported more than one. And again, as with the mental health coercion study, the more reported, the more likely they were to have sought help. The final thing that we wanted to point out about this particular survey was that we found a common pattern of a connection between use coercion and sexual violence. So, they were pressured to use, and then that was connected to forced sex. They were assaulted when they were passed out, or their partners used the substance to justify any kind of sexual behavior. So, one shared that her partner convinced her to drink because, quote, "the sex life was better when she drank," and her partner also convinced her to switch sexual partners when she was drinking. Another caller reported drinking to escape from him and then being assaulted when she was passed out. And another said that her partner just said that, well, if she's drunk, she doesn't deserve to be treated any better.

So, I'm hoping that we have some responses to the poll. And we do. And what we find is that this, although more than half of you didn't answer, of those who did, more than half said that this happened "all the time" or "often" in your experience. So, we're clearly talking about something that is part of your experience in your work. And I am trying to pass this back to Carol now, and I'm not having any success. There we go.

Okay. So, we're going to skip the poll. So, I wanted to just take a minute to ask everyone to take a moment to breathe and think about, and think about ways that hearing all of these really awful and compelling stories may be affecting us, and think about, you know, what it's like for survivors who are experiencing this, and if we're going to be in the hotline callers who are now asking questions about this, and where we need to be to be able to hear this from people so we can respond in the ways that we want to, and what we need to do to take care of ourselves in the moment so that we can stay present and connected.

So, I'm going to move to the next slide. This is sort of, and when we look at the whole picture, what we really see is a kind of chilling constellation. You know, we're aware of the kind of traumatic mental health and substance abuse related effects of domestic violence, and often compounded by many other forms of trauma that we experience in our lives. And then we're seeing the, you know, the really high numbers of women who experience partners who actively undermine their sanity and sobriety and parenting, which wasn't part of this study, but we know that's another critical piece of abusive behavior. And so there's the actively undermining, and then there's controlling treatment and medication and sabotaging recovery, and then turning around and using these issues to further control their partners and undermine their credibility with friends, family, and the courts, and using them to prevent their partners from retaining custody of their children. So, it's really thinking about all this together, and how that affects all the systems where we work and where survivors seek help. I mean, thinking about survivors' responses through these, maybe survival strategies. Hypervigilance someone is experiencing that is often considered part of PTSD, may in fact be something they need to maintain to keep themselves safe. And that we also know that symptoms may be a response to ongoing danger and coercive control. So, I just take a minute to think about how this plays out and how that may be affecting the people that you see in your own practice settings.

I'm not able to advance the slide for some reason. Oh, that's because we need to switch. So, now Shean's going to talk about some of how this changed the practice in, of at the National DV Hotline, and what advocates had to say about asking these questions.

Hello again, y'all. So, as we mentioned before, prior to the beginning of these surveys, our advocates had already completed their service portion of their calls with their callers. So, some of these calls were on the longer end of the spectrum, such as like a 30-minute call or a 40-minute call. So, what the advocates found was that after beginning the survey with the callers was that many times the callers who indeed had these factors present, but perhaps hadn't brought them up within the context of their call earlier, would find that deeper memories and experiences would surface. So, what that meant for advocates is that they would need to delve back into the service portion of their calls with their callers to ensure that they had adequately validated those callers' experiences and that they had safety planned with the caller before ending their call, so they weren't just asking these questions and then saying, "Thank you for your time," and "Thank you for calling us. Call us back if you need." So, they were going back into these calls and providing a deeper level of service than they already had.

See, so, you know, while there was an impact, there was a silver lining to this. At the hotline, our advocates, they have a unique window into the realm of domestic violence. They just do. They speak with victims and survivors. They speak with friends and families of victims and survivors. They speak with callers who they themselves identify as abusers, and a whole host of other callers. So, they hear so many stories from callers from all walks of life, from all over the country. So, undoubtedly, after facilitating these surveys, they were able to see exactly how pervasive and how impactful these experiences were for our callers. Seeing how much this came up from a wide cross-section of callers made a really deep imprint on many of our advocates. So, this ended up prompting them to begin weaving this very specific type of assessment into their calls on a regular basis, instead of waiting for callers to bring these topics up themselves.

So, so some of the things that they heard, you can see on this slide, were just, you know, you've heard some quotes already, but some of the things that they were hearing from their callers were things like, "I wanted to go to an AA meeting, but after I got hung over, he wouldn't let me." Some abusers said that their, their abuser would, some callers said that their abuser said that her counselor was a jerk, and that the abuser would keep alcohol in the house after she returned from rehab. One of our callers said that she started craving alcohol as a way to cope, and that drove her to reach out for help. And anytime a caller, sometimes we had callers who, whenever they thought about even going to a meeting, going to an AA meeting, their abuser would get angry and upset. For other folks within the mental health coercion survey, we would see how the manipulation would rear its ugly head. The partner, one of the callers, their ex-partner recently came back to pick up his stuff from her home and took with him her anxiety medication from the house, and she couldn't get anymore because that medication was a controlled substance. So, if you can imagine the impact of just the abuse itself, and then not having access to something that you really need because your abuser has taken it from you. Some, one caller identified that an abuser would switch stories and events around to make her feel like she was losing her mind or confused her. And when things escalated, he would say, you know, "Go get help," or "What's your personality today?" And so, just some really painful things that our advocates were hearing and seeing throughout these, these services that they were facilitating.

So, one, one of our advocates, so some of the things that we heard our callers say were things like, "I'm so glad you're asking these questions." A lot of callers, sometimes these were the first times that they were having safe spaces to have these conversations, and it was just a relief, you know, to be able to speak to someone about what had been happening. And with our advocates, what we found is by

seeing um by seeing this on a regular basis, it fundamentally would change the way that they assessed within their calls, realizing that no callers aren't always going to bring up all the topics um that and factors that are going on in their lives, and that if we can create a safe space to ask a question, it opens up that door safely for them to move through it.

Sor, okay, so what does this mean for the implications um for our Advocates? One, they had they they knew that there were, you know, that there were factors um when it came to mental health, uh coercion, and substance use coercion. However, truly recognizing it as a part of DV, ensuring that we provided um accessibility of DV services to our callers, that we were searching and providing adequate resources when we were um when we were directing our callers to uh places that they could go and resources that they could look into. Um, a huge part was that intake and assessment process for our Advocates um making sure that they were consistently asking asking um if these if these factors were present for our callers um and then if they were present, implementing adequate safety planning that went hand in hand with that assessment. So we weren't just, they aren't just now asking the questions, they now have the knowledge based on how do we set um safety plan with someone if they identify um that these that these are present within their um their relationships.

So, okay, so around building support and assessment um, what a huge part of of this was, we we needed to shift our view on asking questions and asking and assessing um from seeing it as a screening process to more just an assessment process where we created a safe place for folks to disclose and seek support and ask about substance of use um, I'm sorry, substance use and mental health coercion um and creating opportunities for survivors to get um help and support. And in and in doing so, making sure that when we spoke about this, that we were talking about it from a control and uh power and control dynamic. So we were asking questions in the sense of saying, does your partner force you? Has your partner used this against you? So making sure that they understood that we knew um that there were other factors that were um involved, that it was that we weren't putting the onus on them and putting the responsibility fully on their shoulders.

So one thing that we know is that abuse thrives in isolation, and so creating opportunities to talk about challenging issues um were so important in counteracting a batterer's attempt to keep their partner isolated and under their control. Um, one thing, uh, so so I just want to share with you something that happened um within the within the survey. So um, our caller had called in and was just looking for um referrals and, you know, our caller wasn't really providing many details about her situation. Um, so our Advocate almost hesitated to ask these survey questions because it just seemed like the caller, you know, just wanted just only wanted um, you know, her her resources. So she started out with our intro and she started out by saying, you know, many times people who call our hotline are dealing with an abusive partner who's trying to maintain power and control, and sometimes abusers may use those substance um substances as a way to control or threaten their partners. And at that point, the caller just burst into tears and said, yes. Um, the caller opened up about her experiences and answered the survey questions. Her voice became clearer and more confident with each one. She sounded immensely relieved um about being able to talk about her experience. And at the end of the questions, she said that it, it, she shared that it felt really good to be able to share her story to help others. Um, the information she provided also helped as a way to connect her with even more resources within her community.

Shon, can you s um switch the slide? The ball to me? Yes, I I thought I did. Sorry. He you much have it might have just been slow. Thank you.

So like, you know, what we were so moved by hearing what the hotline Advocates had to say about their experience of actually doing the survey. I know people were a little hesitant at first to ask some of the questions and um, it was just so powerful and it, it just makes it's so clear how important it is to ask about things that um, people feel shame or or there's a lot of stigma about, so that people have a different perspective and and understand that that's really part of the abuse.

Um, so I'm going to talk a little bit about the implications for healthcare, mental health, and substance abuse, substance abuse treatment providers. But a lot of what I'm going to say about um, offering asking questions, offering perspective, incorporating into safety planning, or things that apply to for Advocates and um, attorneys and whatever system that we're working with. So um, first one, I want to talk just to frame the issue, thinking about mental health treatment in the context of domestic violence or trauma treatment. Um, um, just some caveats that we always um, keep in mind. One is recognizing that um, people who abuse their partners may look psychologically healthier than the person that they've been abusing for years. And this comes up when people are um, around custody issues all the time, or when someone goes to the emergency room, maybe after um, taking an overdose, maybe it's a coerced overdose, and who looks like they're more credible? That the um, your s are going to ask about what really happened. So we also talk about um, really thinking about who's providing collateral information. Is it someone who is actually um, abusing the person who's there in the emergency room, or someone who's allied with them? Um, our colleague Denise Wolf Markham has um, chatted me and said, don't tell people not to ask for collateral information. Sometimes a person who's abusing their partner will incriminate themselves, and someone who's savvy about that will actually document things that will help a survivor in court.

Um, another thing to think about in the context of mental health and and coercion and domestic violence is um, about um, abusers who have control over um, finances or guardianships or there's a, I don't know how many of you are familiar with the concept of um, uh, psychiatric advanced directives, which is different than medical advanced directives. It's a legal document, and the person who is given permission to make decisions for someone when they're not in a place where they can make those decisions about treatment for themselves is called the attorney in fact, and often that in in in the context of domestic violence, that person is often the abuser and the person who may be creating the problem in the first place. So doing safety planning around that is is really important.

Um, another thing that comes up in mental health treatment um is that not to focus on helping a person who's being victimized understand why they consciously quote unquote chose to be abused. And we heard we've heard this so many times where instead of focusing on the context of abuse and coercion and control and safety, people are looking at, what are you doing that is um, making you choose to be in an abusive relationship? Which is, we know to be victim blaming.

Um, incorporating questions about coercion, we'll talk about that in more detail in a minute. Um, asking about suicidality in the context of of domestic violence is really critical. Um, some that comes up around issues of abandonment. Patty Bland would talk about um, suicidality as a a form of resistance to abuse. She talked about a woman who said, he's threatening to kill me, and I'll and I'm not going to let him do that. I'm going to be the one to do it. So it's, it's trying to understand the context of that.

Um, so and it may be associated with the cumulative trauma, the lack of realistic options, feelings of exhaustion or helplessness and despair. So really thinking about that in the context of domestic violence is important for mental health providers.

Another um, thing to think about is anticipating potential trauma triggers um, in the context of ongoing danger and help talking with survivors about distinguishing them from necessary vigilance. So from a trauma perspective, we may not understand that someone is actually still in danger. Um, I think anyway.

Um, another thing to think about in this context is is around choice and um, control in the context of medication. So we know that um, from from from our own experience and from listening to the results of the survey, that abusers, one of the tactics of control is controlling medication, controlling access to medication, preventing people from taking medication, forcing people to take too much medication, calling them an addict for taking the medication, stealing their medication, selling their medication um, and um, saying because you're taking medication, there clearly you're the problem, and using that to justify the abuse. So having those conversations is really critical.

Um, uh, also considering the effects of trauma and domestic violence, including traumatic brain injuries on information processing, on people's ability to process information as part of our clinical encounters or advocacy encounters or legal encounters. And again, always making sure that people have access to domestic violence services.

So I I have a few questions here that just as a way to think about the language that you might use in the context of talking to someone about mental health and substance use coercion. Um, we have four more slides with more detailed questions that I'm going to skip over, but we've included them so you actually have a handout with questions on them that you can use. The point isn't to barrage people with questions, but to to do some of the framing that Chedin talked about earlier that we use um to frame the survey questions um, that normalized that this is part of the abuse and and the be the shame and isolation and stigma, but also let people know that you have some idea of what the kinds of things that they may be experiencing. So for example, has your partner ever used substance abuse or or mental health issues against you? Has your partner ever tried to control your medication or access to treatment? Has he or she actively undermined your sobriety or your recovery? Has your partner ever threatened to take your children away because you're receiving substance abuse treatment or mental health treatment? Or has your partner blamed you for his or her abusive behavior by saying, you're the one who's crazy or you're an addict? So I'm not going to read through all the questions, but you can see that these are the kinds of things that we can say in ways that um, actually connect with people's experiences.

Um, okay, so asking about mental health coercion, there's a number of ways that we can ask. Ask um, and it, for those of you who are providing mental health or substance use treatment, you have to understand the factors that lead to their development and the circumstances that impact treatment and recovery. So these are things we need to know. And one way to ask is in the context of a DV assessment. So if you're in a setting where you're routinely asking about domestic violence, which you should be um, you can add in layer in these questions um, in in that context. Or if you're working in y setting, again, layering them in in the ways that said and talked about um, a little while ago. So saying something like, domestic violence is not just physical abuse. Many people say their partners abuse them emotionally or call them crazy or other demeaning names related to their mental health status. Many people say that their abuser partners do things um, to make them feel like they might be going crazy, interfere with their treatment or medication, or do things to undermine them with friends or family, with other people they might turn to for help. Have you ever experienced something like that? So it's just, you know, we all find our own language, but these are just some of the ways to fold it in.

Um, another way to do it is to weave it into um, a mental health history. So um, for example, you know, you might ask about the relationship of of someone's mental health symptoms to um, current abuse or trauma they may have experienced in the past, and then you have a sense of of what that connection is, and it's a way to weave questions about coercion um, as well as the traumatic effects of abuse. And then you might ask about how their partner responds when they're they're feeling anxious or they're feeling depressed or they're having a panic attack. Is their partner supportive? Does their partner criticize and demean them? Did does their partner use their mental health condition to justify the abuse? Or do they try to control their medication or treatment? Is their partner only nice to them when they're not okay? And when they are okay, that's when they become more abusive and controlling.

Um, and it, another thing we could do is ask um, when we're discussing medication and treatment planning about how they think their partner might respond. So might ask whether they have any concerns about their safety, including if their partner knows that they're receiving treatment, or to ask them to consider whether potential side effects of medication will place them at greater risk if they're over sedated um, and they can't attend be to um, things that are going to be important to their safety. So again, once we start thinking about the questions, it's it it's almost kind of logical to think about the kinds of things that might be helpful under those circumstances.

So the next two slides are the ones I'm going to skip um, but I just want you to have them. Another one that we didn't talk about earlier was, has your partner ever threatened to have you committed to a psychiatric institution?

So what next? What how do we respond? Um, of course, we don't want to ask questions before we know how to respond. So some of the things, one of the first things that we want to do um, is offer perspective. And that's part of what you were talking about, Chedin, a little while ago, that helps reframe um, these kinds of experiences. So and it makes all the difference um, when you lose your perspective as a result of an abusive partner's efforts to undermine um, your perceptions of yourself or our perceptions of ourselves. So um, remembering that things you could say like, remember that a partner who's abusive may try to find other people to agree that your mental health needs give him or her a right to control or abuse you. This isn't so, even if you've had many hospitalizations or used medications for years, you have the same right to safety and dignity as anyone else. I mean, those are the kinds of things that we can add into who um, are responses to survivors who may be dealing with these kinds of issues. Or something like, you mentioned that your partner's continually calling you names and undermining you. Is there someone you can call to help you validate your perceptions or offer you other other emotional support?

Um, another thing that we want to think about is um, discussing emotional safety or emotional safety planning. And that's a way that we can help to counteract an abuser's control of our perceptions and of our emotional well-being. So some of the things that a survivor might find it helpful to talk about um, is how the abuse is affecting how they think and feel. So questions you might ask are, are the things you've noticed about how your partner's behavior is affecting you? Um, what are some of the things that you do to cope and that you found to be most helpful? Um, how are your responses to the abuse helping you stay safe, both physically and emotionally? And are there ever times when you find your coping strategies are getting in the way of you're staying safe or creating other difficulties for you? Now, what have you noticed? What have you been thinking about this? Are there things that you think might be helpful? So you know, saying, sometimes I'm so anxious, I can't think clearly, or sometimes I just check out and way, but that actually makes things worse because I'm not responding in the ways that he he wants me to um, so it's just opening up those kinds of conversations that allow people a safe place to think about their responses and what's actually going to be helpful to them.

Um, this is an another um, way of talking about this that um, our colleague Deni Markham developed is part of a incorporating into a DB safety planning tool. So um, you know, talking about how abuse can affect our emotional well-being and some of the things that we might be experiencing like being continually afraid, or being startled by loud noises, or having nightmares, or trouble sleeping, or and and talking about how being aware of those feelings or situations that are likely to elicit that kind of response um, can actually help us make decisions about how to handle them. And this is the kind of thing that often comes up when um, a person's going to court, and their responses may not be the response that a judge wants to see. You know, we've heard lots of stories again from Denise about someone who kind of checks out or dissociates in court, particularly when their abusive partner is is standing there and staring at them, and then the the judge feels like they're not credible um, because they're not making eye contact with the judge. So again, that kind of um, Rachel will talk about this more about the kinds of things we can do to support um, survivors in negotiating experiences like that.

Um, also thinking about how to do safety planning around mental health coercion. One of the things we can do is discuss safe times and places where it's a a person can receive calls, or where we can send bills or explanation of benefits, the thing that you get like from Blue Cross or insurance, that's not a bill um, about your recent treatment, or to schedule an appointment. So finding out if there's safe places that um, they have access to, like work, or a friend, or a family's house um, where they could receive phone calls or bills or statements. One of the things we learned recently is that while um, healthcare providers are bound by HIPAA by confidentiality, and so you can work with them about where they send information to insurance companies or not, and they'll often send those explanations of benefits to the home. So so uh, and it's not making sure that pharmacies or healthcare providers or mental health providers don't call or send email to places that aren't safe.

Another thing to think about is electronic health records and privacy concerns and um, protection of sensitive information. And we know that electronic health records um, there's the technological capability to segment off information and keep it protected, but most um, electronic health um, record vendors don't do that. They choose not to do it. So talking about safety planning around this with survivors is really important.

Um, thinking about options for managing medication safely is also really critical. Are there places to keep your meds so you can take without them? There's some um, breaking up on your line. Is it still happening? Sounds good. Okay. Um, we talked already about legal documents and referrals to DV advocacy programs. And one thing I I know one of you wanted me to talk about documentation. One of the things we know that medical records aren't always safe, but how we document in those records is critical. And documenting coercion related to mental healthcare, substance abuse is really important for survivors, particularly around custody cases. So talking about the relationship of any symptom someone has to the abuse, the potential for them to survive once they're safe, subside, once they're safe, um, describing their strengths and coping strategies and their ability to care for and protect their children, their engagement with treatment um, observations about the abuser um, all the things that we've talked about documenting appropriately in in mental health and substance use and healthcare treatment records is really critical.

So asking about substance use coercion, again, very similarly um, you can ask as part of a DV assessment. And I'm not going to read this, it's very similar to the script that um, we use for the study um, and and letting people know that these are very common and is this the kind of thing that you may be experiencing. One another way to do this is facts is folding questions into questions about a substance abuse history. And one of the things that um, some of you may be familiar with the cage questionnaire, which is a a four question screening tool for substance use and abuse. Have you ever cut tried to cut down on your drinking? Have you ever been annoyed by someone criticizing your drinking? Have you ever felt guilty about your drinking? Or have you ever had an a drink in the morning? And there are ways to even questions about coercion into those kinds of questions that you might already be asking. For example, has your partner ever tried to stop you from cutting down on your drinking or coerced you into using? Have you ever been made to feel afraid by someone's criticizing your drinking? Or has your partner used your drinking as a way to threaten or prevent you from getting help? Um, have you ever felt coerced into drinking or engaging in illegal activities and then felt guilty about it? Um, or have you ever had a drink in the morning because things felt so hopeless or painful or because it felt like the only way you could get through the day? So again, how we ask those questions really reframes the context. And these are the questions I'm not going to go through um, but you'll I just want you to have. And again, thinking about um, substance use context, the relationship of substance use to current and past abuse um, and what role does does the abusive partner play in um, maintaining someone's use of substances? Um, you know, we know that some sometimes partners coerce their partners into illegal drug activity and then exert further control by withholding drugs or threatening to withhold drugs once she's become dependent on it. So this creates an additional layer of entrapment for survivors. And again, being afraid to call the police. So again, talking about all of that is really critical. And talking about what's helpful, what gets in her way, what she what she's tried, what she wants, and how it can be helpful.

So when someone discloses, again, offer perspective. And this comes from Patty Bland, letting people know that no one has the right to hurt them, and they don't deserve it. Um, even if you're using or drinking, that you didn't cause the violence. Um, and also validating that, you know, this is a survival mechanism, and it's great that you found a way to survive. But there might be other ways to cope, and that you really deserve a lot of credit for for talking about this, and how this talking about it can really help um, your safety and your kids' safety. So again, recognizing how talking about how um, recovery efforts can be sabotaged, how keeping scheduled appointments like methadone treatments makes it easier for someone to stalk you because you're always going to be in the same place at the same time. So thinking about all of those and factoring them in to any kind of treatment planning.

Um, Patty also talked about how when you're under the influence, you may have illusions about how powerful you are and how safe you can be. And really factoring that into our conversations um, and how acting using may affect our ability to accurately assess danger and and and our judgment um, and doing that in ways that are are really helpful and not victim blaming. So again, Patty is to do this um, you have to kind of have her way of talking, maybe to to do it well, but thinking about maybe this isn't the safest option right now. Can you think of ways that may be true? Or how your partner might actually use this against you? And what if there's one thing I could do today that would be helpful? What would that be? Or how stressful it is to be involved in custody, and how is this going to affect your case? And what are some other things you might consider? And what might your partner say about it? So it's really engaging as collaborators.

So again, helping people um, talk to a substance abuse treatment provider about what's going on and how it might affect um, relapse prevention strategies. Um, finding a substance use to sort of treatment or peer program that really attends to DV and trauma and is gender responsive um, and working with DV Advocates to help um, support survivors in dealing with these issues.

So now I'm going to turn it over to Rachel. All right, I think I'm on and um, Jen, you maybe you can just chat me if you have any trouble with the with the sound. So um, so hi everyone. I'm just gonna um, I know we have about 10 more minutes left in the webinar, so we're just gonna take a breath. Um, it's a lot to absorb. You will get the PowerPoint slides and um, you will have a chance to um, email us questions if we don't get to everything today. Um, so I just want to take um, probably most of these last couple minutes and just talk a little bit about the legal implications. And to start with that, I just I actually want to go back and highlight um, some of the more the results I thought were were really highly relevant, particularly I'm going to talk just briefly about custody and order protection, and I'm going to talk just briefly about criminal.

So some of the results that we have are that are showing us that a high number of callers are are directly telling us that their partners threaten to report or threatening to report their mental health or substance use to authorities to keep them from getting something they wanted or needed. And this specifically includes in our in the questions that we asked, for example, custody of children in protective orders. Um, and so, and keep in mind with that and with all the results, that this wasn't 50% or 37% of uh of of callers who had identified um, that they were experiencing a mental health condition or identified they were experiencing substance use or addiction. This is 50% and 37% of the total number of of survivors who took this survey. So it's just a really, really uh significant result there. But what I actually want to focus on here is when we look at the number of callers who told us that their partners prevented or discouraged them from getting treatment, a very, very high number of those callers were also telling us that their partners report threaten to report uh to authorities their mental health substance use disorder. And um, so here with mental health, we have 72% of callers who whose partners prevented or discouraged them treatment were then turning around and threatening um, to report mental health to authorities to keep them from getting something they wanted or needed. And 94% so almost almost all of the callers, almost all of the callers whose partners had prevented or discouraged from getting substance use treatment had also threatened to report their substance use disorder or substance use to authority um, to authorities to prevent them from getting something they wanted or needed, specifically including as examples, orders of protection and custody. So highly, highly relevant results here.

I think I can move the slides myself. Yeah. So so the point I want to make here is that abusive partners know that the stigma around mental health and substance use disorders makes it very difficult for survivors to be seen as credible and to be seen as good parents um, and to be seen as not to blame for the abuse. And so we're seeing a pattern of both exacerbating mental health and substance use disorders and directly leveraging the stigma around those issues um, especially in the context of legal cases. And so I just, I can't emphasize that enough. And so this makes it a really relevant issue for everyone working in the legal field. It makes it it makes mental health and substance use stigma a really big issue, I think for for the domestic violence field um, as a whole.

So we're going to go to the next. She'll be on the next slide here. So just to take a quick moment and talk about the implications specifically for custody. When a party raises mental health or substance use as an issue in in a custody case, and just to remind her that something that Eleanor had said, Dr. L had said earlier in the in the webinar today was that when we were thinking of when we when we have been thinking about these issues around mental health and substance use coercion, we're thinking about this in the context of a larger pattern of domestic violence. So a larger pattern of course control that may include physical violence, emotional violence, sexual violence um, uh, economic coercion, etcetera, etcetera. Um, and so when we're seeing in the context of custody, a party raising substance use or domestic or substance use or mental health um, as an issue um, I think obviously a question that that's that's on the table here is whether that's a genuine concern or an attempt to divert attention from the impact of exposure to violence. Because here we're obviously talking about the the best interest of the child standard. And what I would um, excuse me, suggest or offer to you is that there's some things that are really red flags in this area um, or if you're in the position of being an attorney representing someone, there's uh, there's things that can be raised. And one of them is that the party raising the issue is doing things to exacerbate the condition or to interfere with treatment. Right? And we just saw some very compelling results from this study on how how very, very often that happens. I would see suggest to you that that person is not very concerned with the best interest of the child because they're actively undermining something that is um, they're actively undermining uh parenting, they're actively undermining the well-being of their partner um, and the other thing that that tells us is that with increased safety and support, that person's mental health or substance use condition is probably going to get better. And we actually also have separate research that supports that.

And then the second red flag or thing to raise, I would I would offer to you is that um, and this comes again partly from my good good good fortune of of having some mentorship from Denise Scholl Markham, is that the party, if the party raising the issue never indicated concern about the children's safety prior to litigation. For example, they were totally not involved in parenting or showing any other concern about their partner's U mental health or substance use issues, they're raising now in the context of custody, that would suggest to me that that person is not actually concerned about the best interest of the child, but rather what we're seeing here is a pattern of mental health and substance use coercion that's connected quite possibly to a larger pattern of domestic violence or intimate partner violence.

Go to the next slide and talk just for a second about orders of protection. Um, so two, we've got two two ways this can come up here. First, the abuser may raise mental health or substance use as a defense. So this is when a survivor has gone to to seek an order of protection, and in in defense, the abuser is raising their partner's mental health or substance use in order to excuse me, in order to cast doubt on their credibility, or also a way of justifying or explaining away abuse. And this is an example that that Dr. Warshaw had used earlier in the in the program, for example, that saying that she was out of control and needed to be restrained. So this is an example of explaining away the abuse. And um, and also we can see this in the context of abusers raising mental health or substance use in the course of of seeking an order of protection. So Dr. Lion gave us the example earlier on the webinar of an abuser who had stopped um, picking up the medication for their for their partner, and then tried to get an order of protection against their partner saying that she's off her medication and dangerous. Um, so those are some ways that we see that if you want, if you actually want to chat on that, if you see this as something in your your work, feel free to do that. Um, and these are issues that I'm I'm broadly interested in. So if you're interested in how mental health or substance use comes up in custody or order, excuse me, order protection cases, specifically um, maybe actually Jen, you could you could actually just type my email into the the chat. Um, I'd like to to hear from you about what kinds of things you're seeing and if you have thoughts about that. Um, but for the sake of time, we'll move um, thanks. Yeah. So my email is R white domain at ncbtm.org if you want to talk more about those things.

So um, just to make a couple points about uh, the criminal context. Again, high a result that I found highly relevant from this survey. So this is where we're comparing um, we're looking at callers who gave us yes on some answers and yes, yes on other answers. 47, almost 50% really of callers whose partners had forced or pressured them to use alcohol or drugs, and almost 70% of callers who use alcohol or other drugs to reduce the pain associated with the abuse also reported that they had been afraid to call the police for help. And this is this is very, very significant result. Um, and just to recognize that calling the police may not be the right and helpful thing for many people for many reasons. However, it's greatly concerning to me that someone would ever have to choose between calling the police um, we would assume in the context of a of an attack or a time when you need immediate assistance to to um, to protect yourself from violence, and the risk of being arrested um, or not being believed. It's just that that is a choice that just should never, nobody should ever have to make that choice. And here we're actually seeing that we're talking about folks whose partners had forced or pressured them to use or her using alcohol or drugs really has a way of emotional survival, and um, and really high numbers of them also being afraid to call the police for help.

So just moving to the last slide. We've just got a couple minutes here. So I just want to say real quickly some of my thoughts here um, and these are really particular when we're thinking about the criminal context. We're really thinking about um, I mean thinking about uh, domestic violence and thinking about coercion in a general way in the context of criminal build on on the work of a lot of really good thinkers in this area, including Beth Richie, compelled to crime. I'll put that on the recommended reading list. Definitely all the thinking that Patty Bland has done around substance use in domestic violence in general is super relevant here. So you should check out her work if you haven't seen it already. But some of the really specific places where we're thinking about substance use coercion specifically and the and the implications for the criminal legal context are obviously around incarceration for substance use um, so we're now that we're looking at the results of the story, we can really start to think how much of that is related to forced or coerced use um, or related to using substances to numb or survive emotionally. And we absolutely know and we have a lot of data on how many people who are incarcerated in women's prisons are survivors of abuse. It's like 70 to 79% um, for domestic violence survivors of domestic violence. There's actually a study that's specific on Illinois just from a couple years ago saying that 98% of the people in the women's prison reported past experiences of physical violence. 98% reported past experience of physical violence um, that just came out a couple years ago. So that's a big one.

Um, we talked previously about fear to fear of arrest, or else I would add losing children to child welfare, obviously theft, sex work, and I would also um, selling drugs can be part um, can be compelled by addiction in some cases, can also be compelled directly by coercion, but can be compelled by addictions. It's related to um, substance use coercion um, examples of the survivor literally left holding the bag. Dr. Warshaw had talked about this. It's an example that comes from Patty Bland's work, and I'm sure others of you have experiences of that. And then also this issue of we know that abusers, how often abusers are interfering with treatment. And so really just emphasizing that treatment is sometimes required in the context of probation or sentencing arrangements or reunification plans in the context of child protective um, child welfare um, and so just really thinking about whether that comes up in those places and what the impact is on survivors of domestic violence. So so that's my thoughts on that. And I don't know if um, but but email me if you want to talk more about any of those things because I'm super interested in thinking more about the implications of that. And um, I think we're going to close. Jen, do you want to do you want to say something or should I close out?

Um, let's go to the end. Let's let's a some slides um, not much time for a summary of questions. I think you you really summarized nicely, Rachel, about how compelling this is and how important it is for us to factor it in. I just wanted to highlight that resources that you'll receive on our website, including the actual survey report and um, uh, a tip sheet for survivors on mental health and substance use coercion. And we'll have some more tip sheets um, soon for um, for clinicians and also um, around the legal implications of mental health and substance use coercion. So just so you have our our information um, and I'll let Jen close now.

Great um, thanks everyone. I would like to thank all of our presenters for such an exceptional webinar today and for such a a great conversation. Uh, thank you to Cap Colorado for providing today's captioning and thank you to everyone who made the webinar run smoothly. Last but not least, thank you for all of you for sending your time with the center. Within the next week, Aaron will send you all a follow-up email with a link to the recording of today's webinar, in addition to the slides and any handouts that were referenced, all of which will be available on our website. You'll also receive a certificate of attendance for your time today. At the end of the webinar, you will be taken to a very brief evaluation. If you could please take a moment to let us know what was useful and what could have been better, it would be greatly appreciated. Also, if you could let us know if there are follow-up conversations or questions or follow-up topics that would be helpful to you around these issues, that would be great. Thanks again, and we hope you all have a great afternoon. Thanks.