Programming Opportunities
ABSTRACT
Objective: This study explores changes in the use of alcohol and other substances by women in British Columbia as they moved into shelters for abused women and again three months later. We see this time as a key life transition, and potentially a rich opportunity for influencing women's substance use behaviour. The purpose of this study was to document changes in the level of use of alcohol and other substances and the levels of stress among women as they moved through shelters for abused women.
Methods: Standardized questionnaires augmented by qualitative interviews were employed to measure alcohol and substance use, experiences of abuse, and levels and types of stressors facing women in this situation.
Findings: Significant reductions in women's use of alcohol and stimulants were observed from Interview I to Interview II, but there was no significant reduction in use of other depressants or tobacco use. Levels of stress decreased and sources of stress changed for the women after the shelter experience. Stress connected to relationship with partners had the most significant decrease, followed by mental health, housing, and legal issues. Women reported barriers to accessing financial aid and services for substance use outside of the shelter.
Conclusions: Women's experiences of violence and substance use were found to be interconnected in complex ways and changes in substance use were affected by a range of influences, such as financial concerns, mothering, relationships, levels of social support, and physical and mental health issues. Substance-using women who have experienced violence are an underserved population and a multi-sectoral response designed to address psychosocial, relational, and structural issues could better help them improve their overall health.
MeSH terms: Substance abuse; women; domestic violence; stress; social work
Few studies have investigated the use of alcohol and other substances by women experiencing violence.1 Rather, the majority of studies in this domain has focussed on the substance use of perpetrators of intimate partner violence (IPV) and the effect on families.24 However, several studies of substance-using women reveal high rates of IPV.5-12 Given this high prevalence of violence for women in substance use treatment, the study of substance use in the context of shelters for abused women and children is in need of exploration. For simplicity, henceforth the term "shelter" will be used to refer to "shelters for abused women and children".
There are many factors contributing to substance use among abused women. Many women use substances to cope with the trauma caused by childhood abuse,13-22 which can leave women vulnerable to further violence in intimate relationships.23 The impact of ethnicity and socio-economic status in women's experiences of substance use and IPV has also been noted, as women may use alcohol to cope with the negative effects of IPV21,24,25 and/or racism.20 Pregnant women and mothers who experience IPV and have substance use issues26,27 are often hesitant to seek help for fear of losing custody of their children, and/or because they feel guilty and ashamed.28,29 Additionally, substance-using women are often stigmatized and are not welcome in many shelters.30,31 Such issues, combined with a shortage of women-centred, integrated services are all barriers facing women seeking and receiving help on violence and substance use concerns.22,32,34
In this study, we examined substance use patterns and stressors among 74 substance-using women while at shelters, and three months later, to determine the substance use patterns and related health and social issues facing the women and the changes in both substance use and stressors affecting them in this critical period. Consideration of both barriers and supports to these changes is offered to support an improved response to women over diis key life transition.
METHODS
Ethics approvals were received from the Children's and Women's Hospital and Health Centre of British Columbia Review Board, and the University of British Columbia Ethics Review Committee.
Procedure
Thirteen shelters across British Columbia were selected to participate in this study. Over an 18-month period, shelter staff described the study to new residents within the first three days of their arrival. Women who agreed to participate in the study signed a consent form and completed a confidential one-page screening form that measured the frequency and duration of their substance use. Only women with significant levels of substance use (more than 5 times per week, excluding nicotine and/or poly-substance use and/or self-reported problematic use) in the preceding three months were eligible to participate in the study.
Seventy-four women participated in the study and were interviewed twice, with the initial interview taking place while the woman was at the shelter (Time 1) and the second interview conducted on the telephone three months later (Time 2). Interviewers administered a demographic questionnaire, several standardized surveys, followed by a series of open-ended qualitative questions. Each participant received $30 cash or a grocery voucher for each interview.
Measures
Demographic data were collected regarding age, ethnicity, sexual orientation, income, education, partner status, number of children, and any current custody problems. This study used the Timeline Followback (TLFB) Calendar35 to measure alcohol and substance use and the Stressors Questionnaire (SQ) to assess causes of anxiety or stress. Participants were also asked a series of qualitative, semi-structured questions designed to gather additional information in the woman's own words (see Appendix).
Data analysis
Descriptive statistics were calculated for all demographic variables and questionnaire items and comparisons were made between Time 1 and Time 2, using repeated measures tests and the Wilcoxon signed-rank test as appropriate. Qualitative portions of interviews were coded thematically using Ethnograph software. All interviews were coded inductively using a grounded theory approach, with new codes and subcodes being defined as they emerged.36,37
RESULTS
One hundred thirty-seven women screened into the study. Time 1 interviews were completed for 125 women and of these, 74 were successfully contacted for a second interview approximately three months later, representing a follow-up rate of 59.2%. The mean age was 35 years. Selected demographic results for the 74 women who completed bodi interviews are shown in Table I.
Significant reductions in frequencies of both alcohol and stimulant use (e.g., cocaine) were observed among the sample between the time of first accessing help from a shelter and three months later. In contrast, neither medical use of depressants (depressants used in a prescribed fashion) nor non-medical use of depressants (depressants other than alcohol taken in any way other than prescribed) showed significant decreases. Use of tobacco showed no significant decrease (see Table II).
When stressors affecting the women were compared from Time 1 to Time 2, a significant decrease in level of stress was observed for many of the major issues (see Table III). Predictably, stress connected to relationship with partners had the most significant decrease, followed by mental health, housing, and legal issues.
The qualitative data revealed complex interrelationships among women's experiences of violence, substance use, and a variety of psychosocial and structural issues. We categorized the primary interrelated types of issues as: psychosocial, relational, and structural and environmental. Table IV presents the women's experiences by category.
Psychosocial issues
The qualitative findings provided further evidence that substance use and violence are enmeshed in complex ways and that it is not possible to assign causality. Many women described their substance use as a means of coping with violence and stressors and others said that their substance use left them susceptible to abuse. "I used it to cope with the violence and would then put up with more violence. Using (drugs) only served to numb me - that was the only benefit - I got used and abused" (a study participant). Some women's substance use was affected by physical, psychological, and/or sexual abuse they experienced in childhood or earlier intimate relationships. Though not directly queried, the number of women who disclosed that they had been abused as children was notable, and some said they used alcohol and other substances to cope.
Many of the women were experiencing chronic physical and mental health issues which exacerbated their substance use, and/or made it harder for them to leave abusive relationships. These health issues were frequently affected by the violence and served to limit their options. For example, one woman said her chronic pain "increased ten times with the stress of abuse/violence," adding, "This makes it much, much harder to do the self-regulation (i.e., self-hypnosis and meditation) that I use for pain control" (a study participant).
Relational issues
The women recounted a number of issues they faced with their partners, family, and children. Many women had delayed leaving abusive partners because they feared losing custody of their children and/or feared for their children's safety if they left them with their partners. Some mothers had relinquished custody of their children in order to escape their abusive partners while others left abusive partners in order to protect their children. Numerous women said that their substance use and experiences of violence were affected by the degree of support they received from their family of origin. These relational concerns were further aggravated by ongoing pragmatic stresses, such as divorce settlement proceedings and financial concerns.
Structural and environmental issues
Financial concerns were a key stressor for the women. In turn, finances affected other stressors such as mothering issues, housing, access to services, legal concerns and health problems. Many participants had problems navigating the social services system as programs were not coordinated to address the issues of substance-using women who experience violence. The time women spent seeking appropriate assistance often hindered their efforts to address their substance use. For example, one participant was unable to attend an appointment with her alcohol and drug counsellor because she was in a job search program which was a requirement for social assistance recipients. Another woman talked about lack of formal social supports, saying "[you] have a feeling of togetherness when at the house (support with peers) that is hard to create again after leaving the house. Being alone again without the safety net can cause depression and hopelessness. Pretty soon you can't cope again and turn back to your addictions."
The role of the shelter in women's lives
Many women found support from the shelter staff and assistance connecting to services to help them make positive changes in their life. One woman said, "The shelter really helped provide emotional support. The workers helped me to get back on my feet... The staff encouraged me to believe in myself.... They helped me with everything so I don't think they could have helped me any better or done anything differently or more." Other women described the shelter staff as understanding of the issue of substance use and encouraging of change. "The shelter helped me realize it wasn't my fault I had been abused by my spouse and that being drunk during the abuse didn't make it my fault. They pointed me towards helping agencies and encouraged me to approach them." Another woman said, "They (the shelter staff) directed me to A&D counselling. They have provided me with information. Speaking to the women here has made it easier to admit I have an alcohol problem."
DISCUSSION
Four key findings emerged from this study. First, women's use of alcohol and stimulants generally decreased between entering the shelter and the follow-up three months later. In contrast, use of other depressants and tobacco remained relatively constant over the study period. second, substance use and intimate partner violence are not linked in a linear manner, but interconnect in a web of social and structural issues that may improve or deteriorate in parallel. Third, the women's overall substance use was influenced by multiple factors but assistance received at a shelter played a pivotal role in helping restructure their lives in several key areas. Finally, consideration of psychological stress as the key determinant influencing use of alcohol and other substances provides only a limited understanding of women's experience with IPV and does not allow for opportunities to identify the need for structural change.
This research demonstrates a need for greater collaboration among substance use treatment providers, health and social service providers, and more integration of services for women experiencing violence. The findings reinforce previous studies that recommend better social service integration,38,39 increased implementation of substance use interventions at shelters,5,30,40 and improved service provision for substance-using women experiencing violence.15,41 Shelters provide invaluable assistance to substance-using women experiencing violence, but further training of providers is required on issues such as the over-prescription of benzodiazepines and antidepressants to women in abusive situations and the integration of tobacco interventions into addictions treatment and violence services. Continued support is clearly necessary to address the stressors women encounter after leaving the shelters. Suggestions include more assistance regarding streamlined social assistance programs; subsidies for safe, affordable housing and childcare; education and employment training opportunities; and appropriate addictions counselling and health care services.
There are a few limitations to this study. It is difficult to track community samples of people who use substances42 and people who have experienced partner violence.43 A large proportion (40.8%) of women did not complete the interview at Time 2. We speculate that many of the women may have moved between interviews, and others may have preferred not to participate if they had returned to abusive partners. Ideally, an extended period of follow-up research would help to determine whether the positive changes in substance use that we observed are temporary or sustained among women after they leave shelters and resume their lives.
[Reference]
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Received: March 29, 2005
Accepted: January 27, 2006
RESUME
Objectif : Cette �tude porte sur les changements dans la consommation d'alcool et d'autres drogues chez les femmes de la Colombie-Britannique au moment o� elles entrent dans des maisons de refuge pour femmes victimes de violence, ainsi que trois mois plus tard. Il s'agit l� selon nous d'une importante p�riode de transition, qui pourrait �tre une occasion id�ale d'influencer la consommation d'alcool ou de drogues de ces femmes. Notre �tude visait � documenter les changements dans les niveaux de consommation et de stress des femmes qui font appel aux maisons de refuge pour femmes violent�es.
M�thode : Nous avons employ� des questionnaires normalis�s, doubl�s d'entretiens en profondeur, pour mesurer la consommation d'alcool ou de drogues, la violence v�cue, ainsi que les niveaux de stress et les types d'agents stressants auxquels les femmes sont confront�es dans ces situations.
Constatations : Nous avons observ� d'importantes r�ductions dans la consommation d'alcool et de drogues des femmes entre le 1er et le 2e entretien, mais pas de baisse significative de la consommation d'autres neurod�presseurs, ni du tabagisme. Les niveaux de stress ont diminu� et les sources de stress ont chang� pour les femmes apr�s leur s�jour en maison de refuge. Le stress li� aux relations intimes affichait la baisse la plus prononc�e, suivi des probl�mes de sant� mentale, des probl�mes de logement et des probl�mes juridiques. Les femmes ont mentionn� des obstacles � l'acc�s � l'aide financi�re et aux services de toxicomanie � l'ext�rieur des maisons de refuge.
Conclusions : La violence v�cue par les femmes et leur consommation d'alcool ou de drogues �taient li�es de multiples fa�ons, et les changements dans la consommation d'alcool ou de drogues �taient influenc�s par une gamme de facteurs, dont les inqui�tudes financi�res, la maternit�, les relations intimes, les niveaux de soutien social et les probl�mes de sant� physique et mentale. Les consommatrices d'alcool ou de drogues qui ont subi de la violence sont une population mal desservie; une intervention multisectorielle ax�e sur les enjeux psychosociaux, relationnels et structuraux pourrait mieux les aider � am�liorer leur sant� en g�n�ral.
[Author Affiliation]
Lorraine Greaves, PhD1,2
Cathy Chabot, MA1
Natasha Jategaonkar, MSc1
Nancy Poole, MA1
Lucy McCullough, BSc1
[Author Affiliation]
La traduction du r�sum� se trouve � la fin de l'article.
1. British Columbia Centre of Excellence for Women's Health, Vancouver, BC
2. Clinical Professor, Faculty of Medicine, University of British Columbia, Vancouver
Correspondence and reprint requests: Dr. Lorraine Greaves, BCCEWH, BC Women's Hospital, E-311 4500 Oak St., Vancouver, BC V6H 3N1, Tel: 604-875-2633, Fax: 604-875-3716, E-mail: lgreaves@cw.bc.ca
Acknowledgements: This research was conducted by the British Columbia Centre of Excellence for Women's Health and funded by the Alcoholic Beverage Medical Research Foundation. We thank the BC and Yukon Society of Transition Houses and all the women who participated in this study, Ren�e Cormier for her contributions to the design and early phases of the project and Anne VanderBijI for coordinating the interviews.
