Written for domestic violence advocates, direct service providers, policymakers, and anyone else with an interest in working to improve agency and system responses to domestic violence, the Center Quarterly will provide updates and analysis on the latest news and research related to trauma, domestic violence, mental health, and substance abuse, as well as updates on our work at the National Center.
The Center’s mission is to develop and promote accessible, culturally relevant, and trauma-informed responses to domestic violence and other lifetime trauma. We offer training, support, and consultation to advocates, mental health and substance abuse providers, legal professionals, and policymakers as they work to improve agency and systems-level responses to domestic violence. We also work to develop and promote policies that facilitate collaboration between systems and improve system responses to domestic violence, and to analyze and promote research that advances knowledge and builds the evidence base for responding to trauma in the lives of domestic violence survivors and their children. Our work is survivor defined and rooted in principles of social justice.
Earlier this fiscal year, the Center received renewal funding and designation as a Special Issue Resource Center from the Family Violence Prevention and Services Program; Administration on Children, Youth and Families; U.S. Department of Health and Human Services. Many of the exciting projects planned for this grant period are already underway. One of the major goals of the Center is to contribute to building an evidence base for trauma-informed approaches and trauma-specific interventions in the context of domestic violence. As part of this effort, we are currently conducting a formal literature review of the existing research on the effectiveness of trauma-informed approaches and trauma-specific interventions. In collaboration with others in the field, we will then analyze the results of this review, including the cultural relevancy of currently available approaches and interventions as well as their effectiveness for individuals who are experiencing ongoing abuse.
Earlier this year, we partnered with the National Domestic Violence Hotline to administer two focus studies on Mental Health Coercion and Substance Abuse Coercion. These studies will confirm qualitative data from advocates and survivors that mental health and substance abuse coercion—such as doing or saying things to make a partner feel “crazy,” telling a partner that she will not be believed or that she will lose custody because of her mental health history, interfering with a partner’s treatment or medication, or coercing or forcing a partner to use alcohol or other drugs—are common tactics used by abusers against their partners. Preliminary results of this study were recently presented by Center staff at the July 2012 National Coalition Against Domestic Violence Conference in Denver, Colorado. We will soon be announcing the final results of these surveys via our email list and through our website.
Over the past several months, the Center has received numerous requests from DV coalitions for assistance in meeting the new requirements regarding trauma-informed DV advocacy that appeared in the most recent Funding Opportunity Announcement. In response to these requests, the Center is working to expand access to our training and technical assistance on subjects including core elements of trauma-informed services and organizations, strategies for building collaboration with mental health and substance abuse providers, supporting survivors who are parenting, and other topics. The Center is also in the process of conducting a national baseline survey of the 56 state and territory coalitions. The results from this survey will inform our work as we develop strategies to assist coalitions in supporting their member programs to do trauma-informed work with survivors. This fall, the Center will also be offering assistance to the 56 coalitions in developing and conducting baseline needs assessment surveys of their member programs and analyzing the data.
Plans are also underway to increase the breadth and scope of the Center’s training and technical assistance work by launching a Training Institute, which will include a Training-of-Trainers program. This program is designed to provide coalitions with the training, support, and resources that they need to serve as facilitators to their local constituencies as they develop accessible, culturally relevant, and trauma-informed responses to domestic violence.
The Center also works to influence mental health policy in order to improve agency and system responses to domestic violence. This year, our plans in this area include collaborative work with several mental health organizations, including working with the National Association of State Mental Health Program Directors (NASMHPD) to develop Recommendations for Collaboration Between the Domestic Violence and Mental Health Fields. The Center is currently coordinating with NASMHPD staff to plan an initial meeting to begin the process of developing these recommendations and to lay the foundation for future collaborative work.
The Center will continue to provide updates on our work, including opportunities to get involved, through our email list and in the next issue of the Center Quarterly. If you are not currently subscribed to our email list, click here to subscribe. (Link: http://www.nationalcenterdvtraumamh.org/newsletter-sign-up/) Thank you for your interest in our work!
The Affordable Care Act and Mental Health Care Coverage: Implications for Survivors and Opportunities for Advocates
A Question & Answer with Sarah Steverman, Director of State Policy, Mental Health America
Access to health and mental health care is a critical issue for survivors of domestic violence, many of whom experience the health and mental health consequences of abuse. The Affordable Care Act (ACA)—while it does not guarantee comprehensive healthcare coverage for all Americans—has the potential to make some significant improvements in access to mental health coverage as well as to increase access to health care for people diagnosed with mental illness or who are experiencing psychiatric disability. It is therefore important for those working in the DV field to stay informed of the potential benefits of the ACA for survivors as well as to partner with mental health advocates to take advantage of opportunities created by the ACA to advocate for health and mental health care.
As the ACA shifts access to health and mental health care in this country, the DV field may also have opportunities to advocate for a broader reform agenda—for a health and mental health system that is truly trauma informed and responsive to the needs of domestic violence survivors and their children.
The Center Quarterly will cover topics relevant to the ACA, with a specific emphasis on mental health and substance abuse and the implications for survivors. For this issue, we asked Sarah Steverman, Director of State Policy at Mental Health America, to answer a few questions related to the benchmark benefits and essential benefits provisions of the ACA.
|Under the Affordable Care Act, insurance plans sold through the exchanges must provide coverage for the following services:
Mental health and substance abuse disorder treatment is one of the ten “essential health benefits” designated under the ACA. That means that every insurance plan that is sold through the insurance exchanges must provide coverage for these services. But who decides what must be covered?
Each state will have an insurance exchange, or a marketplace where consumers can go to purchase health insurance in a transparent way. As you stated, mental health and substance abuse disorder treatment must be offered in all of the plans sold in the exchange. Some states will operate their own exchanges and some will rely on the federal government to operate them, but each state will have the opportunity to determine exactly what types of coverage will be required of plans sold through their exchange, within the guidelines provided by the ACA and the federal Department of Health and Human Services (HHS). HHS will ultimately need to approve states’ plans, but states will have flexibility in their determination of the coverage requirements within each of the essential benefit categories.
Any plan provided in the exchange, however, will be required to comply with the 2008 Mental Health Parity and Addiction Equity Act. This statute requires plans to offer mental health and substance abuse disorder treatment at parity with, or equal to, the coverage offered for medical/surgical benefits. The details of the parity requirements that were included in the law and a subsequent regulation from the federal government will serve as a minimum requirement for the mental health and substance use benefits offered in the exchange plans.
Given the flexibility that states have to determine coverage and the need to scrutinize states’ plans for their compliance with parity, advocacy by the mental health, substance use, and DV communities at the state level is crucial. State and local advocates, with the assistance of national level partners, should be assessing their states’ plans for mental health and substance use coverage, and promote the inclusion of services that are comprehensive and include prevention, early intervention, and trauma-informed treatment.
By September 30, 2012, states are required to select their benchmark benefit plans. What is the significance of the benchmark plan?
A benchmark plan is an insurance plan that has already been established that will serve as the basis for the plans offered in the state exchanges. HHS has provided states with ten possible plans to choose from in order to use as the benchmark. The chosen plan must cover each of ten essential health benefits (EHB) specified in the ACA, including mental health and substance disorder services, or else the missing benefits must be added. States have the option of choosing from one of the three largest small group plans in the state by enrollment, one of the three largest state employee health plans by enrollment, one of the three largest federal employee health plan options by enrollment, or the largest HMO plan offered in the state’s commercial market by enrollment. If these plans do not include all of the ten essential health benefits and meet parity requirements, those benefits must be added before it can serve as the benchmark. Additionally, if a state fails to make that selection by September 30th, HHS will use the largest small group plan in the state as the default benchmark plan.
Mental health advocates spent the summer assessing the ten benchmark plan options in their states and determining which plan will provide the best standard for people with mental health and substance use conditions. After states submit their plan selections to HHS at the end of the month, advocates will have the opportunity to take a closer look at the selected benchmark plan and advocate for the addition of covered benefits in order to bring the benchmark plan into compliance with the ten essential benefits and federal parity requirements. The mental health and substance use community will be interested in partnering with the DV community to ensure that the final benchmark used for all plans participating in the exchange is adequate and comprehensive.
Will the essential health benefit and federal parity requirements apply to all insurance plans? Are Medicaid plans required to comply as well?
All plans sold on the individual or small business market will be required to comply with the exchange requirements. Insurance companies will not be allowed to offer a less comprehensive plan outside the exchange, which could result in plans being sold to consumers without a full understanding of which services are not covered or the fees that might apply when treatment is accessed.
As those states that will be participating in the Medicaid expansion programs begin to establish their plans for expanding Medicaid coverage to all individuals who make between 0-133% of the federal poverty level, they will be utilizing a benchmark plan to determine covered services. Although the benchmark plan used for this may be different from the one used in the exchange, there will be a standard established in each state to require mental health and substance abuse disorder benefits to be offered at parity to the Medicaid expansion population. Further guidance on these requirements is forthcoming from the federal government, and states will be expected to make more decisions about the design of the plans. The mental health, substance use, and DV communities should be aware of opportunities to be involved in the plans for the Medicaid expansion benefits.
What can the DV field do to support the efforts of mental health advocates working to make sure that the essential health benefits for mental health and substance abuse services are comprehensive?
The mental health community welcomes any and all partners who are interested in advocating for comprehensive mental health and substance use coverage as part of ACA implementation particularly with regard to states’ EHB plans. The Coalition for Whole Health (CWH), of which Mental Health America (MHA) is a part, has developed EHB Consensus Principles and Service Recommendations that endorse full and comprehensive coverage. CWH member chapters and affiliates, including MHA affiliates in 39 states, are using these recommendations at the state level to advocate for their benchmark plan. DV advocates who are interested in getting involved can contact the MHA affiliate in their state, view MHA’s health reform resources, consult CWH local and state resources, or track your state’s implementation progress at http://www.statereforum.org.
We look forward to the involvement of the DV community in our work to implement the ACA in a way that is meaningful to those who need mental health and substance use services. Please feel free to contact me if you would like more information about health reform or if I can help connect you to advocates in your community.
For more information about the Affordable Care Act, see the following resources:
- Kaiser Family Foundation, Summary of Coverage Provisions in the Affordable Care Act, at http://www.kff.org/healthreform/8023.cfm
- Center on Budget Priorities, Health Reform: http://www.cbpp.org/research/index.cfm?fa=topic&id=71
- National Health Law Program, Health Reform: http://www.healthlaw.org/index.php?option=com_content&view=article&id=456&Itemid=212
A recently released report, Meeting Survivors’ Needs Through Non-Residential Domestic Violence Services & Supports: Results of a Multi-State Study, by Eleanor Lyon, PhD, Jill Bradshaw, PhD, and Anne Menard, examines the services being provided at 90 DV programs most of which are located in 4 geographically diverse states, but which also include programs specifically identified by “culturally specific organizations with a national presence” (the Institute on Domestic Violence in the African American Community, the Asian Pacific Islander Institute on Domestic Violence, Casa de Esperanza, and the Women of Color Network). Programs they recruited came from 11 additional states. The report documents the services being provided by DV programs as well as the self-reported needs and experiences of survivors who received services at these programs.
The report demonstrates that DV programs are now meeting a broader range of survivors’ needs than ever before (whether directly or in collaboration with other community agencies), including needs related to physical and mental health, economic security, legal and immigration issues, and transportation. The ability of DV programs to increasingly meet the complex needs of survivors and their children despite ongoing economic crises and budget cuts that often require them to “do more with less” speaks to the commitment of the DV field to serving survivors and effecting social change.
The report also provides guidance on areas where the DV field needs continued resources and support to meet the needs of survivors. In response to questions about the types of things that they wanted help with, over 1/3 of survivors (40%) specifically stated that they wanted “help with mental health services,” and the majority of survivors (88.5%) responded that they wanted “information about counseling options.” When asked if they considered themselves to have a disability or disabling condition, 21% of survivors responded “yes,” and described a number of physical and mental health conditions including anxiety, depression, and posttraumatic stress disorder.
In response to questions about serving survivors with disabilities or other needs, 67% of DV programs reported that their physical building was fully accessible. Of those surveyed, 45% reported that they provided services specifically for survivors with physical disabilities, while approximately 20% reported that they provided services for survivors with mental health disabilities (examples included one-on-one advocacy, collaborative agreements and partnerships with local mental health and/or counseling agencies, on-site counseling services). Approximately 12% reported that they provided services for survivors with cognitive disabilities. These data indicate that DV programs have made significant efforts to serve survivors who are experiencing disability, but also reflect a need for additional capacity building in this area.
Despite the high stigma associated with substance abuse and the resulting disincentive to report needing help, a significant number of survivors in the study self-reported wanting help with substance abuse services (18.6%). Studies have indicated that overall use of substances among survivors of domestic violence is much higher (for a summary of some of the research, see Getting Safe and Sober: Real Tools You Can Use). Approximately 18% of the DV programs in the study reported that they provided substance abuse counseling, while almost 80% reported that they made referrals for substance abuse counseling.
For more information on the relationship between domestic violence and mental health, see Intimate Partner Violence and Lifetime Trauma.
For tips on working with survivors experiencing mental health conditions, see these publications by the Center: Practical Tips for Increasing Access to Services, Tips for Making Connections with Survivors Experiencing Psychiatric Disabilities, Tips for Discussing a Mental Health Referral with DV Survivors, and Locating Mental Health and Substance Abuse Supports for Survivors.
For tips on working with survivors coping with substance abuse, see Getting Safe and Sober: Real Tools You Can Use, by the Alaska Network on Domestic Violence & Sexual Assault (Patti Bland, one of the principal authors of this publication, recently joined the staff of the National Center).
For tips on working with survivors with physical disabilities, see Safety Planning for Domestic Violence Survivors with Disabilities by the Washington State Coalition Against Domestic Violence.
Link to the study: http://www.vawnet.org/research/MeetingSurvivorsNeeds/
911 Dispatchers Frequently Experience Emotional Distress in Response to Domestic Violence Calls, A Recent Study Reports
A recent study published in the Journal of Traumatic Stress examines the frequency with which 911 telecommunicators experience emotional distress in response to emergency calls as well as symptoms of Post-Traumatic Stress Disorder (PTSD).
Participants in the study were asked whether they had received certain types of calls and whether they had experienced fear, helplessness, or horror in reaction to the calls. Domestic violence calls were among the most common type of call received with nearly all (95.3%) survey respondents reporting that they had received these calls and more than one-third (38.6%) of respondents reporting that they experienced feelings of fear, helplessness, or horror while responding to domestic violence calls.
The study also found that 3.5% of survey respondents were currently experiencing symptoms of Post-Traumatic Stress Disorder (PTSD). Although researchers did not ask whether respondents had experienced symptoms of PTSD during the last 12 months or during their lifetime, the high rate at which survey respondents were currently experiencing symptoms of PTSD indicates that 911 telecommunicators may in fact experience PTSD at a higher rate than the general population (which has a 12-month prevalence rate of 3.5%). Acknowledging that the participants for this study were self-selected and were all currently working in the field, the authors of the study speculated that the rate of PTSD symptoms may have been higher among a sample that was not selected out of convenience and that included telecommunicators that had left their job due to burnout.
The study has clear implications for domestic violence advocates, whether they are answering hotline calls or working with survivors in a program or shelter setting. The Center offers training and technical assistance to support advocates in their work with survivors of domestic violence around issues of vicarious trauma.
Webinar: Developing Trauma-Informed Practices and Environments: First Steps for Programs by Terri Pease, PhD, Director of the Training Institute, National Center on Domestic Violence, Trauma & Mental Health
Pease, T. (2009). Reflective leadership as a strategy for accountability. The Voice: The Journal of the Battered Women’s Movement, 4-6. http://www.ncadv.org/files/Accountability%20Issue%20Spring%202009.pdf
Van Dernoot Lipsky, L. (2009). Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. San Francisco, CA: Berrett-Koehler Publishers.
Link to the study:
Pierce, H. & Lilly, M.M. (2012). Duty-related trauma exposure in 911 telecommunicators: considering the risk for posttraumatic stress. Journal of Traumatic Stress, 25, 1–5. doi: 10.1002/jts.21687
New Studies Link the Mental Health Effects of Trauma with Poorer HIV Treatment Access and Outcomes for Women
Women who are HIV-positive and who have experienced recent abuse are over four times more likely to have their drug treatments fail, according to recent studies based on meta-analyses of clinical data and published in the journal AIDS and Behavior.
The studies suggest that several factors may impact a woman’s treatment access and outcomes, including direct interference by an abuser as well as obstacles that may exist if a woman is experiencing the mental health effects of trauma, including Post-Traumatic Stress Disorder (PTSD).
According to the lead author of these studies, Edward Machtinger, the results indicate a need for a trauma-informed approach to HIV/AIDS treatment:
“‘We have to learn to ask about trauma and to develop creative approaches to trauma-prevention and trauma-recovery,’ Machtinger said. ‘This is actually an amazing opportunity to have a significant impact on the HIV/AIDS epidemic, especially among minority women.’” (Bardi 2012)
The study also found that women who are HIV-positive and who have experienced recent abuse are more likely to engage in high-risk sexual behavior, potentially contributing to the spread of infection.
Allday, E. (2012, March 23). Studies see link between HIV and abuse among women. San Francisco Chronicle, p. 1A. Web site: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2012/03/22/BAF51NOBEG.DTL.
Bardi, J. (2012, March 23). Trauma drives HIV epidemic in women: high rate of trauma among American women with HIV/AIDS and its public health consequences revealed in two UCSF studies. UCSF News Center. Web site: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2012/03/22/BAF51NOBEG.DTL.
Links to the studies:
Psychological Trauma and PTSD in HIV-Positive Women: A Meta-Analysis:
Recent Trauma is Associated with Antiretroviral Failure and HIV Transmission Risk Behavior Among HIV-Positive Women and Female-Identified Transgenders:
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