“I know PTSD is not like a cold or the flu, something that you get over. It’s something I will have to contend with for the rest of my life. That’s okay. Thanks to Project WAVE I will continue to use and practice the new coping skills I have learned as well as the tools I’ve been given to help me make healthy, safe choices.” (WAVE client, 2004)
The Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment awarded a targeted capacity expansion grant to Barnstable County Massachusetts in October, 2004. The purpose of this grant was to provide on-site integrated trauma-informed screening, outreach, engagement, assessment, education, intervention, referral and care coordination for substance use/co-occurring disorders to women seeking services from two domestic violence/sexual assault agencies on Cape Cod. Women Achieving Vital Empowerment (Project WAVE) was among a handful of programs nationally which responded to an increasing awareness of the substance abuse needs of survivors of domestic violence through designing a program intervention located directly within non-clinical domestic violence programs (Swan, Farber & Campbell, 2000).
Project WAVE created a unique collaboration between Barnstable County (Cape Cod) MA, the Institute for Health and Recovery, Gosnold, Inc., Independence House and Safe Harbor. Through involvement in IHR’s WELL Project on Cape Cod, the partnering organizations identified the inability of the sexual assault/domestic violence providers to address substance use as a significant gap in services for women. The participating domestic violence agencies were Independence House, the community-based sexual assault/domestic violence agency, and Safe Harbor, a TANF-supported shelter for women and their children fleeing domestic violence. IHR provided the clinical oversight, supervision and training for integrating domestic violence, sexual assault, mental health and substance use services. Other participating agencies were Gosnold, Inc., the substance abuse treatment agency on Cape Cod and Advocates for Human Potential, the evaluators who worked closely with project staff and program implementers.
Women seeking services from the two domestic violence agencies were screened on intake for risk of substance use problems. Over the course of three years, a total of 550 women screened positive with 252 of these women enrolling in WAVE. Across the two sites, the demographic characteristics of the population were as follows:
- The population was predominantly white (78.3%)
- The average age was 34, with a range of 17 to 63
- Most women were mothers (87.5% had children, with an average of 2.2 children per woman)
- 16% had children living with someone else due to a child protective order
- Women were moderately well-educated; 39% completed high school and 39% had some post secondary education
- Women had low levels of employment (23% employed full- or part-time) and income (avg. $621/month).
Compared to the population at the community-based program, women at the domestic violence shelter, were younger, more likely to be non-white, more likely to be Latina, less likely to be in a relationship, more likely to have children or be pregnant, less likely to have completed high school, less likely to be employed, and much more likely to be unstably housed. However, the women at both sites were broadly similar in terms of trauma, mental health, and substance use status.
WAVE Intervention
WAVE was designed as a two-tier intervention targeting change at both the organizational level and the individual client level. The organizational goal was to build the capacity of the domestic violence programs to address the use of substances or other unsafe coping behaviors in response to the pervasive impact of trauma/violence and the relationship of this impact to substance use and other unsafe coping behaviors. The substance use treatment program goal was to identify current domestic violence and abusive relationships as barriers to recovery. Training on screening and the benefits of integrated, trauma-informed approach to services was provided for the domestic violence staff along with training on screening for domestic violence and unsafe relationships for the substance use staff.
At the individual client level, every woman was screened by the domestic violence staff and asked if she would like to meet with a WAVE Family Care Coordinator (FCC) to hear more about the program. If the woman chose to enroll in WAVE, she was assigned to an FCC and invited to access the following services:
- Family Care Coordination (FCC) including:
- Proactive and persistent outreach to engage women who screened positive
- On-site assessment, individual counseling and education regarding the interrelationship of SUD/CODs and trauma/violence
- Home or community-based visits due to rural community and limited access to public transportation
- Service planning and collaborative care coordination
- Seeking Safety skill-building groups to improve retention and reduce relapse
- The Nurturing Program for Families in Substance Abuse Treatment and Recovery
to provide relational parenting skills and WELL Child groups for children exposed to violence.
WAVE’s primary task was facilitating change in how the pervasive effects of the abuse were playing out in the present. Since actions in the present often involve some element of choice, modeling safer, more appropriate ways to accomplish tasks, partnering with women in their attempts to change and celebrating each step toward improved life skills and outcomes became an integral part of the WAVE intervention. Having conversations about where the choice points were and strategizing alternative options that lead to safer outcomes became a key component of the relationship between the woman and her Family Care Coordinator. Further, this encouraged the exploration of past safe, healthy choices that had allowed her to get to this point.
Women stayed in Project WAVE for relatively long periods of indicating that the program was generally successful in retaining women in treatment over extended periods of time. The average length of stay was 248 days (eight months), considerably higher than typical for substance abuse treatment programs for adult women. The FCC’s successfully delivered a total of 5,164 service contacts with participants over the life of the project. The average number of contacts per participant was 24, indicating that women had on average one contact every ten days spent in the program. Most contacts were in person; about one third were on the telephone. Because WAVE was designed to serve women with histories of trauma, who may be particularly wary of service providers and of forming trusting relationships, engagement was a particularly important outcome for this project.
The most frequently delivered services were individual counseling, case management, and treatment services. Due to the survivor dynamic of “come closer, stay away” and the sporadic use of services this creates, it was decided to make groups open-ended. The program implemented 16 multi-session Seeking Safety Groups and 12 multi-session Nurturing Program for Families in Substance Abuse Treatment and Recovery Groups (Nurturing Program Groups). About half (53%) of the women enrolled in Seeking Safety groups; 60% enrolled in Nurturing Program Groups.
Outcomes
WAVE resulted in improvements in women’s lives between baseline and follow-up assessments that were both statistically significant and practically important. All the statistically significant changes are in the positive direction, toward increased stability, decreased mental health symptoms, and greater economic resources. Because the women enrolled in WAVE were seeking help for domestic violence and not substance use, the baseline levels of reported use were quite low. In domains besides substance use, women made marked improvements in their status. Measures of symptoms associated with trauma and mental illness showed particularly strong changes. Using data from the Foa Trauma Symptom severity scale, the percentage of women meeting criteria for a PTSD diagnosis was more than cut in half—from 79% at baseline to 36% at follow-up. The percentage of women with Brief Symptom Inventory Global Severity Index scores outside the normal range, indicating the presence of significant psychological distress, dropped by almost ten percentage points from 72% to 63%. These improvements were not confined to one constellation of psychological symptoms: Scales indexing trauma symptoms, depression symptoms, and anxiety symptoms all showed statistically significant declines.
In the area of living conditions, more women felt safe in their current relationship at follow-up than at baseline (83% vs. 69%) and there was a marked improvement in housing stability. At baseline few women (39%) were stably housed, which is to be expected given the nature of the Safe Harbor shelter program. Indeed, at baseline only 3.8% of Safe Harbor participants reported being stably housed. By follow-up, women at both sites increased their housing stability; at Safe Harbor the increase was particularly strong with 56% of Safe Harbor women living in their own housing in the community. Women’s lives also showed an important improvement with an increase in part- or full-time employment from 26% to 42%.
Sustainability
Project WAVE marked an ambitious and challenging attempt to expand substance use disorder services into the domestic violence service system at two very different program sites—one community based and one residential. The provision of services that addressed trauma, violence, substance use and mental health issues in an integrated way was highly successful. Participant satisfaction and retention in services were both unusually high. Participants demonstrated improvement in trauma symptoms, mental health status, residential stability, safety, employment and economic status. The most effective demonstration of the success of Project WAVE is the fact that both domestic violence agencies continue to screen, assess and refer women seeking their services to substance use/co-occurring disorder treatment. Further, the substance use treatment agency is routinely screening for and referring women with current domestic violence/sexual assault. Staff from all three agencies who were trained in the train-the-trainer model continues to facilitate Seeking Safety (Najavits, 2002)and the Nurturing Program (Bogage et al., 2nd ed., 2006) parenting groups.
Client Feedback
Over 90% of participants agreed or strongly agreed that “my FCC was sensitive to my cultural/ethnic background, respected my values and beliefs, communicated clearly, talked about the relationship between domestic violence and alcohol/drug use, asked about any present threats to my safety, offered me skills to help me deal with symptoms resulting from violence and abuse, and treated me as if I were a whole person rather than pulling me apart into separate problems. Engagement and retention became important intermediate outcomes for any other outcomes to be achieved.
Proactive and persistent outreach
- “To have WAVE keep calling and calling…most people just call once and then forget it.”
Relationship with FCC
- “My FCC helped me understand me. I didn’t trust counselors before this; they said it was my fault.” “My Family Care Coordinator helped me find the strength and courage I needed.”
Home visits
- “It is [was] a very big help having my FCC be able to come to my home or meet me.”
Skill building groups
- “Seeking Safety meetings with the weekly commitments really helped me climb out of the rut I was stuck in.”
- “The parenting skills learned in the Nurturing Program helped me understand my children better.”
Download Project WAVE: An Initiative to Embed Substance Use and Co‑Occurring Disorder Services in Domestic Violence Settings (PDF)