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Integrating Mental Health Care into Domestic Violence Advocacy Services

Published Wilson, Trenecsia LMHC CDPT MHP NCC
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This article was authored by Trenecsia Wilson, LMHC CDPT MHP NCC for the Washington State Coalition Against Domestic Violence, June 2020.

Introduction

We talked to domestic violence advocacy programs from around the state and asked them what they learned when they added mental health care to their advocacy services. What lessons and wisdom could they pass on to all of us?

Where along the integration spectrum do you see your organization?

Below are questions to consider or revisit – whether your domestic violence organization is just getting started with integration of services or your organization has been working with mental health providers for a while.  Thank you to all the advocacy programs who shared their experiences and knowledge with all of us.

What does it mean to integrate mental health care into a domestic violence advocacy program?

In short, it’s the level to which these services are integrated within the day to day program operations and advocacy services. Integration exists on a spectrum from simply offering mental health referral services and a warm hand off to employing a mental health provider* and making mental health care an integral part of advocacy service delivery and collaboration.

Planning – where to start?

It may be easier to think about how to start adding mental health care to your advocacy services, if you approach it in small manageable chunks with a long-term goal of integration.  Many domestic violence organizations that have incorporated mental health care and have shared that “integration is super important.”

Step one – Referrals only

Building a mental health provider list of referrals is not always easy.  Start with your local community health clinic for potential resources.  Sharing your referrals with all staff is a first step towards integration with a big benefit for survivors. When offering referral services there are challenges to keep in mind for program participants. 

Many survivors have no insurance, have high deductible healthcare plans, or only a shared plan with their abuser preventing access to services.  When survivors qualify for Medicaid, your relationships with community-based mental health providers that have understanding or experience in domestic violence are always the best choice.

Step two – Referrals with known experience

Building a consistent process for making referrals and sharing these steps with all staff and volunteers will move your organizational practices toward integration of mental health services.  Ask each other: how do we make referrals? What do we all know? Do we all know the same people? Have we had any feedback from survivors about the professionalism and quality of the providers on our list?

While some of you may already be providing mental health referrals, it is important to revisit this conversation every year, and understand how referrals happen among staff, and to learn about the education and experience of the providers and the importance of directly linking clients. A referral, in the basic sense, entails giving the survivor phone numbers to call. “Linking” is making a warm connection on behalf of a survivor. If we know and have relationships with providers, our connection helps survivors to feel supported through the process. If we can say things like “I have met Jane and I hear good things about her from other survivors,  I send a lot of clients to her, and she understands our agency and a lot about this advocacy and domestic violence,” that’s a much more supportive assist to treatment then saying “here is a list of providers in the area you can call.” Developing a specific list of referrals that is built on your directly asking about each mental health provider’s experience and training in trauma informed and domestic violence practices and it is the next step in integrating quality services for survivors.

Step three – Integration happens and continues to grow  

It is exciting! Your organization is ready to hire a mental health provider as part of staff or as a contractor for continuous services.  There are some key questions to consider as you move forward to integrate mental health care in your domestic violence advocacy services.

 “With integrated mental health services, we see people heal in all the right ways.” –Executive Director

Hiring considerations

It’s important to know most mental health providers receive very little to no training on domestic violence.  Some social work programs include a marriage and family therapy programs; but that does not mean that domestic violence training is included.  When interviewing potential mental health providers, it is critical to ask what type of knowledge and experience they have in working with people experiencing domestic violence.

 “By having a therapist on staff, it really takes the burden off helpline and walk-in services.” Executive Director

Consider this! If you are hiring a mental health provider with no domestic violence training or experience, your agency must be committed to supporting continued professional development that will enable providers to be successful and do no harm to survivors. This could look like shadowing advocates, taking trainings offered by organizations that provide domestic violence advocacy services, and learning opportunities focused specifically on the context and tactics used by persons causing harm and the impact on survivors and their children.

Let’s talk contracts

We have been really successful in finding people who have their hearts in this.

Advocate

What to include in a contract? If you are contracting with a therapist, there are some points you want to be sure to include:

  • the provider’s scope of work;
  • alignment with your organizational mission and purpose;
  • expectations for on-going professional development in domestic and sexual abuse related dynamics and trauma;
  • collaboration expectations with your organization’s staff;
  • understanding of your organization’s practice regarding confidentiality and privacy obligations of written records and conversations with program participants (for example, the provider should not assume that the participant’s files are open for their review without permission of the survivor);
  • clinical supervision (if applicable);
  • funder requirements;
  • other specifics around providing mental health services, such as offering a limited number of sessions in a brief therapy model versus long term ongoing mental health support and assessment expectations.

What is the duration of the contract? With a new therapist, consider a short-term contract in case it isn’t a good fit. This could be something from 3-6 months.

Collaboration between advocacy staff, leadership and the mental health provider

There is a tendency to silo the mental health provider in their own little corner because it seems like the work they do is so different from that of everyone else’s. For a provider, this isolation from staff can make it harder to understand the role of advocacy, how to best support survivors and how they fit into the overall mission of the organization.  

“We really believe it requires a team effort. The therapist goes to team meetings, and everyone working with clients meet with each other to work on client issues . . . it helps avoid triangulation.”   Executive Director

Connection is the antidote to isolation.  Spending time together allows everyone to learn from each other and understand everyone’s valuable contributions. Find ways to make sure your mental health provider feels like they are part of the team! Invite the provider to events, to meetings, to virtual calls – get creative.

There are different models of collaboration. Some depend on organization size; but most depend on the organizational culture and values. Executive directors and middle managers set the tone for collaboration.  One advocate said, “I think that starts at the top.” This statement highlights the influence of the leadership culture and values on collaborative efforts.

Prioritize time together – understand each other’s expectations

It is important for both the mental health provider, the advocacy staff and leadership, to understand the scope of the provider’s mental health practice and the advocacy role. Therapy and advocacy fill two very different roles with minimal overlap. Building a shared understanding happens when everyone takes the time to explore what the leadership and advocates expect of the provider, and in turn, what the provider expects of advocates and the leadership. 

Sometimes there is a tension between therapeutic goals and advocacy strategies.  During therapy, a mental health provider can identify issues that need advocacy expertise and support. This allows the provider to focus their efforts on their strengths – the therapeutic interventions.  Even though the provider may bring up specific needs of their clients to advocates, they are not filling the role of advocates in these moments.  The provider is responding to what is presented in therapy which may bring up the need for specific advocacy services.  It is important for leadership to equally review and value both the advocates and the therapist’s opinion.  Leadership should be careful that the education and credentials of a provider do not appear to be valued over advocacy expertise.  Because advocates work tirelessly to aid survivors in multiple ways, they offer critical information about a survivor’s priorities, wants and needs.

Supervision of mental health providers

How can we provide supervision for mental health care needs, if we do not have a mental health care background? Many of you may have this question or may be in a situation where you are the supervisor of a therapist but do not have any clinical expertise. This limits your scope to providing only administrative supervision which means your therapist is not receiving the clinical support they may need. If you are hiring or contracting with an intern or associate level therapist**, then by law it is required that the therapist obtains clinical supervision.  An associate therapist includes most counseling professionals with less than three years of practice such as licensed mental health counseling associate, licensed marriage and family associate, and licensed clinical social worker. Some advocacy programs have staff that can provide supervision; but most therapists must find and pay for their own supervision. This may make it harder to find a therapist to hire or contract with for your organization. The average cost of supervision is $100 per week. 

Try this! When working together to respond to the specific needs of a survivor, create a list that shows who on the team is providing support.

  1. Safer planning for the survivor and their children when negotiating strategies with child welfare -> Advocate
  2. Survivor needs help negotiating a private/public lease with landlords for housing -> Advocate
  3. Survivor reveals that they have recently started using substances to cope with their depression -> Mental health provider

Also, be aware that the supervisor that is retained by the therapist may not have any training or experience in domestic violence.  It is a good idea to include language in an evaluation that describes specific measures such as provider reliability, feedback from clients, and fulfilling contractual duties. 

Try this! Even if your organization cannot provide clinical supervision to your therapist or therapist contractors. Consider attending trainings to learn more about therapy and behavioral health so that you can make informed decisions about supervision, programming and the quality of the mental health services survivors are receiving.

Building or deepening the cultural relevancy skills in the mental health provider

For every survivor, it is important to understand how culture and personal experiences influence the ability to find, to engage in and to have success with mental health services.

Many survivors from Black, Indigenous or communities of color, immigrant and LGBTQIA (LGBTQIA refer to lesbian, gay, bisexual, transgender, queer or questioning, intersex, and asexual or allied) communities or survivors living with disabilities (hidden or visible) may fear or distrust health care organizations because of historic and continuing mistreatment, misinformation, potential disclosure of immigration status, or inadequate care. Survivors also have difficulty in finding and using mental health care services because there are only a limited number, or not any, providers who speak their language or share cultural, racial, ethnic and community experiences, or identify along a spectrum of gender and sexualities, in their community.

And, as discussed in Hiring considerations and Supervision of mental health providers, the mental health provider your organization has hired or contracted with may have little or no training or experience in domestic violence, including the clinical supervisor for the therapist.

Things to consider: Have a plan to address the need for culturally appropriate services. For some agencies that means having a specific number of clinicians you can refer to or offering translation services. Culturally appropriate services should always be a part of the conversation, now more than ever we must understand and consider that harm may be done when we neglect to consider cultural implications.

Reducing barriers to mental health services

As we know, there are many barriers for survivors seeking mental health services. Barriers such as the cost of services, not meeting eligibility criteria, the provider isn’t linguistically competent or culturally relevant, or the insurance benefits are controlled by the abusive partner. Domestic violence advocacy programs with integrated mental health services reduce some of these barriers by offering free services, with minimal paperwork, and eliminating the need for a medical diagnosis to receive therapeutic care.

Integrated mental health services should include a non-medical model counseling approach where therapist is not required to diagnose clients/program participants. Private and community-based counseling services often require a medical diagnosis to receive services. This diagnosis could be used against a survivor in a family court context or in TANF (Temporary Assistance for Needy Families) or custody agreements.  Offering integrated mental health services means a survivor doesn’t have to get a medical diagnosis in order to receive services.

Telehealth services and COVID-19

During this time of the Coronavirus (COVID-19), with physical distancing and stay-at-home restrictions, many of us of are using technology to deliver both mental health and advocacy services for the first time. Eventually this pandemic will end, and you may be thinking about how service delivery will change or remain the same.

Planning beyond COVID-19 is important to consider, especially if Telehealth services will continue to be available once we can come together again.

Here are some questions to consider:

  • How is Telehealth working for your advocacy services?
  • Are there any benefits to Telehealth mental health services that survivors have shared with you?
  • What are the challenges or negatives that survivors have shared with you?  
  • If survivors want to continue receiving mental health services remotely, how will your organization respond? 
  • Is your mental health provider willing to continue to provide services remotely? 
  • What about creating new or adapting existing organization policies?
  • It is a helpful to look over your data to help answer these questions. Are you serving more clients or fewer? 
  • Would offering Telehealth reduce or remove barriers for specific clients?
  • Is it cost effective to offer Telehealth services? 

For some client’s Telehealth services reduce barriers. This may include transportation, childcare, and time.  Safety and privacy are always a consideration, Telehealth services may not be a sustainable option for clients who are experiencing ongoing violence from their partner, fleeing from their partner, or living in a place where privacy cannot be expected or guaranteed.  

After COVID-19 restrictions are lifted, HIPPA rules regarding confidentiality and client information will be enforced, and some virtual programs that are currently being used will not be able to continue being used.  HIPPA complaint programs include Zoom for telehealth, Google Meets with GSuite, Spruce, Doxy, and others. The current relaxed enforcement is allowing mental health treatment to use by non-compliant HIPPA program options and at some point, that will end. 

Try This! Consider offering Telehealth as an ongoing option for clients who are interested. Therapists who have received Telehealth training regarding the use of technology and following HIPPA are equipped to assess if Telehealth services are appropriate.

How will you fund your counseling services?

Consider the different levels of integration and what makes the most sense for your organization.

“Long term, we would love to have someone on site.” Executive Director

Here are some questions to consider:

  • Is it possible to use funds from a variety of grant sources to support adding mental health services?
  • Is there space in your budget to support additional mental health services?
  • Does it make more since to have a part-time therapist to start?
  • Or does contracting for a specific number of hours per month or partnering with a mental health clinic and offering advocacy services to their clients in exchange for mental health provider services?
  • Would the added capacity of a therapist and anticipated expansion of services fill that gap for you?

Terms:

*Mental health provider (or provider) – we will use this term to cover therapist, counselor, intern or associate therapist unless otherwise specified.

** Interns (in school) and associate therapist (recent graduates) require on average 1 hour per week of clinical supervision. Intern requirements are decided by school, associate requirements are decided by Department of Health/WA State licensure board. Supervision laws and regulations set forth things like the number of hours of supervision that can be provided via telehealth, the requirements of qualified supervisors, and the documentation required to track and prove supervision when applying for licensure. Therapist can fall under several disciplines including social work, marriage and family therapy, psychology, and mental health counseling.

Washington State Department of Health – Licenses, Permits, and Certificates

Resources

Sample contracts:

Two sample contracts from domestic violence advocacy organizations contracting with mental health provider.

Sample Contract 1

Sample Contract 2

Article: “Fragmented Services, Unmet Needs: Building Collaboration Between the Mental Health and Domestic Violence Communities” by Carole Warshaw, Ada Mary Gugenheim, Gabriela Moroney and Holly Barnes, September/October 2003.

Tools and Projects from the Coalition Ending Gender Based Violence:

Domestic Violence and Mental Health Collaboration project

This project is multi-agency effort to improve the experience of domestic violence survivors with mental health concerns.

Trauma and Behavioral Health Systems Coordination Project

This holistic approach ensures that survivors of domestic violence and sexual violence with mental health or chemical dependency concerns have access to well informed and integrated services.