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Journal of Social Work Practice in the Addictions

ISSN: 1533-256X (Print) 1533-2578 (Online) Journal homepage:

Health Care Experiences of Rural Women

Experiencing Intimate Partner Violence and
Substance Abuse

Annah K. Bender

To cite this article: Annah K. Bender (2016) Health Care Experiences of Rural Women
Experiencing Intimate Partner Violence and Substance Abuse, Journal of Social Work Practice in
the Addictions, 16:1-2, 202-221, DOI: 10.1080/1533256X.2015.1124783

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Published online: 05 May 2016.

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Journal of Social Work Practice in the Addictions, 16:202–221, 2016
Copyright © Taylor & Francis Group, LLC
ISSN: 1533-256X print/1533-2578 online
DOI: 10.1080/1533256X.2015.1124783

Health Care Experiences of Rural Women

Experiencing Intimate Partner Violence and
Substance Abuse


Postdoctoral Fellow, Department of Psychiatry, Washington University School of Medicine,
St. Louis, Missouri, USA

Primary health care providers are often some of the only helping
professionals in rural communities, where community resources to
treat substance abuse or shelter survivors of intimate partner violence
(IPV) are scarce. This article reports on qualitative findings from a
larger study examining the responsiveness of rural health care provi-
ders to IPV and substance use. Findings from 27 interviews revealed
that providers rarely assessed for IPV or substance use, and patients
with a history of substance abuse described their health care encoun-
ters in negative terms. Providers and patients differed in their descrip-
tions of typical health care encounters involving women concurrently
experiencing IPV and substance abuse, but agreed on several basic
points, among them the severity of IPV when substances were involved
and the unfortunate shortage of social services to address violence
and addiction. The article concludes with suggestions for future
research on addressing IPV and substance use in primary care set-
tings and the implications for social work.

KEYWORDS health care, intimate partner violence, rural, screen-

ing, substance use/abuse

One of the best known correlates of substance abuse is interpersonal violence,

and decades of research have found that the link between substance abuse and
partner aggression is unfortunately a predictable one (Stuart et al., 2008). Women

Received August 28, 2015; revised October 27, 2015; accepted November 3, 2015.
Address correspondence to Annah K. Bender, Postdoctoral Fellow, Department of Psy-
chiatry, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8134, St.
Louis, MO, 63110 USA. E-mail:

Health Care of Rural Women 203

in substance abuse treatment frequently report a history of complex trauma that

includes child abuse, rape, intimate partner violence (IPV)—or some combina-
tion of all of these (Najavits, Weiss, & Shaw, 1997), what has been termed
polyvictimization (Finkelhor, Ormrod, Turner, & Holt, 2009). In spite of these
troubling findings, trauma-informed assessment and treatment in the health and
social sciences takes place sporadically if at all (Ford-Gilboe, Wuest, Varcoe, &
Merritt-Gray, 2006). A shortage of health and social services, especially mental
and behavioral health services, further limits rural women’s access to treatment
for substance abuse and domestic violence (Peek-Asa et al., 2011).
It is due in part to the invisibility of these women that rural health care
providers, especially those who practice at primary and emergency settings,
could be a crucial point of identification and potential intervention for sub-
stance-abusing women with a history of trauma. Health care providers are,
generally speaking, trusted helping professionals with whom most people—
even in medically underserved rural communities—have some contact
throughout the life course. This helping potential is not lost on policymakers
and researchers: Professional health organizations and many insurance com-
panies, including Medicare, recommend that health care providers screen for
interpersonal violence and substance use during all patient encounters
(Moyer, 2013). Still, the application of these screening practices as well as
the desired outcome of screening (i.e., getting abused or substance-abusing
patients into treatment or shelter) is unknown. The few surveys that have
taken stock of physicians’ substance abuse and trauma assessment suggest
these practices take place unevenly if at all (Shapiro, Coffa, & McCance-Katz,
2013; Waalen, Goodwin, Spitz, Petersen, & Saltzman, 2000). To better under-
stand why this is so, a statewide study of rural health care delivery was
undertaken in 2014. Findings from interviews with 27 individuals—20 female
patients of rural health clinics with a history of trauma and 7 health care
providers at rural health clinics—reveal the complexities of accessing care
when lives are marked by profound partner abuse, addiction, and poverty
(Bender, 2015). The importance of these findings to social work practice,
policy, and research hinges on the necessity of greater communication and
coordination between health and social services, and the need to increase
mental and behavioral health services and outreach in rural areas generally.

Substance Abuse and Trauma
Trauma seems to be particularly important for understanding women’s sub-
stance abuse. The cooccurrence of trauma and substance abuse is more
prevalent among women than men (Brady & Randall, 1999; Najavits, 2004),
as is the cooccurrence of mood or anxiety disorders and substance abuse
(Kessler, Nelson, McGonagle, Edlund, Frank & Leaf, 1996; National Institute of
204 A. K. Bender

Mental Health [NIMH], 2007). Scholarship in this area considers the ways
emotional deregulations following a traumatic incident, such as physical or
sexual assault, place one at higher risk for problematic substance use (Dutton
et al., 2006). Women’s higher risk of experiencing IPV and sexual assault of all
types (e.g., acquaintance vs. stranger) might place them at increased risk for
developing posttraumatic stress symptoms, depression, or substance use dis-
orders (J. C. Campbell, 2002; Najavits, 2004). Jewkes (2002) reported that
much of the sex difference in global incidence of depression could be due
to violence against women. Pathways to substance abuse via trauma can be
set in motion early in life: Carrion and Wong (2012) presented evidence that
youth with posttraumatic stress symptoms had elevated levels of the stress
hormone cortisol, consistently high quantities of which are neurotoxic and
could in fact alter the structure of the brain. Over time, the damage to the
brain could result in loss of executive function and memory processing
(Carrion & Wong, 2012), further impairing receptors that are associated with
learning, pleasure, and risk-taking (Cross, Crow, Powers, & Bradley, 2015).
The interplay between genes and environment (GxE) is also important for
understanding women’s substance abuse following a traumatic event: Enoch
and colleagues (2010) found that certain genetic phenotypes interacted with
childhood trauma to place African Americans at greater risk of developing
both substance use and polysubstance abuse disorders. Although not given
full treatment in this article, brain imaging and GxE paths of inquiry continue
to add to understanding of the risks, mediators, moderators, and assorted
interaction effects that help explain the relationship between trauma and
substance abuse.
Psychological theories of substance abuse have generated several useful
explanatory models as well. One of the best known, the self-medication
hypothesis, posits that individuals use substances to dampen traumatic mem-
ories or to avoid or escape from painful posttraumatic stress symptoms (Brady,
Back, & Coffey, 2004). In a longitudinal study using health maintenance
organization data, Chilcoat and Breslau (1998) found strong support for the
self-medication hypothesis, wherein having posttraumatic stress disorder
(PTSD) greatly increased the risk of developing a substance abuse disorder,
but exposure to a traumatic event that did not result in PTSD did not increase
the likelihood of a subsequent substance abuse disorder.
Compounded trauma and substance abuse can have extremely deleter-
ious health and social effects for women in a shorter period of time than for
men (Greenfield, Back, Lawson, & Brady, 2010). Women with a history of
trauma experience a more rapid onset of substance abuse disorders and are
more vulnerable both to repeated trauma and relapse than women with no
such history, even when controlling for family background and demographic
factors (Najavits, 2004; Najavits et al., 1997; NIMH, 2007). Substance abuse
among women is strongly influenced by proximal male relationships, such as
alcoholic fathers or partners (Brady & Randall, 1999) and women in substance
Health Care of Rural Women 205

abuse treatment often find their recovery compromised by spouses or boy-

friends who might disrupt their progress by offering drugs as a way of
mending an argument (Brady & Randall, 1999; Center for Substance Abuse
Treatment, 2009). The health consequences of cooccurring trauma, PTSD, and
substance abuse disorders are grave for women, who develop alcoholic liver
diseases (e.g., cirrhosis, hepatitis) and proceed on a much more rapid course
of substance abuse (“telescoping”) after comparatively shorter and less intense
use than men (Brady & Randall, 1999; Greenfield et al., 2010; Kilpatrick,
Acierno, Resnick, Saunders, & Best, 1997). Reproductive dysfunction, such
as infertility and menstrual disorders, are more prevalent among women with
a history of physical and sexual abuse as well as substance abuse than the
general population (Brady & Randall, 1999; R. Campbell, 2006; Kilpatrick,
Acierno, Resnick, Saunders, & Best, 1997).
Furthermore, the societal response to women who abuse substances is
different and arguably harsher compared to men. Women tend to experience
profound family and relationship disruptions as a consequence of both trauma
and substance abuse, including divorce or the loss of child custody (Brady &
Randall, 1999; Center for Substance Abuse Treatment, 2009). Homelessness
and unstable housing are more common among women with a history of
trauma and substance abuse, which in turn increases the likelihood of experi-
encing or reexperiencing rape, physical assault, or IPV (Evans & Forsyth,
2004). Poverty differentially affects the experience of trauma and substance
abuse as well, in part by keeping women economically dependent on an
abusive partner (Plichta, 2004). The repercussions of trauma, such as anxiety
or depression, as well as active substance abuse, make it difficult to find or
maintain employment (Greenfield et al., 2007; Tolman & Rosen, 2001). Health
care providers confronted with substance abuse and patient histories of
trauma thus grapple with these and many other factors that affect women
beyond the traumatic event itself. Finally, although good evidence-supported
treatments addressing both substance abuse and trauma exist (TREM1 and
Seeking Safety, among others), such programs are not readily available in
many communities or in every domestic violence shelter, and it is unclear how
many rural women especially would have access to such trauma-informed
addiction treatment. Rural health care providers might be particularly at a loss
for additional helping resources to which they can refer these patients.

Addressing Substance Abuse and Trauma in Primary Health Care

Although IPV and substance abuse are both commonly seen in health care settings,
whether by themselves or through a toxic cooccurrence, there has only recently
been a movement to screen and respond to IPV by primary health care providers
(Ford-Gilboe et al., 2006). Similarly, the primary care response to substance abuse
206 A. K. Bender

is not well known—although this, too, is changing. The Screening, Brief Interven-
tion, and Referral to Treatment (SBIRT) method has been shown feasible and
effective across a variety of health care settings, particularly in emergency depart-
ments (Agerwala & McCance-Katz, 2012), and this overall awareness of proble-
matic substance use and partner violence is a promising direction for the health
care field. Still, there are no reliable national estimates of primary care physicians’
practices regarding substance abuse identification (Shapiro, Coffa, & McCance-
Katz, 2013). Because rural health care providers must often wear many hats due to
the lack of specialized health and social services in most small towns, under-
standing whether and how they respond when confronted with substance abuse
and trauma could be especially important for rural patients. This understanding will
benefit social work practice and research by illuminating the “health care” aspect of
substance abuse and trauma, indicating an integration of health care and social
work that could more effectively address these widespread problems and improve
the quality of life for the individuals affected.


Study Setting
All participants were residing in a rural part of Missouri at the time of the
study. Located in the southern Midwest region of the United States, Missouri’s
rural population copes with the socioeconomic and health disparities roughly
typical of rural areas as a whole. The rural poverty rate is 18.8% compared to
14.0% urban (Rural Assistance Center, 2013). Rural Missourians are signifi-
cantly less likely than their urban counterparts to have health insurance or
obtain a college degree, and they earn less income for similar work (Missouri
Department of Health and Senior Services, 2011). Health resources such as
hospitals, full-time physicians, and dentists are relatively scarce in rural Mis-
souri. A mere 18% of the state’s primary care physicians practice in rural areas
(Kaiser Family Foundation, 2010; Missouri Department of Health and Senior
Services [MODHSS], 2011) with 29 of 117 counties qualifying as a designated
health professional shortage area (meaning a ratio of one physician to 3,500
persons; MODHSS, 2011).
The backdrop of economic and health disparities in rural Missouri colors the
experience of IPV. Over 36% of women in Missouri have experienced physical,
sexual, or stalking violence by an intimate partner, a rate slightly, but not
significantly, higher than the national average of 35.6% (Black, Basile, Breiding,
Smith, Walters, Merrick, … & Stevens, 2011). The need for services is urgent, as
demonstrated by call volume to Missouri’s crisis hotline, ranked the 15th busiest
in the nation (Missouri Coalition Against Domestic and Sexual Violence
[MCADSV], 2012). In 2014 alone, overcrowded shelters throughout the state
were forced to turn away more than 19,000 women and children (MCADSV,
Health Care of Rural Women 207

This study received approval from the institutional review board at the princi-
pal investigator’s university. Two study populations were drawn from the
sampling frame of Missouri primary care clinics meeting criteria for rural
health clinics according to the Rural Health Clinic Act of 1977 (P.L. 85–210)2
or rural Federally Qualified Health Center (FQHC; N = 392). Individual health
care providers with a medical or nursing degree employed at least part time at
any of these clinics were eligible for study participation. Each clinic adminis-
trator was contacted by mail, e-mail, or both to solicit participation. Seven
providers—six nurse practitioners and one medical doctor, all of whom served
as the administrator or sole provider at their designated clinic—responded to
the call for interviews. Patients from these 392 clinics were eligible to partici-
pate in interviews as long as they were female, over the age of 18, had visited
their provider within the past year, and reported a history of IPV. Patients
within the sampling frame as just described were recruited with a mix of flyers
at clinics, Craigslist postings, and snowball sampling. Participants from both
samples hailed from rural areas across the state.

Both interview protocols—one for the provider sample, and one for the
patient sample3—were developed by the principal investigator in collabora-
tion with researchers experienced in partner violence, health care, and qua-
litative methods. The provider interview protocol consisted of 15 open-ended
questions meant to facilitate discussion about the strengths and challenges of
practicing medicine (or nursing) in a rural area, typical health problems and
their etiology or social determinants, and how providers individually handled
cases of interpersonal violence among their patients. These questions were
piloted with three health care providers prior to use and determined appro-
priate. The patient interview protocol, piloted with a domestic violence shelter
advocate in a rural county, was also deemed appropriate for use. This sche-
dule consisted of 18 open-ended questions about the women’s background,
history of trauma, and health care experiences.4
Interviews were conducted in person (n = 23) or via phone (n = 4). (Note
that all phone interviews took place with providers.) Interviews lasted approxi-
mately 65 minutes, although some were as short as 20 minutes and others as
long as 3 hours. Interviews with providers tended to be briefer. Providers were
given a $20 Amazon gift card to thank them for their time, and patients were
given $50 cash and a $10 gas card to cover the cost of transportation to the
interview site. All participants read and gave informed consent, and all but one
agreed to an audio recording of the interview. (Note that all names used here are
pseudonyms to protect the confidentiality of participants.)
208 A. K. Bender

Analytic Approach
Interviews and field notes were transcribed by the principal investigator and
managed in NVIVO, software designed for qualitative field work and analysis.
The analytic approach was a mixture of deductive and inductive interpreta-
tion, as transcripts were close-read for key phrases and themes identified by
the study’s research aims and questions, and then reread for emergent themes.
Findings reported in this article belong to the latter category. Substance use,
abuse, and the role of drugs and alcohol in rural health care delivery and
services access were all themes that emerged repeatedly during interviews.


Table 1 shows the demographics of the study sample. Both study populations
reflected the racial and ethnic demographics of rural Missouri as a whole, which
is majority White. The seven providers interviewed were mostly nurse practi-
tioners with nearly 18 years of experience among them; only one provider was a
physician (MD) and he was also the sole man interviewed. By design, all 20
patients were female and all reported abuse by a male partner, although one
woman had come out since divorcing her husband and now identified as a
lesbian. Most were mothers, with an approximate average of two children

TABLE 1 Participant Demographics

Number % of Total Average (Range)

Providers Race/ethnicity

White 7 100
Male 1 14.3
Female 6 85.7
MD 1 14.3
MSN 6 85.7
Years in practice 17.9 (4–37)
White 17 85
Black 1 5
Mixed race 1 5
Latina 1 5
Marital status
Single 4 20
Married 3 15
Divorced 6 30
Separated 7 35
Age 42.4 (22–67)
No. of children 1.9 (0–6)
Health Care of Rural Women 209

(although 3 women had no children and 1 had six children), and approximately
two thirds had been or were currently married. Providers and patients alike
agreed that substance abuse was a “major problem” for the community, despite
the fact that interviews took place in rural settings throughout the state, with
varying regional characteristics. When asked to describe why substance abuse
was so prevalent in their particular community, providers and patients were
markedly similar in the tone of their responses:

There’s plenty of places to cook meth around here. (Robert, MD)

Less law enforcement. More remote areas, more places to cook the drugs.
Less education. Less employment opportunities. (Sharon, Nurse Practitioner)

It’s out of the way and there’s a bunch of major highways coming straight
up from Texas and Oklahoma right on through to St. Louis. (Cheree,
Patient/Survivor of IPV)

Providers and patients also tended to agree that there was a dangerous
shortage of mental and behavioral health services in general. This problem was
thought to contribute to the prevalence of substance abuse and interpersonal
violence—including IPV and child abuse—because those with an addiction or
mental health problem did not have access to treatment. Lack of services also
meant that women attempting to cope with, or flee from, an abusive relationship
had little or no formal support to address issues of PTSD, depression, or their
own substance abuse attendant with their experiences of victimization. Tracy, a
nurse practitioner and clinic administrator, spoke at length about the dire need
for mental health treatment in her community, citing environmental factors (i.e.,
poverty, low levels of education) that she felt contributed to depression:

We need therapists here. We do. There are no services for behavioral

health—to get that I guess you’d have to go to DFS [Children’s Division,
the state’s child welfare agency] and tell them “I need help,” but I’m not
sure how friendly they are. And then of course I don’t know that they
serve single adults. But it’s just very hard for people here, with the loss of
jobs, the loss of health insurance—I honestly don’t know how some
people are making it.

Domestic violence programs were sparse—most of the patients inter-

viewed had stayed at a shelter at some point during an abusive relationship,
but nearly all of them had to cross a county line (or two) to get to one.
Although the women interviewed appreciated the safe haven their shelter had
provided, mental health services—including substance abuse treatment—
were noticeably lacking from their shelter experience. Only one woman
interviewed had ever been treated by a psychologist; the counseling and
support groups offered at domestic violence shelters tended to fall into the
210 A. K. Bender

realm of case management rather than therapy. Substance-abusing women,

such as Millie, were required to get clean before the shelter would allow them
to stay. “They really need to get on the mental health right away, and they
don’t,” stated Wendy, describing how she had repeatedly asked her shelter
case worker for help accessing a licensed mental health services provider to
deal with a problem she thought was actually PTSD.
Although themes from the providers’ and patients’ interviews dove-
tailed on these two issues—one being the prevalence of substance abuse
and its association with interpersonal violence, and two being the dearth of
mental and behavioral health treatment in their community—perspectives
about the way substance abuse was addressed during a routine health care
encounter diverged neatly along sample population lines. Health care
providers tended to have one viewpoint about substance abuse; patients,
including those who had and had not abused drugs, held quite a different
one. These disparate perspectives are detailed next.

Provider Perspectives
All but one of the health care providers conducted occasional or infrequent
screening for IPV or a general trauma history, but none regularly assessed for
substance abuse. Screening at every visit was seen as impractical, largely
because the providers tended to know their patients fairly well already.
Almost all of the providers described encounters where they had asked
patients about suspected abuse, only to have the patient refuse to discuss
the issue. The stigma and perceived lack of anonymity in clinic settings
—“Everybody knows everybody,” said Krista (nurse practitioner/clinic admin-
istrator)—was thought to inhibit patients’ disclosure of current or former IPV,
and such inhibitions were thought to extend to the issue of substance abuse.
“Even if they will tell you in that [clinic] setting, they don’t want anyone else to
know about it, they don’t want to do anything about it,” explained Alice, a
nurse practitioner.
Providers suspected substance abuse, particularly alcohol and illicit drug
use, were more common among their male patients than female patients.
Purported explanations were the lack of employment opportunities or loss
of industry in the region, contributing to financial stress and the use of
substances as a coping mechanism for this stress and depression. Krista
thought the general low education levels and lifestyle-related health problems,
such as tobacco use, obesity, and heart disease, were also contributors to
prescription or illegal drug use. In Robert’s experience, men tended to use or
manufacture the drugs, with their families bearing the brunt of the violence:
“Yeah, I’ve seen that … he’s usually the one off using, and he’ll come home
and beat her, beat the kids, you know.”
Despite all providers describing the prevalence of alcohol and illicit drug
use in their communities, none were able to call up instances of active female
Health Care of Rural Women 211

users in their recent patient encounters. “I think these are … the women who
we’re not seeing, who don’t come in as much,” said Debbie (nurse

Patient Perspectives
Debbie’s hunch that most female users were not coming in for regular
physical exams was corroborated by the interviews with 20 female rural health
patients, all of whom had lengthy trauma histories. Five of the 20 women
interviewed described themselves as former methamphetamine or “speed”
addicts; 2 others were self-described alcoholics, and one had been addicted
to prescription pain medication. In essence, 8 out of the 20, or 40% of these
women, viewed themselves as former substance abusers. Eighteen made
references to heavy drinking by themselves and their partner during the
worst of fights. Seven of the women had partners who were dealing drugs
(methamphetamine [meth], heroin, prescription painkillers) or otherwise
heavily involved in drug use, and some women mentioned their abuser was
addicted to meth or alcohol by way of explaining some of his actions. “Never
had any trouble the first three and a half years of our relationship, until he
went back to doing meth,” said Karen.
Whenever substances were abused in a relationship—whether by the
male partner only or both partners—the accompanying violence was severe.
Often the histories of trauma had spanned multiple relationships reaching
back into childhood. Five of the 20 women said they had been “left for
dead” by their abuser, and in three cases the abuser had been prosecuted
for attempted murder. One abuser fired shots at his girlfriend as she was
fleeing their house barefoot. Three women had been beaten so severely with
a blunt object (usually the butt of a shotgun or baseball bat) that they required
facial reconstructive surgeries. One had a damaged spinal cord as a result of
this beating, and still another had been thrown out a window during a
drunken brawl with her ex-boyfriend. Strangulation, rape, and threats with
guns were the norm, rather than the exception, during all 20 interviews.
Although interviews took place from disparate parts of the state, each
participant seemed to think that methamphetamine use was a major issue for
his or her specific community. In their view, methamphetamine use affected
several community-wide issues, from the level of violence to the type of help
offered to the reaction of health care practitioners and first responders to
women experiencing IPV. In several cases, the perception by the health
care provider that the woman was on drugs was enough to make the clinic
or hospital encounter a very unpleasant one for the woman, and in a few
cases resulted in participants not getting the help they believed they needed.
Cheree went to her primary care doctor for her allergies and was denied the
medication refill she wanted; the doctor told her she simply had a cold and
seemed “like he thought I was there trying to get drugs.” She characterized the
212 A. K. Bender

meth problem in town as “huge,” so big that all of the clinics and hospitals had
signs alerting patients that drug seeking was not tolerated and physicians did
not give out pain or allergy medication on demand. Health care providers’
vigilance about meth and prescription drug abuse was common throughout
the state. After going to the hospital for burns on her face and neck when her
dryer exploded, Stacy was told she had a “sunburn” and released without a
prescription despite the great deal of pain she said she experienced. She
believed her shoddy treatment was due to the doctor assuming she was
seeking drugs.
The perception by providers of certain women as drug seekers might
have been based on appearance, according to Stacy and Cheree, or a heigh-
tened level of awareness and familiarity with what are real problems with
meth and alcohol in rural areas and among trauma survivors in general. For
women who were using drugs, the health care encounter was always
described in negative terms. Lauren said that the staff at her clinic “looked at
me like I was stupid” and “was real snippy with me.” When asked why she
thought this was the case, Lauren sighed and said, “Probably because I kept
getting beat up by the same guy. And the drugs.” After learning she was
pregnant, Lauren did not seek prenatal care for the duration of her pregnancy
because she was afraid as a Medicaid recipient she would be required to
submit to random drug tests.
Other health care providers tended to downplay the seriousness of the
abusive situation if substances were involved, especially on the part of the
woman. Sadie described having been nearly strangled to death by her abuser
during a fight when both of them were intoxicated; when she woke up at the
hospital and told the doctor what happened, he asked, “But hadn’t y’all been
drinking?” She was released without anyone at the hospital talking to her
about IPV or providing information about the nearby women’s shelter.
Sometimes the health care providers were cognizant of the abuser’s
substance problem, as was the case with Samantha. Her abuser accompanied
her to all of her doctor’s appointments, and would list off her ailments to the
doctor or nurse during her exam, volunteering what medication he thought
she might need to fix whatever pain or ache she was having. The staff at the
clinic caught on to him, and the medication that Samantha legitimately needed
for chronic pain associated with long-standing injuries was suddenly withheld.
Samantha thought that the doctors suspected (rightly so) that her abuser was
taking her medication recreationally or selling it, and she mused that they
might have suspected her, too, because she “always allowed him to come into
the room with me. Maybe they figured I was in on it.”
Each of the substance-abusing participants in this study eventually man-
aged to secure treatment—although not inpatient hospitalization or super-
vised detox—when their illicit use caught the attention of law enforcement
and the state’s child welfare system. In three instances, the Missouri Children’s
Division removed children from the women’s custody, with visitation and
Health Care of Rural Women 213

rights to be regained only on the condition that the mother participate in a

court-approved plan for treatment. Usually this meant leaving the abusive
environment by moving to a shelter or staying with family or friends, getting
clean, and participating in case management and family counseling services.
The 5 women who had abused substances had all spent time in jail or prison
for drug-related crimes, and Marie described how a stint in county jail had
affected her and her children’s lives:

They had me in drug court, yeah, and so through them I found out about
the shelter in Grundy County, that was the nearest one. And they said if I
wanted to see my son again I needed to stay away from him [her abusive
husband]. So when I got out [of jail] I moved there and I was allowed to
because of my probation officer, and I have to do drops for her every
week and have no contact with [her abuser] or else I’ll lose custody again.

Women with a history of substance abuse had also led lives profoundly
affected by poverty, unemployment, and frequent, unpleasant brushes with
local law enforcement. Two had been incarcerated (i.e., served time in a state
prison) for their drug use and were currently completing treatment as a
condition of their release. Three others were going to 12-step meetings and
separated from their abuser on court decrees to regain custody of their
children. These often overwhelming issues of poverty, violence, and addiction
prevented the majority of these women (n = 12) from seeking regular and
emergency medical treatment, often for years at a time. In the most extreme
example, alcohol abuse coupled with a lack of health insurance prevented
Sadie from visiting a doctor for 22 years. She was finally compelled to make an
appointment at a rural health clinic to have lumps in her breasts examined,
which she estimated had been there for “several years by then.” Lauren
explained why she rarely went to the doctor, even though she had insurance:
“You don’t want them poking around in your business, asking you this or that,
knowing they’re going to be back there on the phone with DFS [an old term
for Missouri’s child welfare agency].” Addiction to methamphetamine had also
prevented Lauren from seeking emergency treatment on multiple occasions,
usually after fights with her abusive boyfriend. “I remember one time, he
glassed me [hit her on the back of the head with a bottle]. Then he felt real bad
because I was bleeding all over the place and he stitched me up hisself
because he didn’t want me going to the emergency room.”


Findings from this study confirm that rural women experiencing substance
abuse and IPV have very few avenues for treatment, and health care provi-
ders, although vigilant about both issues, are often not encountering or
214 A. K. Bender

identifying such women in their practice. Such findings have troublesome

implications, as it suggests that these vulnerable patients are missing oppor-
tunities for treatment (although treatment is admittedly scarce in rural areas).
There is some indication that substance abuse and its compounded problems,
including the escalation of interpersonal violence or child abuse, opens door-
ways for formal help more often than women experiencing IPV, but not
substance abuse, receive. It was the women who had been addicted to
meth who had eventually received the biggest cluster of services and com-
munity resources after they were caught up by the criminal justice or child
welfare system—or both. Once clean, these were the women who had the
ability to access behavioral health services and the help with case manage-
ment, transportation, affordable housing, and vocational rehabilitation that
those services signified. Child welfare clients were helped by behavioral
health and a family support team that included case management, legal
services, counseling, and parenting skills classes. Perhaps these cases also
represented the most seriously abusive ones, involving felony assault or drug
crimes as well as compromising children’s safety. Although the substance-
abusing women with severe histories of trauma who were participants in this
study were able to get some forms of (belated) help, their prospects for the
future were dimmer than those who were not in recovery. Patients with a
history of substance abuse that had resulted in prior criminal convictions
found it all but impossible to obtain employment. Jobs in the rural commu-
nities where patients lived were scarce to begin with, and the common
perception was that few employers would hire someone with a criminal
background or even someone who was known by word of mouth to have
abused drugs in the past. At the time of the interviews, all of the patients who
admitted to prior substance abuse were living well below the poverty line, all
were unemployed, and three were homeless. Two thirds of the women also
lacked health insurance, meaning their ability to access mental health or sub-
stance abuse treatment (even if there were such a facility located in their
isolated rural communities) was out of financial reach.
The public awareness of meth addiction contributed to what women
characterized as health care providers’ vigilance—legitimate in some cases,
unwarranted in others—surrounding the issue of IPV, and colored their
responses to the women under their care. Thus the health care encounter
was fraught for patients with a history of substance abuse, and many patients
admitted not disclosing their abuse to providers because of the way they felt
they were treated by their provider. Providers interviewed all recognized this
reluctance to disclose but did not attribute it to possible substance abuse.
None of the providers interviewed suggested that a substance-abusing patient
might be reticent to disclose abuse of any kind out of fear that the authorities
or child welfare system would then get involved. Additionally, providers
appear to misunderstand some pertinent aspects of substance abuse and its
association with IPV. Interviewees acknowledged that alcohol and drugs
Health Care of Rural Women 215

could be causes of violence or correlated with IPV, yet few providers named
substance abuse as a risk factor or “red flag” that might prompt them to screen
for IPV. Providers mentioned the problems of alcohol, painkiller, and
methamphetamine abuse specifically in their communities, but were quite
vague about how many patients with active use they had treated recently or
whether the cases of IPV they had identified involved substance abuse.
Relatively little scholarship has focused on the attitudes or reactions of
primary care providers with regard to substance abuse, particularly illicit drug
use. Notable exceptions include a national survey of physician screening for
substance abuse (Friedmann, McCullough, & Saitz, 2001) and one study that
compiled predictors and consequences of physicians’ attitudes toward the
drug use of HIV-infected patients (Ding et al., 2005). Physicians who were
unfamiliar with substance abuse dynamics, perceived a lack of time during the
patient encounter, or did not feel that referring the patient to outside resources
would be helpful, were less likely to ask about problematic substance use
(Friedmann et al., 2001). Conversely, familiarity with illicit drug use etiology,
patterns, and users predicted more positive attitudes toward substance-abus-
ing patients by physicians (Ding et al., 2005). The caring attitude these
providers demonstrated toward users of illicit drugs was associated with
those providers being more knowledgeable about substance abuse and treat-
ing fewer patients per week (Ding et al., 2005).
These factors predicting an empathic attitude toward the substance abuse
of HIV-infected patients could well translate to the experiences of IPV survi-
vors regarding providers’ reactions to their suspected or confirmed substance
misuse. Caring and empathy were cited as additional factors that providers
used, or need to use, to facilitate disclosure and provide an effective response
to IPV, according to the patients interviewed. Although the providers inter-
viewed for this study appeared to have both a high level of awareness of
trauma and empathy for victims, patients depicted their providers’ attitudes
toward them as mixed at best. Several patients described encounters with a
provider whose distaste for them and their situation was very clear. The 12
women in this study who had been involved with substance-abusing partners
or abused drugs and alcohol themselves were the most likely to characterize
their health care experiences in poor terms.
Mental and behavioral health resources in rural areas might be even
fewer than those for IPV. Therefore, an effective response to a patient experi-
encing both IPV and substance abuse would be particularly challenging for a
rural health care provider. (In fact, a systematic review of IPV screening by
health care providers revealed that “lack of effective intervention or referral
source” was one of the most frequently cited explanations for not screening;
Waalen et al., 2000, p. 230.) Still, an empathic attitude that encourages
discussion of all aspects of the patient’s history, even when the patient is a
suspected or confirmed substance user, would likely lead providers to identify
additional health concerns or problems related to IPV in addition to the
216 A. K. Bender

substance abuse. By contrast, a judgmental attitude about substance abuse—

or an automatic assumption that a patient is abusing drugs or seeking drugs
based on her partner or physical presentation—might discourage survivors
from continuing with necessary preventive care or seeking the more specia-
lized behavioral health treatment they might need. Each of these scenarios has
poor overall outcomes for women’s health and, by extension, the resolution of
their abuse.


The dearth of all health services, but particularly mental and behavioral health
treatment, was a common theme among the interviews. Considering the
frequency with which providers say they encounter trauma, and their own
perception of substance abuse’s high prevalence,5 this lack of services repre-
sents a potentially lethal gap in basic health care. A significant first step to
addressing this gap takes place at the policy level, where increasing mental
health services and expanding health care coverage to ensure access to
mental and behavioral health treatment is sorely needed. Within health care
education and clinic settings, adopting specific protocols for the assessment of
substance abuse and trauma—along with training to understand the dynamics
of both, and their frequent cooccurrence—could improve health care provi-
ders’ identification of and response to these patients. Although many patients
in this study admitted to going years without a doctor appointment, health
care providers remain an important point of intervention for both substance
abuse and IPV. Had more of these patients been assured of accessing treat-
ment in a nonjudgmental atmosphere—or had they possessed insurance to
facilitate any health services access at all—their stories could have ended

A methodological limitation of this study was inherent to the sampling meth-
ods. The two study populations—providers and patients—were drawn from
disparate areas of the state and different clinic settings, which might have
heightened the applicability of the study’s findings by capturing perspectives
from multiple study sites. However, the variability in study populations makes
verification and triangulating findings from interviews difficult. Additionally,
the patients who participated in this study recounted very severe histories of
IPV and addiction, and their experiences might not reflect the majority of
women who experience either problem. The analysis was undertaken by one
person (the principal investigator) and was not transcribed, read, or coded by
anyone else, meaning that the final interpretation of this interview data
remains solely that of the researcher.
Health Care of Rural Women 217

This study’s findings point to numerous areas for social work involvement
at the practice, policy, and research level. Generally, social workers must
adopt a more active role in the health care system and health promotion of
their clients. The providers in this study lacked information and knowledge
about substance abuse and trauma, including community resources for
treatment that might have been addressed by a consultation with a health
social worker or shelter advocate. Social work practitioners, particularly in
rural, underresourced communities, might need to expand their repertoire
of services, their catchment areas, or the sites where they practice, to
ensure other helping professionals are aware of their presence. In so
doing, social workers—especially those with addictions training—could
become an especially important resource for collaboration and advocacy
within the health care system.
Some practice and policy innovations, building a steady evidence base,
have great promise for addressing substance abuse and the broader problems
associated with interpersonal and family violence in rural communities. Asser-
tive community treatment approaches and nurse–family partnerships are
demonstrably effective at treating cooccurring disorders (Gomory, 2002) and
preventing both IPV and child abuse and neglect (U.S. Preventive Services
Task Force, 2004), respectively, yet they are too few and far between in most
parts of the country. Adapting and evaluating such outreach approaches might
be especially significant for women involved in substance abuse and for those
experiencing interpersonal violence, as these women are likely those living in
isolation and poverty (Annan, 2008).
Finally, this study indicates that more research on rural social work
practice and addressing substance abuse and trauma in health care settings
is needed. These findings were reported as part of a larger study examining
the ways rural health care providers identified and responded to IPV, but as
these narratives demonstrate, it was impossible to detangle the problem of
substance abuse from IPV. The significance to social work of this and
future research on women’s health care experiences, especially when sub-
stances and trauma are involved, is clear. These detrimental health out-
comes and costs point to the need for integrative approaches to addressing
such problems. Social workers have an ethical mandate to provide effec-
tive, culturally competent care to their clients and to engage in fruitful
interdisciplinary collaboration when possible. By virtue of their education,
social workers are well positioned to understand the social determinants of
health and the multiple interlocking systems of oppression that affect
people’s lives. Rural areas in particular grapple with many disparities in
health and health care access, pointing to an urgent need for social work
involvement overall.
218 A. K. Bender


Funding support for this project was provided by grant number R36HS022818
from the Agency for Healthcare Research & Quality.


1. TREM = Trauma, Recovery, and Empowerment Model.

2. Under federal provisions, a rural health clinic is located in an area designated as rural or small town
according to the Economic Research Service and also qualifies as medically underserved or a Health
Professional Shortage Area (both are official federal designations).
3. See the Appendix for sample questions from each interview questionnaire.
4. The interview protocols did not specifically ask about substance abuse. This construct emerged
during data analysis.
5. State-level estimates from the National Survey of Drug Use and Health place the prevalence of
adult substance use disorder (having carried a diagnosis of alcohol or drug dependence within the year
prior to the survey) at 477,000, roughly 10% of the state’s population (Missouri Department of Mental
Health, 2008).


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Selected Interview Questions: Provider Interviews

What, if any, challenges or barriers do women face when fleeing an abusive relationship in this
What, if any, services for victims of IPV are there in this community/area? What are your
perceptions of the effectiveness of these services in addressing victims’ needs and reducing
What are the challenges of identifying IPV in your practice? What are the challenges of
responding to IPV in your practice?
How do you manage or ensure patient confidentiality when IPV is disclosed? What challenges, if
any, does confidentiality present in a small community like this?
In your experience, in what ways, if any, does the overall health status of women experiencing
abuse differ from nonabused women?

Selected Interview Questions: Patient Interviews

What made you decide to talk with your doctor/nurse about the abuse you were experiencing?
OR What prevented you from talking with the doctor/nurse about the abuse?
How did the doctor/nurse response when you told him or her about the abuse?
What community services, if any, have you used during your abusive relationship (i.e.,
domestic violence shelter/program, hotline, couples’ counseling)? How did you find out
about these services [IF USED]?
How easy or difficult is it for you to get to the places you need to go (school, work, babysitter,
grocery, doctor’s office, police station, etc.)? In what ways, if any, does this affect your sense
of safety?
What are some of the challenges you’ve faced as both a rural resident and survivor of abuse?
What are some of the positive aspects of living in a rural area and coping with abuse?