1. 4/29/2010
THE PERINATAL IMPLICATIONS
OF SUBSTANCE ABUSE,
DEPRESSION AND VIOLENCE
A Workshop Presented by
José A. Rivera, J.D.
Rivera, Sierra & Company, Inc.
jrivera@riverasierra.com
FACES OF
VIOLENCE
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QUESTION
In our agency, our work be a lot easier if
the clients would only…
QUESTION
Women stay in abusive relationships
because…
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3. 4/29/2010
Mirror, Mirror
On the wall,
Who s
Who’s most unbiased
Of them all?
LOOK IN THE MIRROR
 Even good people have biases
 Even good staff have issues
 Even good counselors need to understand
boundaries
 Even good listeners are under pressure to
judge or superimpose one’s values or
one s
upbringing on another
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4. 4/29/2010
OTHERING
 Consider the following pronouns:
5 demonstratives: the, this, that, these, those
2 personal pronouns each with four forms: thou,
thee, thy, thine; they, them, their, theirs
 The TH sound is used by speaker to differentiate
the speaker from the person spoken about so a
third party will know and understand that the
speaker is different from the person spoken
about.
Domestic
Violence
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1 4
Substance 3 Depression
Abuse
What does this mean?
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5. 4/29/2010
THE ADVOCACY/SELF ADVOCACY RELATIONSHIP
Time
P
e
r
c
Self-Advocacy
e
n
t
a
g
e
/
A
Advocacy
m
o
u
n
t
© 2005 Rivera, Sierra & Co., Inc.
ADVOCACY/SELF ADVOCACY
 When a client comes to us, they are often in
need of 90% advocacy and bring with them
about 10% self-advocacy.
 The goal of case management is to reverse this
over time so that, in the end, a client is a 90%
that end
self advocate and relies upon systems for 10%
advocacy.
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6. 4/29/2010
A VICTIM
 Can be found within any level of education
 Can be found within any level of job
satisfaction
 Can be poor as well as extremely rich
 Can be physically beautiful as well as not
 Can be childless, childbearing, pregnant
 Can be preconceptional or interconceptional
 Can be straight, gay/lesbian, transgender
THE VICTIMS
“When people meet me, and find out
that I ve been in an abusive
I’ve
relationship,
they just can’t believe it.”
“Looking at me, with all the things
I’ve done in my life..
They think, how could I have been in
Stacy
a relationship like that?”
First American woman to summit
Mount Everest
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7. 4/29/2010
THE VICTIMS
“Either dinner wasn’t exactly what
he wanted, the house wasn t
wanted wasn’t
immaculate, I didn’t look
presentable enough…
any excuse at all, really…
and it was always my fault.”
“ It was very debilitating,
I ended up walking on eggshells.
I began questioning my own
competence to do anything.”
Psychosocial Definition
of Domestic Violence
The use of physical, sexual, economic, and/or
s p ys c , s , c c, d/
psychological/emotional abuse by one person in
an intimate or social relationship in order to
establish and maintain power and control over
the other person.
This power and control becomes a pattern of
behavior not just for the abuser but also for the
abused as well.
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8. 4/29/2010
Example A:
Abuser Uses Abuse to Hurt
Example B:
Abuser Uses Abuse to Get
Power &
Control
DOMESTIC VIOLENCE = BEHAVIOR
 Because it is learned
 Because it evolves over time
 Because it becomes engrained and second
nature
 Because it becomes natural
 And then it becomes nature
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9. 4/29/2010
The Mind of the Abuser
The New Cycle of Domestic Violence
New
Abuse
Setup Self-Directed Guilt
Rationalization
Planning
Fantasy False Normality
Isolation
The Buzz
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10. 4/29/2010
THE MIND OF THE ABUSER
 Excuse Making  Fragmentation
 Blaming  Minimizing
 Redefining  Anger
 Success Fantasies  Power Plays
 Lying  Playing Victim
 Assuming  Drama and Excitement
 Above the Rules  Closed Channel
 Making Fools of Others  Ownership
 Self-glorification
Addiction
“A chronic progressive relapsing disorder
A progressive,
characterized by compulsive use of one or
more substances that results in physical,
psychological, or social harm to the
individual and continued use of the
substance or substances despite this
harm.”
Schnoll, 1986
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11. 4/29/2010
CHARACTERISTICS OF ADDICTION
 A Brain Disease
 Chronic
 Progressive
 Ignores Adverse Circumstances
 Relapse
 Treatable
 Reversible
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12. 4/29/2010
ADDICTED CLIENT CHARACTERISTICS
 50% + History of intergenerational TANF
 50% + have abuse/violence histories
 50% + have criminal justice issues
 50% + have CPS issues
 50% + resisted employment efforts
 50% + lack HS diploma or GED
 50% + had teenage pregnancy
The Layers of Trauma
Alcohol and
Substance Abuse
MH Issues
PTSD, OCD, BPD
LD/CD
Trauma
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13. 4/29/2010
WOMEN AND TRAUMA
“The core experiences of psychological trauma are
disempowerment and disconnection from others.
others
Recovery, then, is based upon the empowerment of the
survivor and the creation of new connections. Recovery
can take place only within the context of relationships; it
cannot occur in isolation (p. 133).”
Herman, Trauma and Recovery (1992)
THE POWER OF RECOVERY
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0
2 © 2005 Rivera, Sierra & Co., Inc.
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14. 4/29/2010
DOMAINS/TYPES OF DOMESTIC VIOLENCE
 Physical
 Sexual
 Economic
 Psychological/Emotional
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15. 4/29/2010
PHYSICAL VIOLENCE
 Scratches, bites, grabs or spits at a current or former intimate partner.
 Shakes, shoves, pushes, restrains or throws her.
 Twists, l
T i t slaps, punches, strangles or b
h t l burns th victim.
the i ti
 Throws objects at her.
 Physically restrains her from movement.
 Puts her in fear of possible assault or battery
 Subjects her to reckless driving.
 Locks her in or out of the house.
 Refuses to help when she’s sick, injured or pregnant, or withholds
medication or treatment.
 Withholds food as punishment.
 Abuses her at mealtime, which disrupts eating patterns and can result
in malnutrition.
 Abuses her at night, which disrupts sleeping patterns and can result in
sleep deprivation.
 Attacks her with weapons or kills her.
SEXUAL VIOLENCE
 Is jealously angry and assumes she will have sex with anyone.
 Withholds sex and affection as punishment.
 Calls her sexual names
names.
 Pressures her to have sex when she doesn’t want to.
 Insists that his partner dress in a more sexual way than she wants.
 Coerces sex by manipulation or threats.
 Physically forces sex or is sexually violent.
 Coerces her into sexual acts that she is uncomfortable with, such as sex
with a third party, physically painful sex, sexual activity she finds offensive or
verbal degradation during sex.
 Inflicts i j i that
I fli t injuries th t are sex-specific.
ifi
 Denies the victim contraception or protection against sexually transmitted
diseases.
 Deliberately infects her with a STD in order to make her less desirable to
others.
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16. 4/29/2010
ECONOMIC VIOLENCE
 Controls all the money.
 Doesn’t let her work outside the home or
sabotages her attempts to work or go to school.
 Refuses to work and makes her support the
family.
 Ruins her credit rating
rating.
 Uses household money to buy gifts as apology
for violence instead of paying bills.
PSYCHOLOGICAL VIOLENCE
 Verbally attacks and humiliates his partner in private or public.
 Attacks her vulnerabilities, such as her language abilities, educational
level,
level skills as a parent, religious and cultural beliefs or physical
parent
appearance.
 Plays mind games, such as when he denies requests he has made
previously or when he undercuts her sense of reality.
 Forces her to do degrading things.
 Ignores her feelings.
 Withholds approval or affection as punishment.
 Regularly threatens to leave or tells his partner to leave.
 Harasses her about affairs he imagines her to be having
having.
 Stalks her.
 Always claims to be right.
 Is unfaithful after committing to monogamy.
 Controls her schedule, actions, cell phone, etc.
 PAVLOV
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17. 4/29/2010
IMPACT OF VIOLENCE
What is the Domino Theory?
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18. 4/29/2010
MEDICAL IMPACT OF PHYSICAL VIOLENCE
ON PREGNANCY
 Insufficient weight gain  Delayed prenatal care
 Vaginal/Cervical/Kidney  Miscarriage
infections
 Low birth weight
 Vaginal bleeding
 Ruptured membranes
 Abdominal trauma
 Separation of the placenta
 Hemorrhage
 Uterine infection
 Increase of chronic illness
 Fetal bruising, fractures, and blood
 Complications during labor clots
 Irritable Bowel Syndrome
Source: American Medical Association
TRAUMA AND PREGNANCY
“Maternal anxiety disorders have been linked
with low birth weight and irritable neonatal
behaviors as well as a doubled risk of
hyperactivity.”
“Women with PTSD during pregnancy were at
higher i k for t i
hi h risk f ectopic pregnancy, spontaneous
t
abortion, and hyperemesis (nausea) than were
those who did not have PTSD.”
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19. 4/29/2010
TRAUMA AND PREGNANCY
“Pregnant women who had experienced
childhood sexual abuse, domestic violence or
rape as an adult, exposure to a violent crime,
or another interpersonal trauma exhibited a
lower quality of attachment to their unborn
q y
children.”
TRAUMA AND PREGNANCY
“In addition, infants of mothers who were
depressed during pregnancy show
changes in neurobehavioral functioning
and are more withdrawn, irritable, and
inconsolable than infants of
asymptomatic women.”
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20. 4/29/2010
TRAUMA AND PREGNANCY
“Asthmatic women are at risk for
idiopathic preterm labor, preeclampsia,
hypertension, chorioamnionitis, and
cesarean delivery, and their infants are at
risk for preterm birth and low birth
weight.”
TRAUMA AND PREGNANCY
“Women with eating disorder symptoms during
pregnancy are at higher risk for cesarean
section and have more difficulty maintaining
breast-feeding than women without eating
disorder symptoms.”
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21. 4/29/2010
Signs and Symptoms of DV
SIGNS AND SYMPTOMS OF DV
Behavioral cues
 Changes in appointment pattern — This may reflect the abuser’s desire to
hide physical indicators of abuse (scratches bruises, welts) and control
(scratches, bruises
the victim’s access to information and possible support. Cancellation of
two or more appointments by a male partner is indicative of possible
domestic violence.
 Overprotective partner — The partner frequently or always accompanies
the patient, seems controlling and always speaks for her.
 Threatening partner — Batterers may glare at their partners, use
threatening words or gestures, restrict their partner’s movements, or use
other tactics designed to maintain power and control over victims and
anyone offering assistance.
ff i i t
 Multiple visits for vague somatic complaints — Battered women use
medical services eight times the rate of non-battered women, yet are
identified and referred to domestic violence programs only 4-6% of the
time.
 Late entry or sporadic utilization of prenatal care.
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22. 4/29/2010
SIGNS AND SYMPTOMS OF DV
Physical cues
 Poor management of asthma, diabetes, or other
chronic conditions
 Chronic pain
 Headache
 Pelvic or abdominal pain
 Dyspareunia
D i
 Irritable Bowel Syndrome
 Somatization Disorder
 Frequent vaginal or urinary tract infections
SIGNS AND SYMPTOMS OF DV
Psychosocial cues
 Chronic substance misuse/ alcohol or other drug addiction. While
not a cause of addiction domestic violence may be a co occurring
addiction, co-occurring
problem.
 Stress-related symptoms such as fatigue, anxiety, headache,
difficulty concentrating, appetite disturbances, palpitations,
dizziness, paresthesia (pins and needles), and dyspnea (shortness
of breath).
 Post traumatic stress disorder (PTSD) symptoms including
hypervigilance, exaggerated startle response, feeling detachment
from others, sense of shortened future, difficulty sleeping and
irritability or outbursts of anger. (For many battered women there
is nothing ‘post’ about their stress. Providers are encouraged to
screen all women presenting with PTSD symptoms for both past
and current abuse histories).
 Eating disorders
 Depression
 Suicide attempts
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23. 4/29/2010
THANK YOU AND REMEMBER
Honor Recovery
Honor People in Recovery
And in doing that
Honor Yourself
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