Hello. I'm Nancy Glass, professor at Johns Hopkins University School of Nursing. Today we're going to focus on safety planning and harm reduction for survivors of gender-based violence. So as an overview for our presentation, we're going to focus on the survivor-centered approach to safety action and harm reduction and how to support a survivor in establishing a safety action plan in partnership with the available health and community resources. So I think our challenge as health care providers is, can we be a positive influence in women and children's lives who are living with violence. So we know that as, in the health care system, we see violated and abused women and girls. And we do provide essential health services. And those supports include the first line psychosocial support, but also we need to be able to provide action plans for safety and referrals to appropriate community resources. And with these services together, we think that we can increase the safety and provide better outcomes, both for health and social outcomes, for women, children, as well as the larger community. So when we talk about a survivor-centered approach, that means we focus on the women's strength. Her goal is often to live free of violence, not necessarily leaving an abusive relationship, for example, or leaving a family, or leaving a community. So achieving a survivor's goal for safety is a process. It's not an event. A woman cannot oftentime make a decision to leave her relationship in a 30-minute session with you as the health care provider. It's often a process of decision-making and safety. And it can be a timely process, so providing, being aware and being willing to provide ongoing support is critical. The principles of survivor-centered approach are those mutuality and reciprocity, meaning that you're sharing and trusting each other and that you give choices, that you don't pressure women to take action when they're not sure that that's safest for them, or you don't pressure them in a health choice, to use certain treatments or not. And it's oftentimes a process of brainstorming solutions. Sometimes helping her think through options, even when she feels she doesn't have options, is critical, and then helping her to make sense of what's next. What are her steps for safety and what are her priorities? So we often use this visual to focus on empowerment in advocacy in a survivor-centered approach. So the key is respect, but also confidentiality, believing her and validating her experiences, not telling her it's really not that bad, acknowledging the injustice. But, yes, violence in the home or violence in the community, sexual exploitation, or sexual violence, is a human rights violation. And she has a right to demand services that respect her autonomy, her self-determination that she can make decisions for herself, but also, in working with child survivors, helping them understand what is happening, and that, find the right advocacy for those young survivors. And sometimes the parents or the caregivers may not be the right advocates. They may be the perpetrator. So making sure understanding the resource in the community is critical. Helping her plan for her future safety, recognizing that oftentimes when they come to us in the health care system, they've already experienced violence. Our goal is to reduce their risk of future violence. So helping to think through safety options that she may have, even in a limited resource setting, and then that means oftentimes promoting her access to available community resources, knowing those resources in a community, if there's a hotline, if there's a advocacy program, if there's a safe house. Even if there's just somebody in the community who's well-respected and known to talk and provide confidential services to women, that's a real help. So also, we've talked previously in other discussions, we need to create a safe place in the health care center. So we certainly don't want signs outside our center that say Entrance Post Rape Clinic, because people would know, anybody that's entering that clinic, they may be there as rape survivors. So that could be stigmatizing. So when we set up our centers as a safe place, we have to think of that survivor-centered care and that safety planning and harm reduction are part of a safe space. And that also includes the site assessment, the clinic's unsafety, wonder if the abusive partner or the perpetrators of the violence come to the clinic, how can the survivor be kept safe, but also the staff at the clinic. Support options in the community, who's available in the community that can be an immediate support option that the woman would have access to and feel safe and trustful. Risk minimization. So again, many of the women who we see in the health care system, they've already experienced the violence. Now our job is help minimize the risk of repeat severe violence. And at risk, some women can be at risk for lethal violence. And this requires often an action plan for safety and harm reduction, because remember, for many women, leaving the abusive relationship, or leaving a community, or a family, that's not within their options. So we need to talk about safety or harm reduction when the woman is staying in the situation. So many women report that they feel better even having a chance to talk about their experiences with a safe person, someone that they trust and they feel confidential, can keep their information confidential. So I think our challenge is, as health care providers, is to dare ourselves to ask, to build that relationship, to establish confidence and use careful questioning, not saying, not asking or saying things like, you're not a victim of violence, are you, but asking, or expressing concern, I'm concerned about your safety, is there something happening in a home or in your community that you would like to discuss with me. It's a very different approach. And be prepared to make appointments for follow-up and referrals. It's often not a one-time, one-session solution, that women may need to come back multiple times because situations are dynamic. Relationships are dynamic. Communities change. So having access to resources as an ongoing basis is critical. And then if you're not sure, as a health care provider, you may not have all the answers. Feel confident in yourself to ask for advice and locate those community resources. They can be a great help in planning for safety. So health care providers are always concerned, what if she says yes, yes, I'm experiencing violence, yes, I was raped, yes, I'm concerned for my safety. Our goal as providers is to be empathetic and active listeners, that we validate what happened to them rather than minimizing the violence. We can't say things like, oh, it couldn't be that bad, I'm sure he didn't mean to do that. That's minimizing what they've experienced, and they won't come back for you to help because that is not supportive. Nonjudgmental, and also thinking about that risk assessment. There are tools that I'll discuss in the next slide that are called Danger Assessment that help the woman or the survivor identify potential risk in her relationship that may increase repeat violence or lethal violence. And then working with her through her options in creating that action plan that is often focused on harm reduction. Support her decisions for safety. And these referrals that are provided have to be based on her priorities, not our priorities as a health care provider, and her own decision-making about safety, because she knows best about the situation. Validating really requires us to say, I'm concerned about your safety and the well-being of you and your children. Letting her know she's not alone. Oftentimes survivors say, I felt like I was the only person that experienced this. So letting them know that there are other women, other community members that experienced this, certainly without sharing names, but letting them know that they're not alone. And also confirming to them that it's not their fault. Only the partner or the community member or that authority who abused her, that is the person who can stop the behavior. It's not her responsibility. And no one deserves to be violated or abused. And there's no excuse. Doesn't matter if he was drinking or taking drugs or any other reason that is given by families or communities, it's not acceptable. And there are options. Even in the least resource-rich community, there are services. They may not be traditional services that we have in more well-established systems, but there are support networks, and we need to discuss with women what's available and what they can reach out to. So risk assessment, as I mentioned, there's a really well-validated tool called the Danger Assessment, and it's accessible online and it's in multiple languages. And it's really used to inform safety action plans in partnership with survivor. It lets her know how risky the abusive partner has become, or the ex-partner. So it asks questions about, has the violence increased in severity or frequency in the past year, is he drunk often, has he threatened to kill her. These questions, if she responds yes to these questions, they could indicate a higher risk of repeat severe violence. And that can inform, as a health care provider, your priorities and safety planning, in discussing her options, in helping her decide about what's the next step. But also, thinking about risk minimization while she is there at the clinic and when she leaves the clinic that day. Is the abusive partner or the perpetrator of the violence, did he or she accompany the survivor to the clinic? Are they in the clinic? Does the partner have access to weapon and has he threatened to use it? Has the partner threatened to kill her? And are the children at risk? These are valuable questions that can help in safety planning. So when we talk about action plans, we are working on helping a woman, or a girl, to recognize the violence and the impact that it's having on their well-being, their health. And help her clarify priorities for safety. Her priorities may be her children's safety. Having resources, meaning having a place to live. She's afraid if she reports the violence that she may be thrown out of the home, so how would that affect her and her children. And also, you know, as a partner, for example, this is the person they love, they want to be in a relationship with in most cases. And so we have to understand the feeling for the partner and that they want the violence to end, but they may want to stay in that relationship. And that includes the feeling for the larger family, the feeling for their culture and their community. People don't just want to leave everything they know. So helping them increase their safety within that context is critical. And also there's a lot of concern about the stigma, about being defined as a victim, and then the privacy of everybody knows, will they be rejected by the community. And helping them identify alternatives or support for their priorities. Is there a trusted family member that she could stay with for a short period of time? Is there leadership in the community that can consult with the husband to talk with him about the violence and how to reduce the violence? Are there programs within the community that can support drug and alcohol treatment? So there's many options, but helping her think through those options are critical. Also remember, it's also important that safety changes, that this, typically violence is not a one event and that women are at ongoing risk, certainly within the home and the community. But they need to be aware of the dynamics of the danger and be prepared to seek resources as their safety changes. And as providers, we need to respect her decisions. It may not, they may not be our choices, but, again, trusting that she has the best understanding of what's happening and her safety for herself and her children and family is critical. So what's not helpful, which women have told us and girls that's it's not helpful, is to try to counsel people if you don't have the skills. Giving advice, if you're not sure of the options, if you're not listening, that's not helpful. Also, women don't expect you to solve the problem. What they need is support, listening, and brainstorming the solutions oftentimes. And they may need to go away and think through their options and they may come back and discuss them with you again, remembering they're always thinking about what's safest for themselves, their children, and family. And we can't set the pace for that decision-making. Again, it's a process. It's not an event. So, again, it's not on our timeline. And we have to be patient and supportive. Labeling a woman or a girl as a victim can be very damaging, and women don't need to be rescued. They need to be provided options that make sense within their context and their priorities. And then, critical, is to never break the confidentiality. That certainly can increase their risk. So when we talk about safety and harm reductions in the referrals in our communities, they vary certainly by community to community and the resources that are available. But critical is that the resources are culturally and contextually appropriate. There can be resources right at the health care center for reproductive health, HIV, and AIDS programs. There could be focus on harm reduction in the sense of HIV counseling and testing, access to condoms, emergency contraception, family planning, so choices that women can make that maybe an abusive partner doesn't know about that she decided to use the pill or to get the shot. And helping her know about the range of services, what's available in her community, even in a limited resource setting. Not all communities have refuge or shelters or safe houses, but there may be a woman or a community member who does take in women if they need just a place to stay why things calm down. Or there may be a trusted family member, so helping her think through that. Also making sure that the partner, the abusive partner, or the perpetrator, is not aware of that safe place. And counseling is something that can be very helpful. Psychosocial support. Helping her slowly make the changes she wants to. It could be helping her engage in economic activities. It could be helping her to have educational opportunities. So it's really setting her priorities as well as oftentimes it could be working with other groups of women. So children's counseling. Certainly children in the home or have witnessed extreme violence in a community, they need support as well. So determining if there's available resources for children in the community and engaging them in that trauma-informed care. There could be advocacy, gender-based violence programs that could be advocates to provide support for women and children that don't demand that women leave the relationship, but let them know their options. Certainly attorneys and legal services, women may very well want to go through the court system and prosecute the perpetrator. Oftentimes it can be long and demanding and can be stigmatizing, but many women feel like that's the best option for their safety. So supporting them through that decision, not telling them that it's no good, the perpetrator will never go to jail, is not necessarily the best response. And then using the protection systems that exist, if they're appropriate. So, for example, in refugee settings or post-conflict settings or other humanitarian settings, there may be child protective officers that can relocate a family or community from an unsafe area. So making use of those services are critical as well. So the key message is assessing your community as a health care provider, making relationships with these organizations, because you're a critical part to safety and harm reduction for survivors. Thank you.
