November 2006

Domestic Violence & Women with Mental Illness

Where Do I Belong?

This issue of State Policy Focus will identify some of the barriers to working with domestic violence providers and highlight successful models that ensure women with serious mental illness receive both the mental health and trauma services and supports they need when addressing abuse.

When a woman has been abused she feels helpless, worthless, fearful, and is often physically injured. Internalized victimization, fear of disbelief, and possible physical repercussions from her abuser may prevent survivors of domestic violence from reporting the abuse for several years and may prevent sexual assault survivors from ever reporting. Fortunately, numerous services exist that provide assistance to women - unless the woman has a mental disability.

The Department of Justice estimates that one in four women will be assaulted or face violence in their lifetimes. According to the 2000 U.S. Census, women with disabilities comprise 9.2% of the population. While a small percentage of the population, they have a high probability of being abused. The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that women with severe mental illness are 24 times as likely as non-disabled women to be victims of sexual assault. The increased likelihood of abuse plus societal perceptions of mental illness combine to create additional obstacles for women with severe mental illness.

Ignorance of mental health needs and treatment, coupled with societal stigma, translates into a denial of access to specialized sexual assault and domestic violence services or fragmented services. Often a woman is referred to a mental health provider for her mental health needs, but the assault is dealt with elsewhere because the provider does not have appropriate training to deal with abuse or is not made aware of it. Frequently, for those who do not have specialized training, the symptoms of abuse may be mistaken as symptoms of the womans disability. According to one study, many women with mental disabilities stated that when they have tried to obtain services for abuse they received inadequate responses. Many were not believed, some were blamed, and others were told that they were overreacting. Often, they were prescribed medication and/or placed in a group home without being provided sexual assault or domestic violence services. The women also reported they did not receive referrals to domestic violence or sexual assault programs; they were told that such counseling was not available to them.

Unfortunately, the above statement is often accurate, as many domestic violence programs do not serve women with mental disabilities. Some shelters explicitly refuse to allow women with mental illness to live in the shelter. Shelters that do allow women with mental illness may not allow them to control their own medication, or refuse to allow women taking medication to live in the shelter.¹  Although these entities are covered by the Americans with Disabilities Act and/or Section 504 of the Rehabilitation Act of 1973, many domestic violence providers have established policies that inadvertently or deliberately discriminate against women with mental disabilities.

Furthermore, when mental health providers invite domestic violence advocates to address overlapping issues concerning women with severe mental illness, philosophical barriers emerge. Domestic violence advocates give a multitude of reasons for their reluctance to work with mental health providers. Advocates are concerned about weaving mental health into their projects because it would compromise their grassroots social-justice focus.²  Advocates are also worried that a mental health diagnosis would pathologize a survivor of domestic violence and increase the control that her abuser has over her life.³  Lack of funding is also cited as a barrier to providing domestic violence services to women with psychiatric disabilities who have been abused.

Challenges to Working with Domestic Violence Programs
Perceived differences and stigma associated with mental illness impair a mental health organizations ability to collaborate with domestic violence services. One National Council member has described its unsuccessful attempts at bridging the gap between mental health and domestic violence: Heartland Human Services in Illinois. Heartland Human Services encountered resistance from domestic violence advocates when they sought to incorporate a small domestic violence agency into their existing program. State agency representatives expressed skepticism at Heartlands suggested venture, even though without outside help the domestic violence agency was going to close its doors. Domestic violence advocates were insulted at the idea of mental health caseworkers dealing with domestic violence victims because they could not imagine that licensed mental health counselors could comprehend the experiences of an abused woman. Furthermore, the domestic violence advocates did not understand that the mental health provider organization was already treating many of the same clients served by the domestic violence services agency and did not appreciate the service gaps Heartland could fill by incorporating the agency within its own program. Because of these concerns, the state domestic violence agency did not fund Heartlands proposed project.

Successful Collaborations with Domestic Violence Programs
Fortunately, several National Council member organizations have overcome the usual obstacles to successfully collaborate with domestic violence service providers.

In Texas, the Central Plains Center, a community behavioral healthcare provider, and the Hale County Crisis Center, a domestic violence program, have developed a working relationship to support women who have been victimized and who also have a serious mental illness. The women may go into either agency because each has similar procedures to identify women who need treatment for both mental illness and victimization. When a woman is found to be in need of services at both agencies, staff at the Central Plains Center and the Hale County Crisis Center refer her to the other agency and accompany the woman to her first appointment at the other agency. This allows the staff assisting the woman at each agency to make contact, enabling the staff to coordinate the womans care. Staff remain in contact with one another regarding their common clients for the duration of the womens treatment. The Hale County Crisis Center services are free to clients through grants from the State of Texas Victims' Assistance Discretionary Grant Program and funds distributed under the federal S.T.O.P. VAWA grant.

Cape Cod, Massachusetts has also been successful in establishing a collaborative program. The arrangement began because of program and consumer input from the Local Leadership Council of the WELL Project (one of IHR's SAMHSA/CSAT Women, Co-occurring Disorders and Violence study sites) that identified untreated and pervasive issues of co-occurring disorders and histories of violence. The Institute for Health Recovery (IHR), along with Barnstabe County, created a partnership with Gosnold, Inc., the primary substance abuse and co-occurring disorder agency on Cape Cod , and Independence House and Safe Harbor, two domestic violence/sexual assault agencies, , to provide outreach, engagement, intervention, integrated treatment and care coordination to women and their children seeking services for domestic violence and/ or sexual assault. While sited at these agencies, IHR staff provide direct services, oversight of clinical programs, clinical supervision, as well as training and supervision to the collaborating facilitators of the of the group interventions. This collaborative program is entitled Project WAVE (Women Achieving Vital Empowerment), which is funded by a Targeted Capacity Expansion grant from the Center for Substance Abuse Treatment (CSAT) at SAMHSA.

As part of Project WAVE, staff at Gosnold, Independence House, and Safe Harbor all serve clients who potentially have serious mental illnesses and who are victims of domestic violence. All staff at Gosnold, Independence House, and Safe Harbor have been trained to screen for mental illness, substance abuse, and both current and past experiences of violence. The project funds at least one staff member at each agency who specializes in the needs of women with serious mental illnesses and co-occurring disorders who have been victims of domestic violence.

National Council members in Rhode Island have been successful in two counties, Kent and Woonsocket. In Kent County, the Kent Center, a community behavioral healthcare provider, collaborates with the Elizabeth Buffum Chace House, a domestic violence/sexual assault service provider, through regular referrals and ongoing treatment of shared clients. When a woman comes into the Kent Center, a trauma and crime assessment is part of the initial process. Kent Center staff has discovered that many of women with serious mental illnesses have also been victims of crime or trauma. The two agencies collaborate as needed and typically provide services to a specific client simultaneously. The Kent Center and Elizabeth Buffum Chace House staff work together to meet the needs of the clients treatment plan. The funding for this project comes from two Victims of Crime Act (VOCA) grants through the city, one focused on victims of trauma, the other focused on victims of crime.

Woonsocket County has a ongoing successful collaboration between NRI Community Services and Sojourner House. Women who have been victims of a crime and have a serious mental illness can receive services from either agency. Each agency has procedures in place to identify women who need treatment for both mental illnesses and victimization and to refer her for additional services. NRI also has a case manager on staff to help with any services that a woman may need that Sojourner House does not provide. The program is funded through a grant from Victims of Crime Act (VOCA).

In Pueblo County, Colorado, Spanish Peaks Mental Health Center, a community behavioral healthcare provider, collaborates with Posada, an agency serving the homeless, and the YWCA Domestic Violence Shelter, a domestic violence/sexual assault service provider. The agencies regularly refer women to each other, participate in ongoing treatment of shared clients, and have two full-time staff that split their time between the three agencies. The partnership is funded by a Projects for Assistance in Transition from Homelessness (PATH) grant.

One National Council member, Peace River, has taken a different approach to serving women with mental illness who have also experienced domestic violence or sexual assault. Peace River located in the Florida counties of Polk, Hardee, and Highlandsis a community mental health center with a certified domestic violence shelter and rape recovery resource center. The organization offers a full continuum of care for those who are mentally ill and for victims of domestic violence. Peace Rivers victims services are funded by a variety of sources, including: the State of Florida; the Florida Coalition Against Domestic Violence; United Way; county matching funds from both Polk and Highlands Counties; Florida Counsel Against Sexual Violence; the Florida Department of Health; and the Childrens Services Foundation.

State and Federal Legislation
Currently, the only enacted federal legislation that addresses women with disabilities generally is the Violence Against Women Act of 2000 (VAWA). As discussed below, VAWA includes grants to train police, service providers, and women with disabilities to recognize neglect, exploitation, and abuse involving women with disabilities. However, legislation addressing the intersection between behavioral healthcare and domestic violence is still in its infancy, and there is much progress still to be made.

In 2006, two state legislatures enacted domestic violence legislation that addresses behavioral healthcare in some way. In West Virginia, bill H.B. 4488 created the Comprehensive Behavioral Health Commission. According to the legislative findings, the Commission was created because the states behavioral healthcare system is rapidly moving toward a state of crisis as a result of overcrowding of the beds in state facilities and prisons, and inadequate community support services to prevent these problems. The members of the Commission include a representative from the West Virginia Behavioral Healthcare Providers Association, as well as several state agencies, advocates and professional organizations. The Commission is charged with studying the current status of prevention, treatment, education, related services and appropriate workforce development for behavioral health, including substance abuse and
domestic violence when those conditions have an effect upon the system. (emphasis added) The Commission recently held its first meeting, and its final report is due to the governor and the legislature on January 1, 2008. The West Virginia Department of Health and Human Resources then has until July 1, 2008 to submit a report regarding implementation of the Commissions recommendations.

In California, the Domestic Violence Shelter-Based Programs bill, AB 2084, revises the requirements applicable to domestic violence shelter-based programs that receive state funding. The bill requires domestic violence programs to provide services accessible to people with physical disabilities, when feasible, or refer them to a facility that may meet the persons needs. Unfortunately, the bill does not address accessibility for women with mental illness.

However, AB 2084 does mention the intersection between mental health and domestic violence in relation to four California counties. Alameda, Contra Costa, Solano, and the City of Berkeley. Under the bill, these four counties are permitted to increase their marriage license fees by a prescribed amount. The bill would require 96% of the additional fee be made available to organizations and agencies that assist in the prevention or early intervention of domestic and family violence, and the legislation explicitly states that the additional fees may be used for mental health and domestic violence purposes. On September 30, Governor Arnold Schwarzenegger signed AB 2084 into law.

Conclusion
The bills discussed above demonstrate that legislatures are beginning to acknowledge the need for service collaboration between behavioral healthcare and domestic violence services. Although the barriers to collaboration are challenging, the successful programs run by our members demonstrate that cooperation is possible, particularly when specialized funding is available.

The Criminal Justice Program of the Council of State Governments (CSG) is currently working with the National Council to develop a set of policy recommendations that will offer guidance to mental health service providers, victim service providers, and criminal justice personnel on how to collaborate to serve their shared population. The recommendations, which are due out 2007, will draw on examples of National Council members and other mental health service providers that appear to have achieved a significant degree of service integration with a victim service provider. CSG is developing these recommendations with support from the Center for Mental Health Services (CMHS) as a part of project to address the unmet needs of women with mental illness who have been victimized. For more information on this project and to access an issue brief that CSG has already developed on this population of women, please visit: http://consensusproject.org/projects/victims/vwmi/, or contact Hope Glassberg at hglassberg@csg.org.

Funding Special Programs for Women with Mental Illness
The issue of fragmented services for women with severe mental illness who have been victimized is increasingly a topic of discussion among mental health and domestic violence providers. Domestic violence and community mental health organizations, alike, cite funding as a reason why there is a lack of collaboration between the fields. While funding is always a challenge, there are innovative federal and state grants available that will fund collective projects between mental health and domestic violence providers. Below are some grants available for these types of projects, many of which have been used by National Council members to aid in developing successful programs.

The 2000 amendments and 2005 reauthorization of the Violence Against Women Act (VAWA) include grants to train police, service providers, and women with disabilities to recognize neglect, exploitation, and abuse involving women with disabilities. The following two federal VAWA grants can be used by providers.

The Education and Technical Assistance Grants to End Violence Against Women with Disabilities Grant Program (Disability Grant Program). This grant would assist with projects that provide education and technical assistance to ensure that women with disabilities can access the full array of services available to women who have been victimized. For information concerning this grant, click here.

S.T.O.P. VAWA Grant. The purpose of this grant is to develop and enhance victim services involving violent crimes against women. While the purpose does not specifically address disability, the list of targeted populations list underserved women with disabilities. This grant is administered through individual states and is subject to federal guidelines.

The Victims of Crime Act (VOCA) is federal legislation which allots grants to assist with victim services provider program. This grant offers funding for both emergency services, such as shelters, and training programs for providers. For information regarding this grant, click here.

The Federal Family Violence Prevention and Services Grant (FVPSA) is available to statewide nonprofit State Domestic Violence Coalitions. The grant provides funding for the prevention of family violence and immediate shelter for victims of family violence. The main goal of the grant is to develop and improve comprehensive services for victims of family violence. This grant would assist with the collaboration between domestic violence coalitions and behavioral healthcare providers, in order to design more cohesive and inclusive programs. The FVPSA Grant is available through individual states and is subject to federal guidelines.

SAMHSA has also previously granted funds for this issue. Two such SAMHSA grants have been used in Colorado and Massachusetts are Targeted Capacity Expansion from Center for Substance Abuse Treatment (CSAT) and Projects for Assistance in Transition from Homelessness (PATH). For more information regarding PATH, click here, and for the Targeted Capacity Expansion Program click here.

State Funding: In addition to federally funded programs, states have begun to address the need for interdisciplinary projects. Some such grants that have already funded projects can be found in Texas and Florida. For information regarding the State of Texas Victims' Assistance Discretionary Grant Program, click here.

Also, the success of Peace River in Florida, as discussed in this article, came from the support and recognition of the need by various different sources within Florida. Another state funding opportunity is Colorado's State and Local VALE (Victim Assistance and Law Enforcement) Grant. The purpose of State and Local VALE Grants are to fill in the gaps in victim services by funding programs which provide services on a statewide basis. For information regarding these grants, click here.

¹ Denice Wolf Markham, Mental Illness and Domestic Violence: Implications for Family Law, in Cearinghouse Review Journal of Poverty Law and Policy 24 (37, no. 1-2, 2003), available at http://www.lri.lsc.gov/pdf/03/030142_dv.pdf.

² Carole Warshaw et al., SPECIAL REPORT: Fragmented Services, Unmet Needs: Building Collaboration Between The Mental Health and Domestic Violence Communities, in Health Affairs 231 (22, no. 5, 2003), available at http://content.healthaffairs.org/cgi/reprint/22/5/230.

³ Ibid.

State Policy Focus is a monthly e-newsletter published by the National Council for Community Behavioral Healthcare. Director of State Policy - Tammy Seltzer.