A decade ago, Christina Love was dropped off at a domestic violence shelter in Anchorage, Alaska, fearing her partner might attempt to kill her. There was alcohol on her breath, so the shelter turned her away. Feeling like she had nowhere else to go, she went right back to her partner, who she says sexually assaulted her that very night.

Love was using substances, both alcohol and heroin, to cope with trauma, she said, including the trauma of intimate partner violence, or IPV.

Another time, her partner hit her in the face with a 2-by-4, and her jaw had to be wired shut. “Police brought me to the shelter, and they wouldn’t take me,” Love told Rewire.News in an interview. The same shelter turned her away because Love had been kicked out before for allegedly using and selling heroin.

Again, she went back to her partner.

Love says she was kicked out of six shelters over the years for substance-related offenses.

“The only place I had to go back to was my partner or else I would be homeless,” Love said. “There were times where [shelters] didn’t take me, and I had no where to go back to, and so I tried to commit suicide.”

Love still spends a lot of time going in and out of shelters that treat IPV, but now she’s teaching the people who run them how to improve their services as a training project specialist with the Alaska Network on Domestic Violence and Sexual Assault.

“These systems were designed to help me, and they did more harm by rejecting me, by telling me messages that I wasn’t worthy,” she said. “It was so dehumanizing to not be able to access services.”

No person turned away

Currently, government-funded shelters technically shouldn’t be turning anyone away, Love noted. In 2017, the Family Violence Prevention and Services Act (FVPSA) established that all services and programs funded under the act must help survivors regardless of substance use, and that “programs cannot impose conditions for admission to shelter by applying inappropriate screening mechanisms, such as criminal background checks, sobriety requirements, requirements to obtain specific legal remedies, or mental health or substance use screenings.”

The FVPSA, part of the U.S. Department of Health and Human Services, funds over 1,600 domestic violence organizations and programs across the nation. Despite the ruling, Love claims that “every single” shelter in Alaska still rejects people for using, which she finds particularly devastating—she believes many are using to cope with their trauma like she did.

Substance use is common among survivors and victims of IPV. After interviewing 477 women from 1997 to 2001, the Integrative Services Project in Iowa found that 93 percent of women in substance use treatment experienced emotional abuse six months before going into treatment, and 67 percent had been physically abused six months prior to treatment. A study published in 2014 found that “IPV has been significantly associated with mental health challenges including substance use problems.” Though lower than the Iowa study, the researchers found that between 25 percent and 50 percent of women in substance abuse treatment programs report IPV.

“What we hear from survivors as well as providers across the nation is that many DV shelters need more support and resources to be able to [address substance use],” said Gabriela Zapata-Alma, director of policy for the National Center on Domestic Violence, Trauma & Mental Health (NCDVTMH). “Unfortunately, without the needed resources, what ends up happening is that many survivors still get turned away or discharged from DV shelters due to substance use concerns.”

Zapata-Alma said there is no data available to know how many comply; Tonia Moultry, deputy director at the National Network to End Domestic Violence, told Rewire.News that no person or agency oversees compliance.

Early explorations in integrated services

Treatment that integrates both substance use and IPV treatment has only been initiated in tiny pockets of the country, including Iowa, Alaska (led in part by Love), and now Vermont.

Over the past year, experts have been studying the intersectional impact of IPV, opioid misuse, and rural poverty in Vermont, and they believe their initial observations warrant immediate action. They have started taking the steps to create a new recovery housing unit in the state, which will be run by an IPV shelter, a meaningful step considering facilities rarely treat both substance use and IPV trauma under the same roof.

The Lafayette House in Joplin, Missouri offers both substance use disorder and IPV services, according to its director of development Louise Secker. And though they are considered two separate services, they are located on the same campus for easier access.

Barb Rindels-Rasmusson, a victim service advocate at the Integrative Services Project in Iowa, says the percentage of shelters addressing this cross-section of trauma nationally is incredibly low, a handful of states with one to five shelters with integrated services.

The most widespread effort to integrate these services is in Iowa, due largely to Integrative Services Project, which Rindels-Rasmusson co-founded with University of Northern Iowa professor William R. Downs. The pair began researching the intersection of IPV and sexual assault with substance misuse in 1996. After receiving federal funding in 2001, the organization began training domestic violence, sexual assault, and substance use disorder treatment agencies across the state. (Integrative Services Project is no longer operational as of 2018, but Rindels-Rasmusson continues doing this work with research partner Megan B. Jones under an LLC called Integrated Service Strategies.)

Substance use treatment centers rarely provide IPV services. A study published in 2014 of over 10,000 substance use treatment facilities found that only 38.4 percent provided IPV-focused services, while another study published in Psychiatric Services earlier the same year found that among 13,342 substance use treatment facilities, only 36 percent offered IPV services. Neither study specified whether the services were for survivors or perpetrators, according to NCDVTMH.

Most substance use treatment centers are also unprepared to handle abusive partners. For example, in Vermont, 42 percent of people leaving substance use treatment are women, yet only 27 percent of recovery housing beds in the state are reserved for women. Providers had experienced issues with abusive partners stalking patients and felt ill-equipped to deal with the risk involved with providing recovery housing to IPV survivors, according to Emily Rothman, a professor of community health sciences at Boston University who is working on the Vermont initiative.

Rebecca Stone, a sociology professor from Boston’s Suffolk University and another expert working on the Vermont initiative, said survivors should be able to experience substance withdrawal in a safe place. “Withdrawing is painful. In some ways, that can be used against [a person in an abusive relationship],” Stone said, explaining that abusive partners will use substance addiction to manipulate or trap their partner in this vulnerable state.

Love noted that substance use centers tend to focus more on morality than treating patients’ traumas, which she said is at the heart of a lot of substance misuse. Rehabilitation facilities in the United States still default to the 12-step program, which is rooted in religion, morality, personal shortcomings, and making amends to those you have wronged, rather than focusing on any possible trauma that may have precipitated the desire to use. Love said it was frustrating seeking help for her substance use while she was also struggling with IPV because she felt like her trauma wasn’t being acknowledged.

When another IPV survivor, Tiana, who chose to use a pseudonym for fear of her ex, left her abusive husband, she entered substance abuse treatment. She had been using opioids to cope with the IPV she experienced, Tiana told Rewire.News, and her ex-husband would often use opioids to lure her back to him. The treatment center she entered focused solely on sobriety, not healing the trauma she endured. Tiana said the facility encouraged her to seek outside help healing from her abusive relationship, which was helpful, but both issues—Tiana’s opioid use disorder and her recovery from IPV—had to be addressed separately from one another.

What could help?

“In a perfect world, if we had all the funding available, it would be ideal to have transitional housing or permanent supportive housing for survivors who have substance abuse issues,” National Network to End Domestic Violence’s Moultry said, “so they can both be working with a domestic violence advocate and be getting treatment at the same time.”

Research shows that treating the issues in an integrated way has yielded positive results.

In fact, a 2002 report funded by the U.S. Department of Justice made it clear that integration should be the norm, stating that “there are very good reasons to consider integrating domestic violence and substance abuse programming, the most important ones being that client needs may be better served and client outcomes might be improved by doing so.” And that “failure to address the substance abuse problems of female domestic violence victims may increase their risk of further victimization after they leave treatment.”

Integrating these services “comes down to human compassion really, just understanding everything about a person, not just what’s on the surface,” Tiana said.

Crisis Intervention Service, which works with women in IPV crisis in Mason City, Iowa, is one agency that received training from Integrative Services Project.

“It really opened our eyes because we saw that a lot of the people we were working with were using drugs and alcohol to cope with the violence in their lives,” the center’s executive director, Mary Ingham, said. She said the center has stopped kicking out people for using substances, including intravenously, at their location. Ingham said the policy has helped many women stay safe as opposed to going back to their abusers.

A recent report from the Centers for Disease Control and Prevention found about 55 percent of all female homicide victims were killed as a result of intimate partner violence. And yet, many states have not followed Iowa’s lead.

Rindels-Rasmusson said getting funding on a national level is a major hurdle.

“There’s no steady funding stream for this particular issue at all,” she said. “I’m not understanding it.”

If funding for services reflected the complex needs of survivors, lives could be saved.