Victims of Crime Research Digest, Issue No. 4

Practice-Based Perspectives: Victimization and Substance Use

  • Bill Morrison, W. Morrison & Associates
  • Cynthia Doucet, W. Morrison & Associates
  • Brenda Thomas, Victims Services, Department of Public Safety, Government of New Brunswick
  • Patricia Peterson, W. Morrison & Associates

Recent literature supports a positive and frequently-cited association between victimization and substance use. A major hypothesis for this relationship is that substance use is a coping strategy for dealing with the physical or emotional discomfort associated with the trauma of victimization (Danielson et al. 2006; Office for Victims of Crime 2005). This includes using substances as a means for “avoiding, escaping or distracting from the overwhelming distress associated with trauma-related memories” (Danielson et al. 2006, 2). Research indicates that trauma associated with victimization contributes to increased vulnerability to both mental health conditions and problem substance use behaviours (Jacobsen et al. 2001; Logan et al. 2002). Problem substance use has also been associated with a host of other concurrent risk issues related to the health, safety, and security of victims. These may include conflict with the law, exposure to communicable diseases, involvement in unhealthy and violent relationships, self-harm, disruptions in education and career functioning, and homelessness. Consequently, problem substance use by victims may also increase potential vulnerability to further areas of risk and to victimization.

In January 2008, the New Brunswick Department of Public Safety Victim Services undertook a research study to investigate better practice considerations related to supporting and intervening with victims of crime with substance use problems. The overall study consisted of five phases. One component involved the completion of a series of key informant interviews with health and treatment professionals who have extensive knowledge and experience in the design and delivery of problem substance use intervention services for victims of crime.

Methodology

Key informants were identified in consultation with the members of the Project Advisory Committee and research team. Initial contact was subsequently made with the key informants to review the purpose of the initiative and their potential participation in this aspect of the project. Upon obtaining their consent, individual interview times were arranged. Interviewed key informants had on average 17 years of direct work or clinical experience with populations involving victimized individuals with problem substance use. Interviews were completed with 18 key informants from Eastern, Central, Western, and Pacific regions of Canada.

A semi-structured interview guide was developed with a range of open-ended and more focused questions intended to provide essential information relating to understanding the needs profile and treatment strategies for victims of crime who experience substance use problems. For these interviews, areas of inquiry included

  • key client considerations (circumstances, gender, specific populations);
  • early intervention (screening, early intervention support, and service provider preparedness);
  • key roles in intervention services (family, victim services, mental health/addictions, Community-based services, criminal justice services);
  • service delivery considerations (theoretic stance/philosophy, treatment implications, support strategies, integrative case management, follow-up, and evaluation); and
  • potential service developments and elaboration (screening tool for problem substance, multidisciplinary training sessions, common service protocols).

Responses from key informants were recorded and merged for each area of inquiry. Content analysis was used to analyze the key themes emerging from the outcomes of the interviews. Specific theme categories were included based on endorsement of a minimum of three informants.

Client Considerations: Circumstances and Gender

Circumstances Faced by Victims Experiencing Substance Use Problems

Risks and consequences

Key informants were asked to describe the unique circumstances facing victims of crime who have substance use problems. All key informants identified that incidents of victimization were associated with trauma both during and following the event. They indicated that problem substance use often occurs following victimization as a coping response to deal with trauma.

Key informants noted that trauma may be accompanied by feelings of shame or social stigma. It is this social stigma that contributes to risks associated with development or exacerbation of problem substance use. Additional personal distress may also be experienced by clients as a result of fear associated with the possible repercussions of problem substance use, including

  • removal of children from the home by the child welfare system;
  • legal ramifications associated with the use or possession of substances;
  • rejection and alienation from family members;
  • loss of credibility with respect to their reports of victimization;
  • blame for the actual occurrence of victimization; and
  • loss of financial resources to address basic need concerns or family-focused responsibilities.

It was also noted that continued problem substance use may place clients at increased risk of being re-victimized. In this regard, clients who had experienced past victimization and problem substance use within their own home or family context were identified as having the greatest vulnerability for repeated occurrences of victimization.

System-related factors

Key informants also reported that victims of crime may not have sufficient knowledge of the available services that address problem substance use. A few key informants indicated that clients may mistrust formal service systems if they have experienced a “history of inappropriate responses” from service providers. For example, clients may not be considered eligible for mental health counselling to deal with trauma because of service protocols which require them to first seek treatment for substance use problems. The opposite situation may also occur in which addiction service providers require clients to initially address mental health issues prior to receiving substance use treatment. Other reported system-related barriers include prolonged wait times, multiple and/or complex intake procedures.

Personal and family factors

In addition to system factors, victims of crime may also experience a range of other personal circumstances that limit or impede their access to needed services. These may include parenting responsibilities, fixed work schedules, inadequate financial resources to be released from work, and lack of transportation. Such personal factors may also be accompanied by interpersonal or relationship stressors when family members are not supportive of client decisions to access needed support or treatment. Key informants underscored that such family dynamics may be evident in situations when victimization has occurred in the family context or when family members do not have adequate understanding of the recovery process or of the relationship of problem substance use to trauma experienced by victims. In other instances, cultural family values may discourage disclosure of victimization or help-seeking behaviours outside of family relationships. Families in rural areas may also be reluctant to disclose issues related to victimization or problem substance use because of perceived lack of privacy or confidentiality in smaller community settings.

Gender Needs and Differences

Key informants were asked to describe the experiences and needs of both female and male victims with substance use problems. With respect to female victims, key informants indicated that women often have family responsibilities and care giving roles. For example, women may be required to arrange and coordinate child care to facilitate their attendance at health or treatment appointments.

Key informants underscored that female clients are often alone or do not have social support to assist in addressing concurrent family or treatment concerns. This may be particularly evident in social and cultural contexts in which there is pronounced disapproval or stigma associated with women's substance use. According to various informants, women's perceived stigmatization may decrease their likelihood of sharing areas of personal concern or actively pursuing accessible supports or treatment options. It was also noted that women may be at risk for developing unhealthy relationships in treatment contexts which include both male and female clients.

For both female and male clients, the sensitivity and trauma associated with incidents of victimization may impede their openness to sharing potential problem substance use concerns. Male clients were identified as particularly reluctant to describe past incidences of victimization. As one informant indicated, male clients may be hesitant to disclose their past experiences of trauma (e.g., sexual abuse) because of perceptions of weakness, vulnerability or the notion that “men should be able to look after themselves.” Others noted that crimes experienced by male victims tended to be more violent and that younger men are often overrepresented among populations of male crime victims. Overall, key informants asserted the need for increased research and investigation into the needs of male victims with potential substance use issues.

Early Intervention

Key informants regarded early intervention as specific actions or interventions undertaken for individuals identified as being at risk for, or currently engaging in, harmful behaviours. With respect to victims of crime with problem substance use, early intervention was noted as critical for preventing the progression and severity of problem substance use patterns. Such efforts were viewed as beneficial for decreasing and eliminating the range of risk factors (e.g., safety issues and re-victimization) and psycho-social consequences that accompany problem substance use (conflict with the law, loss of social supports, family relationships, poverty).

Screening

Early identification or screening of problem substance use behaviours was regarded as an important aspect of intervention for victims of crime. The majority of key informants highlighted the value of screening for problem substance use as part of initial intake processes for victims. For those currently employing screening approaches, both structured and informal methods were identified. With respect to standardized measures, the CAGE, the MAST, the DAST, and the OQ45[1]were mentioned as instruments currently in use.

With regards to informal screening formats, key informants highlighted the use of conversational or narrative approaches for exploring potential problem substance use. In using such formats, specific questions pertaining to substance use were often introduced as a result of discussion of themes related to current or past methods of coping or seeking support. One key informant also mentioned the use of a semi-structured narrative approach using “story webs” to explore clients' perceptions of their needs and circumstances. Informal conversational screening formats were regarded as beneficial in that they were particularly helpful for decreasing clients' anxiety and for creating an environment conducive to the development of a collaborative relationship. As one key informant noted, it is important in conversational approaches “not to make it sound like a screening questionnaire.”

Key informants highlighted a range of key areas of inquiry that could be included as part of informal or structured screening processes to identify potential concerns related to substance use. These included

  • current stressors and concerns;
  • types of coping strategies;
  • nature of social supports;
  • sleeping patterns;
  • physical and emotional health concerns;
  • use of prescription medications;
  • family history of substance use;
  • partner substance use;
  • previous use or problems with substances; and
  • previous treatment for substance use.

In exploring such areas of inquiry, more specific questions related to substance use might also be subsequently introduced as part of screening interactions with the clients if deemed appropriate. These might include areas of inquiry and discussion related to awareness of potential substance use concerns, patterns of use, intentions for future use, and openness to receiving support or treatment.

Key informants highlighted that screening methods may be embedded in pre-existing health intake or assessment processes. Others indicated that screening for substance use could also be included as part of victim screening or assessment protocols. In the application of structured or informal screening approaches, key informants underscored the importance of being sensitive to the unique needs and circumstances of victims and ensuring the use of a non-judgmental approach. A few key informants expressed concern that information gleaned from such screening processes might be used to exclude clients from specific essential services. In this regard, they asserted that client information should only be used to plan appropriate treatment strategies and to facilitate clients' access to needed services.

Early Intervention Support and Service Provider Preparedness

Key informants highlighted that victims of crime with substance use problems may seek support from diverse professionals and community service providers to address a range of personal and basic needs. Interactions with these individuals provide unique opportunities for initial identification of potential concerns related to victimization and problem substance use, as well as for facilitating linkages with appropriate sources of support or treatment. Potential service provider contacts might include

  • family physicians;
  • emergency health personnel;
  • financial aid or income assistance case managers;
  • employee assistance program providers;
  • public mental health clinical services;
  • pharmacists;
  • employers and union representatives;
  • school or community counsellors;
  • community social workers;
  • shelter or transition agency staff;
  • police and other justice personnel (e.g., probation workers);
  • victim service workers;
  • community outreach workers; and
  • clergy.

Key informants underscored that the settings in which clients meet helping professionals should ideally be comfortable and place clients at ease in sharing concerns they may have regarding victimization or problem substance use. Office type settings or contexts that involved prolonged wait times or distractions because of external work activities (people arriving and leaving) were characterized as less conducive for disclosure of areas of significant concern.

Key informants were also invited to describe the essential helper knowledge, attitudes, and skills that would support early interventions with victims who have substance use problems. They highlighted a range of professional competencies, including

  • effective use of active listening, reflection, and clarification skills;
  • demonstration of accepting and respectful attitudes towards victims;
  • awareness of social perceptions and stigma regarding substance use;
  • sufficient knowledge about victimization, trauma, and its link with substance use;
  • adequate knowledge of community resources, their services, referral and intake processes; and
  • ability to link clients with needed services or to be an advocate for them.

With respect to the preceding competencies, informants described the value of providing community service providers with targeted training to support their participation in reaching out to victims who may be experiencing substance use problems. The following specific content might be included in either training or orientation sessions:

  • awareness sessions on the potential link between victimization, trauma/mental health concerns, and problem substance use;
  • educational workshops on types of substances, their effects, and typical patterns of use;
  • training in nonjudgmental methods for reaching out, engaging and supporting victims of crime (e.g., effective listening and communication skills); and
  • information sessions on the range of support and treatment services that may be accessible to victims and how to initiate appropriate referrals.

In discussing early intervention and screening approaches, several key informants highlighted the potential of adopting common protocols for service collaboration among helping professionals in local and regional areas. Others suggested the use of common screening methods or questions that could be applied by community service providers.

Key Roles in Intervention Services

Key informants also described the potential roles that various individuals could play in supporting early intervention efforts for victims with problem substance use. They highlighted potential contributions that could be made by family members, victim services personnel, and mental health and addiction therapists.

Family Members

Key informants highlighted that family relationships can provide a viable source of ongoing support for clients as they seek out and engage services and treatment. Family efforts may include providing tangible assistance to address basic need or transportation concerns or extending support through listening “without judgement or blaming.”

It was also recognized that the dynamics of various family situations may not be conducive to enhancing clients' well-being or supporting treatment plans. This may be particularly evident in family or home situations in which there are concerns regarding client safety (e.g., intimate partner abuse) or ongoing problem substance use by close family members or partners. In such cases, specific changes in family relationships or interactions may be a key consideration in realizing and sustaining positive changes for clients.

Victim Services' Coordinators/Workers

Key informants emphasized that victim services workers have a responsibility to be knowledgeable about community resources and the referral processes required for clients to engage needed services or treatment supports. Their primary role includes assessment of clients' needs and ensuring clients' access to essential support services through coordination of referrals, collaboration with community service providers, and provision of supportive client contacts and follow-up sessions.

Key informants highlighted that victim services workers could benefit from educational sessions on themes related to the link between victimization and substance use. Identification of screening questions for substance use was identified as an area for future development and possible training for victim service workers. Some concerns were also expressed regarding the inclusion of questions in existing screening processes and the potential for the use of such areas of inquiry to impede development of an initial collaborative relationship with clients. Other key informants commented on the benefits of exploring problem substance use concerns through informal discussion of clients' current and past coping approaches.

Mental Health and Addiction Service Providers

Mental health clinicians and addiction workers were identified as key treatment providers in supporting the recovery process of victims with substance use problems. Key informants reported that mental health and addiction services are particularly helpful to clients when they are accessed in a timely manner and when treatment services are coordinated or integrated. Several informants highlighted the importance of applying concurrent treatment approaches, harm reduction perspectives, and strength-focused interventions in the delivery of treatment services for victims. Key informants also asserted that mental health and addictions service providers could benefit from educational sessions focusing on the victimization recovery process, issues relating to client safety, and the relationship of coping with trauma and problem substance use.

Other informants highlighted the potential consultation role that mental health and addictions personnel could provide to both victim services workers as well as to other community service providers on the provision of screening and support services for victims with substance use problems. In this regard, they asserted the need for enhanced collaborative and joint case planning activities among service providers who serve victims of crime in the community setting.

Community-Based Service Providers

Victims of crime with problem substance use may face other key needs related to health issues, family responsibilities, or basic living concerns. In addition to victim and treatment-related services, key informants recognized the value of the provision of available community supports offered by local volunteer groups, religious organizations, and non-governmental agencies. With respect to community-based services providers, key informants highlighted a range of key supports, including

  • support services to single parents;
  • sexual health centres;
  • peer support groups;
  • child care services;
  • individual personal supports and counselling services;
  • outreach services; and
  • transportation services.

Key informants emphasized the importance of engaging and coordinating such services in conjunction with structured case management or treatment plans for victims with problem substance use. They also asserted that it was often necessary to have such services in place to ensure clients' engagement and sustained participation in needed treatment programs or services.

Other Justice Personnel

Other justice personnel who may interact with victims with problem substance use may include police, crown prosecutors, and judges. Key informants underscored that such justice personnel would benefit from awareness sessions on various key themes related to their work with victims, including the experience of victimization, supportive approaches for working with clients, and the relationship of trauma with problem substance use.

Potential Service Developments

In addition to sharing perspectives related to client needs and responsive service delivery, key informants also described potential areas of service elaboration or development that it may be beneficial to initially consider for enhancing services to victims with problem use concerns. The potential areas described included the following.

Development or Identification of a Screening Tool for Problem Substance Use

Such an instrument would ideally be useful for victim services workers in assessing the potential of problem substance use among victims of crime. This type of measure might involve the administration of a series of core question items that could be incorporated as part of existing community-based or victim service assessment processes.

Execution of Multidisciplinary Training Sessions

The majority of key informants asserted the value of delivering interprofessional training opportunities for clinicians and community service providers from diverse fields and areas of expertise. Possible training content should include the nature of victimization, victim typologies, client safety and coping, the recovery process, and trauma and its relationship to problem substance use.

Adoption of Common Service Protocols

Within each regional jurisdiction, efforts should be made to ensure the development of coordinated and integrative case plans for clients. The organization of awareness forums for service providers to gain increased mutual understanding of their respective roles, mandates, and services may be a preliminary step in encouraging greater cohesion in working collaboratively. A subsequent step would involve identification of common intake, screening, information sharing, and service delivery strategies that would ensure timely access to appropriate support and treatment services for clients and their families.

Next Steps

This article has summarized part of the research undertaken with the New Brunswick Department of Public Safety – Victim Services to investigate better practice considerations related to supporting and intervening with victims of crime with substance use problems. This research study consisted of five phases that will be completed by March 2011:

  • a review of peer-reviewed literature and program delivery publications;
  • interviews with key informants who were service providers involved in the delivery or coordination of programs for victims with problem substance use;
  • interviews with victims of crime from a New Brunswick context;
  • an analysis of convergent themes relating to promising practices for addressing concurrent substance use and victim-related issues; and
  • the development of a tool to screen for problem substance use among victims of crime.

It is hoped that the findings from this research effort will assist Victim Services personnel, as well as other health and community professionals in the development of responsive strategies for working with victims.

References

  • Danielson, Carla Kmett, Michael A. de Arellano, Jill T. Ehrenreich, Liza M. Suárez, Shannon M Bennett, Daniel M. Cheron, Clark R. Goldstein, Katherine R. Jakle, Terri M. Landon, and Sarah E. Trosper. 2006. Identification of high-risk behaviors among victimized adolescents and implications for empirically supported psychosocial treatment. Journal of Psychiatric Practice 12(6): 364-383.
  • Jacobsen, Leslie K., Steven M. Southwick, and Thomas R. Kosten. 2001. Substance use disorders in patients with post-traumatic stress disorder. American Journal of Psychiatry 158(8): 1184-1190.
  • Logan, T. K., Robert Walker, Jennifer Cole, and Carl G. Leukefeld. 2002. Victimization and substance use among women: Contributing factors, interventions and implications. Review of General Psychology 6(4): 325-397.
  • Office for Victims of Crime. 2005. Substance abuse and victimization – Video discussion guide. U.S. Department of Justice.

[1] The name of the CAGE in

strument is a mnemonic for four key questions containing the words “cut down, annoyed, guilty, and eye-opener.” The CAGE is designed to assess for problem alcohol use. Similar to the CAGE, the MAST (Michigan Alcohol Screening Test) is composed of question items which provide an indication of possible alcohol abuse and dependency. In contrast to the CAGE, the DAST (Drug Abuse Screening Test) is a scale intended to screen for problem drug use. The OQ45 is a comprehensive screening instrument which includes a number of core questions intended to screen for alcohol and drug misuse. This instrument is also applied following treatment to measure changes in client functioning and overall treatment gains.

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