Hello and welcome. I'm Kareem Khan, Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services and also social work expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Intimate Partner Violence and Disabling Psychiatric Conditions, Unique Risks, Needs, and Strategies. This webinar is particularly timely as October is National Domestic Violence Awareness Month. Next slide, please. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, one social work continuing education credit, and one nursing continuing professional development contact hour. Credit for participating in today's webinar will be available until November 21st, 2021. Next. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. You can select the link there to download the PDF. Next. And please feel free to submit your questions throughout the presentation by typing them into the question area also found in the lower portion of your control panel. We will reserve 10 to 15 minutes at the end of presentations for your Q&A. Now, I'd like to introduce you to the faculty for today's webinar, Gabriela Zapata-Alma. Gabriela Zapata-Alma, LCSW-CADC, is the Associate Director at the National Center on Domestic Violence, Trauma, and Mental Health, as well as a Senior Lecturer and Director of the Alcohol and Other Drug Counselor Training Program at the University of Chicago. Gabriela brings over 15 years of experience supporting people impacted by structural and interpersonal violence and their traumatic effects through evidence-based clinical housing resource advocacy and HIV-specific integrated care programs. Currently, Gabriela authors best practices, leads national capacity-building efforts, and provides trauma-informed policy consultation to advance health equity and social justice. Gabriela, thank you so much for leading today's webinar. Thank you so much for having me today. It's my pleasure to be here with all of you. I know that time is really valuable. And any time that I'm taking folks away from direct practice is a time that I want to make sure that we are getting the most out of our time together. Because, of course, the most important thing is to really be present with folks who are accessing our services. So thank you so much, Shireen, for that warm welcome. And thank you, SMI Advisor, for having me today. A little bit about the National Center on Domestic Violence, Trauma, and Mental Health. We are a special issue national resource center dedicated to addressing the intersection of domestic violence, sexual violence, trauma, mental health, and substance use. We offer training and technical assistance, research and evaluation, policy development and analysis, and public awareness. And then I also want to share our disclaimer that the points and perspectives in this document, as well as things that I share today, are not necessarily the official positions or policies of the U.S. Department of Health and Human Services. And here you also see our integrated framework at the National Center. So everything that we do is rooted within this framework of using survivor-defined approaches that are rooted in relationship and connection, physical and emotional safety, and foster hope and resilience. And with this at our core, then we are able to engage in trauma-informed approaches, be able to collaborate and offer domestic violence and sexual violence advocacy that are also empowerment-based approaches, approaches that are rooted in human rights and social justice, and that also have an awareness of and responsiveness to cultural, historical, and community context. And I have no disclosures or, you know, no relationships or conflicts of interest to disclose. So our plan for this next hour, our hope is that after completing this activity, you'll be able to describe the multidirectional relationships between intimate partner violence and disabling psychiatric conditions, that you'll be prepared to assess the potential presence of intimate partner violence in precipitating or exacerbating mental health crisis, and actively collaborate with survivors of intimate partner violence to develop individualized, person-centered safety strategies in mental health crisis prevention and recovery planning, including IPV-informed psychiatric advance directives. So first, some context, and just getting a sense of what are some of these complex connections between intimate partner violence and disabling psychiatric conditions, and what is some of the prevalence, and just getting a sense of just how they impact one another. So first, understanding that intimate partner violence can have significant traumatic mental health effects, and is prevalent in mental health care settings. So, you know, look, this is based on our literature review, looking at all the prevalence data of intimate partner violence and mental health conditions, some of the most major mental health conditions. And so what we found was that in the research literature, there's been found at least a three times or higher risk of developing post-traumatic stress disorder, major depressive disorder, as well as engaging in self-injury, four times higher rate of suicide attempts, and over six times higher rate of a diagnosable substance use disorder. And then looking at the prevalence of experiences of intimate partner violence among women accessing mental health treatment, and this is where a lot of the research tends to focus on feminine identified individuals. So I'll be sharing across additional genders in the slides that follow. But among women, on average, around 30% of women in outpatient mental health settings, 33% of women in inpatient or residential mental health settings, and then once we look at acute psychiatric emergency settings, this really jumps up in a range from 30% to 60%. Are reporting victimization by an intimate partner. This is active ongoing victimization. Now drilling a little bit deeper and looking specifically at individuals living with a disabling psychiatric condition. There is a wide range that's found here. A lot of that has to do with how severe mental illness is defined in the research literature, as well as how intimate partner violence is operationalized in the research literature, as well as if they're looking at past year experiences or lifetime prevalence. So with that mind, what's been found is that this prevalence varies between 22 and 76%, depending on which definitions and methodologies are used. So this comes from one population-based study that is called the recent intimate partner violence among people with chronic mental illness, findings from a national cross-sectional survey. And so what was found was that women living with a disabling psychiatric condition, that 20% of women had been impacted by intimate partner violence in the past year versus the general population that only 20% of women had been impacted. Being 5.3%. And then men we see here also were more impacted if they were living with a disabling psychiatric condition versus the men in the general population. This study did not capture people who are gender non-conforming or non-binary. We know that that is very common in the research literature, that there is very often erasure of people who are transgender and gender non-conforming and non-binary. Also something to note here is that only a very small portion of the sample were people of color. And so there were no significant differences found between white people and people of color in this specific research study, but the sample is likely too small to have any kind of statistical power. So in that way, it doesn't tell us much about experiences of people of color. We see here also that past year's experiences of specifically sexual abuse among women and the relative odds that it was 30 in a thousand women living with a disabling psychiatric conditions versus four in a thousand women in the general population. Also, it was found in the study is that people living with a disabling psychiatric condition versus those who were not, were two to five times more likely to experience all the different forms of intimate partner violence, were two times as likely to experience mental or emotional difficulties following the abuse, five times more likely to attempt suicide as a direct result of the intimate partner violence, and were more likely to exclusively disclose intimate partner violence to health professionals than to informal social support networks. Now, this is something that I invite us all to keep in mind as we move forward through today's session. And then of course, in practice, that it is much more likely that at least I'll say this, this study suggests that it is much more likely for folks who are experiencing a disabling psychiatric condition to feel safe and able to be able to share that with us as their health professional rather than with a social support. So that really raises the ethical duties that we have to create safety in our programs and to create programs and practices that are DV-informed and DV-responsive. So while this is one study, the results of the study do align with many other studies, including the results of different systematic reviews and meta-analyses. And then something I want to point out as well is that when looking at specific mental health diagnoses, Moritz and all in their 2013 article, they reported finding the highest prevalence rates of physical and sexual abuse were amongst people with schizophrenia spectrum disorders, borderline personality disorders, and those labeled more generally as having severe mental illness as compared to those who had a diagnosis of depression. And then now looking at some of the data available specifically about experiences of psychosis, and this comes from four U.S. cities. And again, here we're missing data around gender identity, people who are non-binary and gender non-conforming. But what was found was that experiencing at least one form of intimate partner violence was found to be significantly associated with the four subtypes of psychotic experiences that they were studying. So this being strange experiences, paranoia, thought insertion, and hallucinations, and that this was true for both men and women. That intimate partner violence was associated with an over three times higher odds of reporting at least one of the psychotic subtypes, and that being threatened by an intimate partner had the strongest associations with strange experiences, paranoia, and hallucinations. And so I want to be really clear here in that a lot of times in our key informant interviews with providers and our different research with providers, we have come to learn that many times survivors have their experience, and also I should say key informant interviews with survivors and listening sessions with survivors, that survivors, when they attempt to share the intimate partner violence that they're experiencing, many times those reports are dismissed and are kind of written off as paranoia or as delusions. And so understanding that we want to be really, really clear in believing survivors and that there may be paranoia present, there may be hallucinations present, but that that doesn't preclude that a person is being threatened by an intimate partner or ex-partner, of course. We know that many times when a relationship ends that the intimate partner violence doesn't necessarily end when the relationship ends. Another finding of this study was that participants of color as well as sexual minority participants, so those who identified as lesbian, gay, bisexual, and other sexual minority identities, that in this sample that they were found to be disproportionately impacted by psychotic experiences following intimate partner violence. And when we are looking at this data point, it's important to understand social identity within its greater context and not devolve to any kind of biological determinism because we know that biological determinism very often is just perpetuating racism or perpetuating homophobia, biphobia, et cetera, and that it really is about the contextual structural violence that people are exposed to when they have a social identity that is marginalized within our society. And so, in order to be able to properly contextualize intimate partner violence in the context of historical and structural violence, we offer this visual to unpack the traumatic legacies of historical trauma and how those continue in present day ongoing structural violence and policies and systems that reinforce that social control, reinforce things like poverty and ongoing discrimination and health disparities, and that these are inextricably linked with being at higher risk and experiencing traumatic effects of abuse, as well as then the ongoing interpersonal coercive control. And I'll be saying a little more about that ongoing course of control as we get farther along. So here, offering this slide and the next slide, a couple of visuals that help illustrate some of the complex connections between intimate partner violence. In this meta review, they also included sexual assault and serious mental illness. And so, through the meta review, identifying there being evidence that supports both direct and mediated relationships between intimate partner violence, sexual assault, and serious mental illness, so both as a causative factor, as well as one where the effects of intimate partner violence and or sexual assault precipitate homelessness, are risk factors for developing diagnosable substance use disorders, as well as impacts on mental well-being. Substance use disorders, as well as physical health impacts. And that then all of these also act as risk factors for increased targeting, as well as traumatic effects of intimate partner violence. So many times we see a vicious cycle here. I'm getting ahead of myself, though. The next slide depicts that. But that then these increased risks around homelessness, substance use disorders, and physical wellness then also act as precipitating factors and increased risk for developing serious mental illness. And then now, looking at the other side of the coin here, again, also finding direct and mediated relationships between serious mental illness and then increased targeting for intimate partner violence and sexual assault, both as a direct relationship, as well as through these different risk factors. Lacking of support, lacking healthy relationships, including intimate relationships, substance use and substance use disorders, a history of trauma, abuse, or assault. The age of onset, we know, is also a factor here. Experiences of housing instability and homelessness. And barriers to medication. And then also know that there is a risk factor here where, with the development of personality disorders. So in addition to these, some of the research that we've conducted at the National Center in partnership with the National Domestic Violence Hotline has uncovered a specific form of abuse that is targeted at undermining a partner's mental health, as well as their access to mental health treatment, recovery, and just overall support resources. And this is something that has come to be known as mental health coercion. And so on the right here, you see some of the quantitative results from that study, where it was over 2700 callers. So just general callers, the National Domestic Violence Hotline, who were seeking domestic violence support. So there was nobody prescreened for any kind of history of mental health or anything like that. It was just general callers who weren't in crisis at the time of the call and agreed to take part in the study. And so what was found in this survey style study was that four out of five callers said that their partner had accused them of being, quote, crazy. So really trying to emotionally abuse them as well as discredit them based on their mental health. Three out of four, so their partner deliberately did things to make them feel like they were, quote, losing their mind. And that this is something that is very common in a pattern of intimate partner violence. It's very often referred to as gaslighting. And then one in two callers, so 50% of general callers who weren't in crisis at the time and agreed to be a part of this study said that their partner threatened to report that they were, quote, crazy to keep them from getting something they wanted or needed. And many times this is to discredit people with sources of support and safety, including law enforcement, including courts, including being able to maintain custody of their children, as well as things like being able to obtain or maintain employment or maintain education. We know that anything that creates any sense of economic stability in a survivor's life is often specifically targeted because it's so much harder to be able to escape abuse if that economic stability isn't there. Also, out of the callers who had tried to get any kind of help to support their mental health, whether that was feeling depressed, feeling upset by an abusive partner or ex-partner's actions, that of those who tried to get some kind of help, one out of two of those, so 50% said that that partner had tried to prevent them or discourage them from getting any kind of help or taking their medication as prescribed. So really sabotaging someone's access to mental health services and overall mental health support. We also had a qualitative arm of this study that found many, many themes, but of course I wanna highlight these two kind of most common themes that emerged. First, interfering with mental health services. And so this showed up in a lot of different ways. Some of the most common ways were attempting to influence a person's diagnosis, so really trying to control mental health providers' assessment and perception of the person accessing or seeking care and trying to really control the way that they seek care and the kind of care they receive. And then another part, another sub-theme that came up here was attempts to have a person hospitalized or institutionalized as a way to intimidate them, harm them, or control them. And so that's something that we'll be talking a little more about when we talk about crisis response as well as psychiatric advance directives. The second major theme that came up was the controlling of prescribed mental health medications. And so here, some of the sub-themes were not allowing the survivor to take their medication as prescribed in attempts to exert power and control over them, coerce them into activities that they don't wanna be involved in, as well as in an attempt to precipitate mental health crisis. And then the second sub-theme here that most commonly came up was coercing to take too much of their medication. So again, not taking it as prescribed, but in kind of the opposite direction, forcing them to take too much of it, which we know, of course, can be incredibly dangerous depending on which psychotropics are being prescribed. But with many of them, it's going to be not only interfere with their care, but also be incredibly dangerous. So this naturally raises the question. When it comes to the relationship between intimate partner violence and psychiatric disabling conditions, is it a relationship of risk? Is it one of vulnerability? And so here, we really see multi-directional complex connections between these, so that people who are seeking to exert power and control over their partners, abuse their partners, will use those mental health concerns to control their partners. And that this is then made possible, or what really reinforces the effectiveness of these tactics and this targeting is all of the stigma that exists around mental health and mental illness, all of the poverty, right? Understanding poverty as a form of structural violence, the discrimination and the institutionalization that people face when they're living with a mental health condition. And so here, just seeing how with the induced debilitation, here, we know that for mental health care, for supporting one's own mental health, how important it is to have appropriate sleep, appropriate nutrition, have established routines. And so this becomes an area where a partner seeking to exert power and control over a survivor can really interrupt sleep, sleep deprivation, can really disrupt those healthy routines and precipitate crisis. And then of course, then blame the abuse and control on the mental health, including being able to deny that there's any kind of abusive tactic or control tactic being used. As well as then using legal documents to enable control. And we'll be talking specifically about psychiatric advanced directives there. But some other legal documents that can be used in this way also include guardianship and representative payeeship for people who receive disability benefits. And so those are also some pieces that we wanna be really aware of. And when I was working in community-based settings with people experiencing serious and often persistent mental health concerns, many times representative payeeship became a very common form for partners who are seeking to abuse the person in our services to exert that power and control and abuse them. So why is this so effective, right? As I mentioned earlier, the reports of abuse being attributed to paranoia, to delusions, to hallucinations, many times misdiagnosed or just completely missed trauma. Many, many times in my different experiences practicing, I would have people who, I'd be working with people who had been institutionalized, people for long, long periods of time, people who had been through a lot of different providers and not really found what was going to work for them yet and was continuing to have a lot of crisis. And then when I came to work with them, come to find out that what they had was a very, very significant trauma manifesting that had been completely missed and misdiagnosed as schizoaffective disorder. Not to say that there weren't symptoms present of schizoaffective disorder, but at the same time, the trauma had been, not only the trauma, but the ongoing sexual assault, the ongoing domestic violence, the ongoing threats to their safety had been completely missed in their situation. And so that we know that that safety is gonna be primary and being able to really start supporting somebody and their self-defined goals. And then of course, the stigma and the isolation, that the violence is really gonna thrive within that stigma and within that isolation. And I wanna point out here, of course, that I've been using the language of intimate partners or ex-partners, but that many times, this abuse doesn't just come from an intimate partner, it can also come from family members, it can come from more casual social supports, it can come from acquaintances, especially when someone is experiencing housing instability, this can come from someone that they were able to just have a place to be that night and not be out in the street or in an abandoned building, for example. And so we really wanna be sure that when we are looking at these complex connections and assessing and offering services that we are thinking beyond maybe our own definition of intimate partner and thinking beyond into a broader social environment. So now I'm looking at screening, assessment, brief intervention, and then linkage to intimate partner violence resources. So effective screening and assessment is going to build on existing trauma-informed approaches. So this is, it's gonna be paramount to have trustworthy, respectful, non-judgmental, and caring relationships with providers. And that, of course, that is the experience of the person accessing services with us. And our services are supporting safety and confidentiality, understanding that privacy and confidentiality are safety concerns for people who are experiencing intimate partner violence or have a history of intimate partner violence. So when we look at the different ways that things like HIPAA being loosened or different kinds of databases, kind of public databases being used, we want to be really, really wary and cautious and always uphold really the highest levels of confidentiality. And especially understanding that many people who access our services are experiencing interpersonal violence and we don't know it yet. So this isn't something that, this confidentiality can't just come in on the tail end once we become aware of there being, of the presence of interpersonal violence. Which brings me to the next piece, taking a universal precautions approach and routinely creating opportunities to discuss safety and relationships. So this is not just a, you know, you ask a screening question and if the answer is no, then you never talk about it again or the conversation ends there, but that this is, we are really, the much more effective approach is to be routinely creating opportunities for these discussions to emerge and for people to be able to have the safety to share their situation with us. So in that way, we're not seeking to collect information, we really need to take a minimally invasive approach and instead of trying to find out what's happening in someone's life, to focus on building safety and trust for people to be able to have these conversations with us. And what's been found time and time again is that the quality of the clinical interaction has a huge effect on how somebody responds to questions about abuse that they may or may not be experiencing. And so in this way, because it can increase somebody's danger to disclose that they're experiencing intimate partner violence, it becomes that much more important for our services to create access to intimate partner violence information and resources without requiring that self-disclosure, right? So this is information that we should be prepared to provide that we know what the resources are, that there's both general information as well as specific resources available and that people can easily access this in ways that protect their privacy and that they don't have to, you know, find a way or a time to tell staff about it. Although we certainly want to be, you know, routinely creating opportunities to have these conversations. Sometimes it's not, sometimes it has even been found effective to rather than, you know, if questions around intimate partner violence aren't really yielding much, then just asking more generally about someone's social context, you know, who they tend to spend their day with, as well as asking just in general around healthy relationships and offering information on healthy relationships. So now, folding in attention to IPV in our assessment processes, we want to recognize and ask about the relationship between emotional and mental health and intimate relationships. So just having that gentle curiosity around kind of what are some of the connections there. And then asking about how intimate partners or other close social supports might respond to them when they're experiencing symptoms. Is it the only time that someone is kind to them or does the person tend to become more controlling or potentially even abusive when they're experiencing symptoms? If they were to share their service plan, if they were to share information about medications that they were prescribed, how would the person respond, right? How would they anticipate them responding? And then to be always contextualizing, how can the symptoms and presenting concerns be understood as potential threat responses and survival strategies? And this folds in with a more general trauma-informed approach as well. And of course, when we're asking about intimate partner violence, we always want to be sure that we are talking privately with a person. And so, actually, let me show this slide while I mention this. We always want to make sure that we're talking privately with a person. So if it is telephonic or a virtual visit, then some things that we can do is ask more yes or no questions until we're able to confirm that the person is alone, that this is a confidential session. If we're meeting in person and there's somebody apparently present, then we can ask if they could step out for a moment, if we could meet alone. And then if the person who's seeking services says no, like if they say, for example, no, I want my partner here, like I can say anything in front of this person, there's nothing I have to hide, then we neither insist on that person leaving nor do we ask about relationship safety. So we just reserve those questions for a time that we can have a private conversation. And if we insist on somebody leaving the session in order to ask these questions, then what can happen is that that can increase a person's danger as well as increase the likelihood that their ongoing access to this mental health service will be sabotaged. So just kind of some how to proceed there. So in addition to being able to ask about intimate partner violence, we also need to be ready to be able to recognize it. So here's some pieces to listen for, particularly around mental health coercion. So the undermining, denigrating or discrediting somebody because of their mental health. The blaming, so somebody blaming their own behavior on somebody's mental health. This can sometimes come in the form of things like, they don't know what they're talking about, they don't understand what happened, they were delusional and I had to restrain them, right? So kind of that blaming behavior. The gaslighting, which we talked about before. And then the jeopardizing. So a partner who is seeking to exacerbate the mental health symptoms, and this can come both in interrupting healthy routines as well as interfering with their care. And other sources of safety and stability like interfering with their housing. When I was a housing first provider for many, many years, I can't tell you the number of times that I would receive calls from people who are trying to sabotage the housing stability of the folks in our program. So being really aware of those dynamics. Threatening, so using a person's mental health to threaten them with hospitalization, institutionalization, loss of child custody and any other outcome that they would see as being negative in order to intimidate, harm and control them. And then of course, any attempts to control or control a person. We want to be really aware and have our IPV ears and assessment engaged. And so some of the common ways that this can come up is somebody trying to influence a formal diagnosis, control somebody's mental health services, control what they share in services. So if somebody is kind of allowed to speak for themselves and then also their decision-making power, including controlling finances, their medical decisions and as we talked about earlier, legal documents. So what comes next? Someone has shared experiencing intimate partner violence or this kind of coercive control, how can we help? So we want to validate, affirm, listen and offer strengths-based support. So for any point you are feeling kind of a knee jerk reaction to try to jump into problem solving or trying to kind of advise somebody, we wanna really slow down and kind of notice that response in ourselves and really focus on remaining present and remaining a validating and affirming presence. And then being able to offer that strengths-based support, what or who has been helpful and we can talk about safety strategies and possible resources if you'd like. But being really, really clear that it is never somebody's fault when somebody harms them, that a person always deserves to be treated with dignity and respect and that we believe them and that we are with them as they navigate this. Some things that we want to be prepared to safety plan around is to really focus on their continued safe access to the services that we're providing. Of course, there's more safety planning needed, likely. There's likely more safety planning needed than just this, but that's where we can hopefully link them with an anti-violence advocate who specializes in that safety planning. So for our setting in mental health services, we really want to be able to discuss save times and places that they can make or receive calls, that they can receive information, as well as safe strategies around their appointments, attending both in-person or through telehealth, their options for maintaining control of their medication and managing those medications safely, privacy and confidentiality around particularly things like explanation of benefits, electronic health records, and just all the ways that we're going to protect their sensitive information. There's people who, so for example, if someone has a child in their care, somebody who has escaped to a different community or a different state, and then an unsafe ex-partner puts that child on their insurance in a different state without that survivor knowing, and then now is able to get explanation of benefits and be able to locate a survivor because of that. So the depth of the privacy and confidentiality needs are really important, and being able to have that built into our programs, but also to be able to discuss those pieces with folks. The legal documents, which I'll talk about in a moment, and then collaboration with anti-violence advocacy programs. So for supporting coping strategies and emotional safety, this is going to map onto a lot of the services that likely you're already offering. So things like expanding and strengthening safe support networks, exploring how their responses to abuse support their safety, taking a trauma-informed and strengths-based approach, everyone makes sense within their own context, right? Exploring whether and how any of their responses or coping strategies are creating hardship, and then offering that individualized person-centered support around it, offering psychoeducation on trauma responses, and help with differentiating a trauma response from the necessary vigilance, the vigilance that is actually helping them to stay as safe as possible as they're experiencing this ongoing violence and targeting. And then, you know, anything that, any safety planning that we're doing, being sure to adapt that to cognitive strengths, and how the person best processes information and takes action during crisis. And never, never, never, never advise or try to persuade someone to leave a relationship. One of the times that people are at highest risk for being killed by an intimate partner or ex-partner is when they have escaped that relationship. And so this is an intensely personal decision. It's one that we should not take lightly, and that comes with risk. And in best case scenario, we want to be sure to have, you know, a domestic violence advocate that is working collaboratively to help safety plan around any kind of exit strategy. So we actually want to say the opposite. We actually want to say to the person, your relationship and any decisions that you make around your relationship are wholly your decision. We are here to support you, regardless of whether you're in this relationship, in no relationship, and another relationship, our support is unconditional in that way. And then some different resources to help locate services as well as crisis support. So in my five minutes before we open it up for question and answer, I'm going to quickly go through integrating some of what we've talked about into crisis response and recovery tools. So what's been found from meta-review are the following protective factors as well as risk factors. And so focusing on really promoting the protective factors of housing, economic stability, and social connectedness. A lot of our programs are likely already focused on these pieces. So really investing in these pieces, shoring them up, advocating for expansion of these pieces, because these play a huge role in safety from inter-partner violence and sexual violence for people in general, and then especially people living with a disabled and psychiatric condition. And then a risk factor that has been found time and time again is active substance use. And so what's really important here is offering harm reduction-based services and integrated care around diagnosable substance use disorders, and never turning someone away because of active substance use, never limiting somebody's options or resources because of substance use, but actually quite the opposite. For psychiatric advanced directives, these can support safety when they're used to increase self-determination, especially when we're naming who a person wants and does not want involved in their care. On the other hand, they can increase risk if they give legal authority to an unsafe partner or someone that the unsafe partner is able to influence. So we want to establish who are those significant social supports and are they safe before we include them in psychiatric advanced directives. And of course, it's never that simple, so we want to do our best to assess that and then continue to update the PAD if new information comes to light. And then we need to be really responsive to any concerns that a PAD could be used against them. And then, of course, advocate on behalf of people for that PAD to be honored. And then for crisis evaluation and hospitalization, in crisis evaluation, we need to include in our assessment whether the person is not only a danger, an eminent risk to themselves or others, but also are they in danger from somebody else, especially because we know that intimate partner violence often precipitates mental health crisis. And so, and if a person is an eminent danger from another person, then that immediate safety need takes precedent. And then for hospitalization, we want to assess the role of IPV and victimization in the mental health crisis at entry, we want to offer IPV specific support and resources, and then fold in that safety planning in discharge as part of discharge planning. Hospitalization may be a time that someone chooses to reduce contact with a partner or other social support that is unsafe. And if they choose to do that, then, of course, supporting that, honoring that, never forcing it. We always need to remain survivor-defined. But that said, something that can be really helpful is if they do have children, making sure that they still are able to have contact with their children if they're limiting contact with that unsafe partner. And we have this resource here that we did in collaboration with the Suicide Prevention Lifeline on responding to intimate partner violence. So that can be a resource here for some additional crisis evaluation and response when suicidality is present. We talked about psychotropic medication. So the one thing that I'll say here is be careful about, if you're a prescriber, be careful about how side effects may reduce vigilance if somebody is experiencing ongoing abuse and violence, and be sure to be transparent in discussing those potential side effects and how that may fit in with a safety plan. And then here, I'm quickly running out of time, and I want to be sure that we have time for questions. So you have access to the slide. And I want to just point out some of the ways that, through our collaboration with Mary Ellen Copeland, that we, together, just added some pieces to wellness recovery action plans to be responsive to intimate partner violence safety planning. These are very, very slight additions, and it's actually a really natural fit. So for folks who are employing teams, or if you yourself are using RAP, then this can be a really seamless way to include some attention to intimate partner violence and safety planning. And so with the six components, we have here the different pieces that were added, again, in collaboration with Mary Ellen Copeland around how to incorporate that attention to safety planning. So you have these here for reference. And lastly, I'll say, for partnerships with anti-violence programs, anti-violence advocates are experienced with crisis support, when it comes to domestic and sexual violence, advocating across complex systems, locating needed resources, and partnering with people to support their physical, emotional, and financial safety. I know that many times when I was helping to link people to different advocacy organizations, there was a common concern of, well, they're going to tell me not to see this person anymore. They're going to tell me to leave the relationship. And the opposite is true, that advocacy services are always going to be survivor-led and defined. There is a huge need for collaboration, and our needs assessment of over 500 domestic violence programs found that there's just an enormous need for trauma-focused mental health services among survivors that are in DV programs, that there's a sense of not being able, kind of not being prepared or equipped to meet the needs of survivors with disabling psychiatric conditions. And so the top requested resource from DV programs was expedited referrals to mental health services. But what we have found nationally is that cross-training, linkages, collaboration, and then, of course, co-location and interdisciplinary teams are all really important strategies to help address this overlapping experience of intimate partner violence and severe mental illness that too often gets siloed and kind of just, I'll just say that, just gets very, very siloed and what a disservice that does to people. So our references here and different resources, my email, as well as our handle on different social media platforms, please feel free to reach out if we can be a resource. Thank you, Gabriela, for such an interesting and important presentation. Before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. You can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app now at smiadvisor.org slash app. Also, since Gabriela mentioned psychiatric advance directives, we do have a psychiatric advance direct app, which you can find more information out on smiadvisor.org, and you can complete pads with your clients or patients directly through that. Okay. So we just have time for probably just a couple of questions. The first question, Gabriela, is when there is intimate partner violence and serious mental illness, how do you decide what to work on first? Is there some sort of hierarchy when someone is experiencing something like this and also has significant symptoms and other challenges? Yes. That is such a great question. Thank you. So what's been found time and time again is that integrated approaches are best. When the approach can't necessarily be integrated because of the resources that exist, then at the very least, collaborative approaches and services. But that many times the different symptoms that may be increasing risk or that the person may be naming as highly distressful or impacting their functioning, that if we can't also support people with establishing some safety, then that accessing mental health services and that overall stability is going to be that much more difficult. And then of course, I think we always say in our different fields, safety first. Now that said, I would also say, so kind of a both and here, that the person whose life it is, that person is the person who knows best what's possible to do right now, what's safest to access and do right now, and what would yield the best results when it comes to where to start. So defaulting to integrated approaches and person-centered approaches. Great. Now to shift a little bit, kind of an ethical question. So is there a point when we as mental health providers would intervene either by reporting abuse to a state governing body or by calling police? Is there a point where we would have to do that? So in different states, there are different mandated reporting laws when it comes to domestic violence. So some states do have mandated reporting for domestic violence. And that's actually something that we really, really advocate against and caution against because of all the ways that that can increase danger. And so typically, you know, we would not be involving either a mandated report or law enforcement without a survivor leading that. And you know, unless there was something like, you know, for example, you know, an active public violent event in our setting that requires that kind of crisis intervention, we would not be calling another entity or reporting it without the survivor leading that because of the risk that they face. It really has to remain survivor-led. Okay. Great. And then, so if somebody is either, you know, somebody doesn't agree or doesn't identify what we would know as, you know, mental health coercion or abuse, or if they're unable to ask for assistance, if they have intellectual disabilities, have any, that might be two different questions. But do you have any ideas on how to approach this when the person themselves is either unable to or just doesn't believe that what is happening to them is causing them safety issues? Yes, that is such a great question. So there is so much stigma around interpartner violence, about abuse, so much internalized stigma of people, even if they were to, you know, identify for themselves that this is something that is, you know, abusive. And so what we can do is really move away from using any kind of label and instead taking that truly person-centered approach where however the person describes their situation, their relationship, their goals, really meeting them there and focusing on that. So many times someone might really bristle at the idea that their relationship or someone in their social circle is being labeled abusive. And so instead, you know, but maybe really open to talking about how sometimes I feel really bad when this person does this, right, or I really feel like it's my fault, but like, is it really all my fault? And so really meeting people where they are, avoiding the use of labels, and just focusing on their goals, because in one way or another, people's goals are always going to come back to wanting to feel emotionally and physically safe, wanting to feel, you know, connected with themselves and within their social sphere. And so there's a lot of ways that we can help people in their self-stated goals without kind of forcing our own problem definition. All right, thank you so much. I was going to try to squeeze one more in, but I don't think we have time. So if you do have follow-up questions, though, about this or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. So any mental health clinician can submit a question and receive a response from one of our SMI experts, and these consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention CTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met a requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. And please join us next week on Friday, October 29th, as Emma Parrish with the University of California, San Diego presents Crisis Management Using Asynchronous Telehealth and Apps for People with Serious Mental Illness. Again, this free webinar will be on October 29th, 2021, from 12 to 1 p.m. Eastern Time. Thank you so much for joining us, and thank you to Gabriella. Until next time, take care.

Intimate Partner Violence

Disabling Psychiatric Conditions

Trauma-Informed Approaches

Prevalence of IPV

Risk Factors

Safe Spaces

Screening and Assessment

Support Strategies

Traumatic Mental Health Effects