October 2020 Office of the Assistant Secretary for Planning and Evaluation and the Family and Youth Services Bureau, Division of Family Violence Prevention and Services U.S. Department of Health and Human Services Understanding Substance Use Coercion as a Barrier to Economic Stability for Survivors of Intimate Partner Violence: Policy Implications _________________________________________________________ KEY FINDINGS WHAT IS SUBSTANCE USE COERCION? Substance use coercion occurs when This brief seeks to further the limited research, policy, perpetrators of intimate partner violence and practice on substance use coercion and to undermine and control their partners increase awareness about this issue among relevant through substance-use related tactics and stakeholders. A literature review and key informant actively keep them from meeting treatment conversations identified a number of findings and areas and recovery goals. for potential policy and practice responses to substance use coercion: WHAT ARE EXAMPLES OF SUBSTANCE USE COERCION?  Substance use coercion is common among victims of abuse. Substance use coercion can take many forms. For example, an abuser may:  Substance use coercion is a barrier to victims’  Force, initiate, or pressure their partner economic stability because it can affect their to use substances. finances, employment, housing stability, social  Sabotage their partner’s recovery networks, and public benefits for which they are efforts by deliberately keeping eligible. substances around their home.  Tactics of substance use coercion differ by  Refuse to provide their partner with context (e.g., whether the abusive partner uses childcare or transportation needed to substances, whether the survivor has children). participate in substance use treatment.  Both the domestic violence and substance use fields can strengthen their response to HOW COMMON IS SUBSTANCE USE substance use coercion by training staff; COERCION? providing safe, gender-responsive, trauma- A survey of National Domestic Violence informed services; including survivors’ children Hotline callers who had experienced as part of service delivery; and addressing high domestic violence revealed that 43 percent staff turnover rates. of respondents had experienced at least  Systems-collaboration and education efforts are one of three types of substance use needed between the domestic violence and coercion: substance use fields, but also with other  Had a partner pressure or force them stakeholders including child welfare agencies, to use substances; the criminal justice system, home visiting  Had a partner threaten to report their programs, housing programs, and trauma- substance use to the authorities to informed mental health services. keep them from getting something they  Federal agencies can support the work of states wanted or needed; and/or and local programs to address and mitigate  Were afraid to call the police because substance use coercion. a partner said they would not be  Innovative program and treatment models (e.g., believed or they would be arrested integrated programs, peer-led activities) should based on substance use. be provided and evaluated. METHODS This project is a collaborative effort by the Family and Youth Services Bureau’s (FYSB) Family Violence Prevention and Services Act (FVPSA) Program1 and the Office of the Assistant Secretary for Planning and Evaluation (ASPE)2 within the U.S. Department of Health and Human Services (HHS). Subject matter expertise, research support, and technical assistance was provided by the National Center on Domestic Violence, Trauma & Mental Health (NCDVTMH), a FVPSA-funded special issue resource center. It has long been recognized that intimate partner violence (IPV)3 has significant mental health and substance use-related effects, and the lack of collaboration between systems often leaves survivors and their families without ways to address both safety and recovery needs. HHS is addressing this need for systems collaboration through an Information Memorandum 4 calling for increased collaboration between these systems and a range of research and SUD and human services, including a forum on Human Services Programs and the Opioid Crisis 5. Building on these recent efforts, this policy brief seeks to further the understanding among policy stakeholders that IPV is often targeted toward undermining a partner’s substance use treatment and recovery. Findings are based on a literature review and 19 key informant conversations. 6 Key informants represented a wide variety of fields, including individuals with lived experience, practitioners and frontline program staff, domestic violence coalition staff members, and researchers from the substance use, domestic violence, and human trafficking fields. Some key informants also provided insight into population-specific perspectives, including from their experiences with Tribal, immigrant, and LGBTQ communities. Together, the literature review and key informant conversations informed a final report and an October federal convening on substance use coercion and ongoing federal work. FINDINGS Key informants identified a number of findings on the prevalence, nature, and impact of substance use coercion and made a variety of policy and practice recommendations to improve responses to this abusive tactic. PREVALENCE, NATURE, AND IMPACT OF SUBSTANCE USE COERCION Substance Use Coercion is Common but Data Collection is Limited Nearly all informants noted that in their experience or observations, substance use coercion is very common; anecdotal estimates ranged from as low as 30 percent to as high as 90-100 percent of clients. However, few programs collect formal data on the issue. Substance Use Coercion is a Barrier to Economic Stability Key informants identified a number of ways that substance use coercion prevents survivors from achieving economic stability. Below are some areas in which it can serve as a barrier: 1 The Family Violence Prevention and Services Act (FVPSA) provides the primary federal funding stream dedicated to the support of emergency shelter and related assistance for victims of domestic violence and their dependents. Learn more at w ww.acf.hhs.gov/fvpsa. 2 The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of HHS on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. Learn more at w ww.aspe.hhs.gov. 3 Within this brief, the term ‘intimate partner violence’ is used w hen describing abuse by a partner. The term ‘domestic violence’ is used, as per convention, w hen describing services that address intimate partner violence. 4 https://w ww.acf.hhs.gov/fysb/resource/information-memorandum-on-the-intersection-of-domestic-violence- mental-health-and-substance-use 5 https://w w w.irp.wisc.edu/resource/human-services-programs-and-the-opioid-crisis/ 6 These semi-structured discussions asked the same question of no more than nine people at a time. ASPE and NCDVTMH developed separate semi-structured interview guides for individuals w ith lived experience, domestic violence experts, substance use experts, human trafficking experts, integrated program staff members, policy experts, and researchers. 2  Finances: Abusive partners may control a survivor’s own money or force them to spend it on substances. Inability to access, retrieve, and use money impacts survivors’ ability to purchase food, housing, childcare, transportation, etc.  Employment: It can be difficult to get or keep a job if a survivor is using substances or being coerced into using substances. It may also be difficult to reliably get to work if the abusive partner is the source of transportation and refuses to provide a ride to/from work. For survivors with a criminal record related to their substance use, it can be even more challenging to find and maintain employment.  Housing stability: Survivors are often dependent on abusive partners for housing, and many housing programs and domestic violence shelters deny admittance to survivors who use substances. Landlords may also deny housing to survivors with histories of eviction or “nuisance calls” to police, though a survivor may have had to make repeated calls to authorities related to IPV and ensuring safety for themselves and their children.  Social network s: Abusive partners may intentionally leverage the shame and stigma surrounding substance use to isolate survivors from their supportive social networks, and without these supports, it can be difficult to become economically stable or to envision a path to economic advancement.  Public benefits for which they are eligible: Depending on the state, substance use and any drug-related felony record can be a barrier for survivors trying to access transitional public benefit programs for which they are eligible like TANF, SNAP, or other housing benefits to help them escape an abusive partner and stabilize in the short term as they transition toward self-sufficiency in the long term. Tactics of Substance Use Coercion Differ By Context People who abuse their partners may use many different substance use coercion tactics. The most common tactics as described in the literature include the following: abuse directly related to survivors’ substance use, coercion related to supplying and controlling substances, threats to call law enforcement about survivors’ substance use, coercion related to children and custody, undermining survivors’ recovery efforts and access to treatment and services, and coercion into sex trafficking.7 While any abuser may use these tactics, the strategies used can vary based on a number of characteristics:  Whether the perpetrator uses substances: If the perpetrator does not use, they may shame and guilt the survivor, exploiting the stigma often faced by individuals who use substances. If the perpetrator does use, they may initiate the survivor into substance use and/or keep substances around the home to encourage continued use or relapse.  Whether the perpetrator is selling illicit drugs: In this scenario, the perpetrator may be more likely to control the survivor’s access to substances, coerce the survivor t o transport or deal drugs themselves, or engage in human trafficking by forcing the survivor to engage in sex in exchange for substances or funds to purchase them.  Whether the survivor is a member of a particular subpopulation: Some individuals are more likely to experience multiple threats to safety and wellbeing, which can lead to more severe consequences because of substance use coercion. Tactics may also vary across communities; for example, one key informant noted instances where the perpetrator from a certain community would sometimes coerce the survivor into substance use by falsely saying that substance use was necessary to be included and accepted in the group. 7 See “Literature Review : Intimate Partner Violence, Substance Use Coercion, and the Need for Integrated Service Models”. 3  Whether the survivor has children: In these instances, perpetrators may leverage the survivor’s children to prevent them from leaving, sometimes attempting to sabotage the survivors’ relationship with their children by telling the children that the survivor does not care about the children because the survivor is using substances. Abusive partners may also threaten to call child protective services. POLICY AND PRACTICE RECOMMENDATIONS IDENTIFIED BY KEY INFORMANTS Key informants identified a number of areas for policy changes at all levels: individually within both the domestic violence and substance use fields, in the use of innovative models, in systems-collaboration efforts, and in federal funding. Federal Agencies Can Support Survivors Key informants made a number of policy recommendations related to funding:  Incentivize collaboration at the state and local level through funding announcements, trainings, and state-level pilot programs.  Make federal funds that address IPV, housing, and other services more flexible, including VAWA and VOCA, so that programs can address substance use coercion in their program activities.  Provide and increase funding for innovative programs that concurrently address substance use coercion, IPV, human trafficking, housing, and economic stability .  Increase resources for domestic violence programs and substance use treatment in general, as resources are limited relative to the large number of people in need of services and treatment.  Encourage and fund services that incorporate the needs of survivors with children, such as treatment services that accept children in treatment settings and childcare assistance for individuals accessing treatment.  Support development, implementation, and evaluation of innovative approaches by authorizing new research and improving data collection in existing federal surveys.  Explore ways to make activities addressing substance use coercion reimbursable for substance use treatment providers and domestic violence programs. However, do not overlook the work in this space that can possibly leverage existing reimbursable activities or happen without reimbursement. Strengthen Responses in the Domestic Violence and Substance Use Fields Key informants noted that there are key areas where the domestic violence and substance use fields can improve their response to substance use coercion, and these areas have implications for potential policy changes. Some recommendations apply to both the domestic violence and substance use fields:  Train all staff on the following, potentially through cross -trainings: o The intersection of substance use, IPV, mental health, and trauma; o The prevalence, dynamics, and impacts of substance use coercion; o Harm reduction strategies that meet survivors where they are; o The stigma of substance use and IPV and how to address it; and o Existing resources to address substance use coercion. 4  Include survivors’ children in service provision: o Accept children in substance use treatment programs, as survivors may have no other choice than to leave their children with their abusive partner when seeking treatment. o Use a two-generation approach to address children’s needs by offering parenting classes or groups, including children in safety planning, providing trauma- informed services to children, and addressing child-parent attachment. o Promote the parent-child bond between the survivor and their children as the abusive partner or ex-partner may actively seek to undermine and/or disrupt that relationship.  Address the high turnover rate among direct service providers through methods such as increased pay and trauma-informed services for staff.  Avoid implementing unnecessary program rules, as these rules can undermine survivor agency and remind them of the control their abusive partners have subjected them to.  Offer language access services for survivors who have limited English proficiency. Some potential ways to improve domestic violence programming specifically include:  Identify best practices that are inclusive and that support individuals who are actively using substances as they engage in services, including shelter or residential services. Continued substance use and seeming lack of engagement may be a direct result of experiencing substance use coercion.  Train and equip staff to recognize and respond to individuals experiencing complex trauma, substance use, substance use coercion, and overdoses. Develop protocols to help someone experiencing an overdose.  Work with expungement clinics to address survivors’ criminal history and/or history of eviction to assist survivors with accessing housing and employment options.  Plan strategically to braid funding together, both public and private funding, to increase housing and employment supports to survivors, including developing and s trengthening partnerships with state and local U.S. Department of Housing and Urban Development Administrators, Section 8 Programs, housing authorities, and workforce development programs. Key informants also identified areas for changes in the substance use field that would improve the response to substance use coercion, including the following:  Train and equip staff to recognize and respond to IPV, sexual violence, and trauma with a resiliency-oriented approach.  Ensure services are trauma-informed and safe. For example, allow flexible treatment times for survivors receiving Medication Assisted Treatment, as the regularity of appointments can make it easier for abusive partners to track, stalk, and harass survivors, which is a major safety risk.  Provide gender-specific and gender-responsive substance use treatment programs, which are trauma-informed and may serve genders separately to avoid triggers and increase feelings of safety for survivors.  Remain cognizant that given the limited availability of resources in some areas, survivors may be placed into substance use treatment programs with their abusive partner or ex - partner. This can affect survivors’ treatment engagement, recovery trajectories, and 5 physical and emotional safety. Service providers need policies and protocols in place to ensure the safety of survivors seeking treatment. Increase Collaboration across Systems There are many areas where the domestic violence and substance use fields can continue to increase collaboration on both local and state levels. Key informants also noted a number of other fields that are important stakeholders in addressing substance use coercion. The domestic violence and substance use fields can collaborate in the following ways:  Continue to establish and foster partnerships between domestic violence and substance use programs, such as detox treatment centers and health care providers working with those who are using substances.  Have a domestic violence specialist on staff at substance use programs, and vice versa. Consider bringing on peer support specialists to coordinate comprehensive service delivery and connect survivors with treatment options.  Work together to develop domestic violence-focused safety protocols for substance use treatment programs as well as supportive response protocols focused on substance use or overdose in domestic violence programs.  Support and learn from innovative models, such as DV Housing First and Coordinated Entry Systems that can prioritize the needs of survivors using and/or recovering from substance use to access permanent housing options and bring services into the home. Areas for collaboration with other fields include:  Engage stakeholders in other systems, including child welfare agencies, the criminal justice system, housing programs, home visiting programs, trauma-informed mental health services, and anti-trafficking providers.  Provide cross-trainings between disciplines.  Establish multidisciplinary teams to address substance use coercion on the state and local level.  Formalize partnerships and collaboration through MOUs or applications for funding.  Address racial disparities across programs and systems responses.  Educate policymakers and practitioners in all fields about substance use coercion and the intersection of IPV and substance use using short, digestible products . Implement and Evaluate Innovative and Emerging Models Other recommendations were related to strategies that address substance use coercion:  Implement a variety of innovative models so that survivors can access the programs that are the best fit for them. Examples may include: o Integrated programs o Co-located programs o Harm reduction models that meet survivors where they are o Domestic Violence Housing First and other programs that do not require participants to be sober before they can access housing o Peer-led programs and activities o Culturally responsive programs 6 o Syringe Service Programs to mitigate harm, decrease transmission of infectious diseases, and connect survivors to treatment and recovery support 8 o Comprehensive pregnant and parenting programs o Programs that allow survivors to bring and keep their children with them  Evaluate which strategies addressing substance use coercion are most effective in general and among specific populations (e.g., rural areas, immigrant communities, persons with disabilities, Native Americans, LGBTQ communities). CONCLUSION This project has identified important lessons and areas for policy change and responses at all levels. In addition to the lessons and recommendations outlined, key informants spoke of the need to address the stigma around both substance use and IPV. Substance use coercion will remain pervasive if service providers and policies do not recognize the intersection of substance use and intimate partner violence and ensure that survivors are able to disclose their experiences without fear of stigmatization. Federal agencies can help address this issue by exploring potential strategies and creating flexible opportunities for states and local service providers to increase survivors’ options to attain economic stability and access trauma-informed mental health treatment services. To address this stigma and consider the lessons and recommendations identified in this project, it is important to listen to individuals who have experienced substance use coercion and leverage policy responses to address their needs. 8 https://w ww.cdc.gov/ssp/index.html 7