Intervention Facilitator’s Guide

• In facilitating the WINGS of Hope intervention, you may find or feel like you do not have an appropriate referral for the client/participant. This may feel discouraging and though it can be difficult to continue with the intervention when you are feeling like there are limitations to what may be helpful to the client, it is important to remember that the goal of this project is to begin making small steps forward for the women in Kyrgyzstan who are experiencing risks.
• Part of making these steps might just be identifying one safe person the woman can talk to or identifying some activity that the woman can do to take care of herself, if no appropriate referrals are possible. The other main goal we have here is to document the needs and barriers of the women so that if we see that very few referrals etc. are possible, we have documentation that we can take and use in the future to advocate for improved services and access for women.
• As you go through the intervention with the participants, it is very important to share the messages of conveyed in the text closely, but conversationally. It is important to be consistent in the language provided below and as you work with different women so that we can identify how well this intervention works and how it may be adapted, systematically as issues arise.
• This does not mean you shouldn’t explain concepts, as needed, to someone who is struggling to understand something (for example, if low literacy is a concern), but that one should not change the materials or ideas so much that we are no longer delivering the intended intervention.

• Wherever in the session script you come across the Kyrgyz-specific references, names, regulations, statistics etc, replace them as appropriate with your region or country.

• Briefly introduce the program’s purpose and session activities of the WINGS of Hope.

Thank you for taking the time to participate in the WINGS of Hope. My name is _______, and I will be speaking with you for our two sessions and throughout the next hour and 1/2.

The purpose of the project is to raise awareness of the needs of women and to provide information and connections to resources.

We’ll begin by talking about relationships and different types of conflict women experience and then I’ll ask you a few questions about your relationships and experiences of being physically or sexually hurt by partners, family members, police, bosses, drug dealers, acquaintances, or others including strangers.

At the end of the session, we’ll discuss danger and ways to plan for safety, and support, and the importance of setting personal goals. We will then set up a time within 7-10 days to meet again for one more session to follow up on your goals.

• Remind the participant that everything they say in the session, is confidential, as reviewed in the consent form and during the consent process.

• We know that some women are hesitant to talk about their personal issues for fear that others may find out and respond negatively. We again want to remind you that what you say here is confidential and is only shared with our program staff and with your permission our partner organizations who serve women — for example in Kyrgyzstan these are Asteria, Podruga, Chance Crisis Center,  Sotsium, Plus Center and Positive Dialogue — to help you access needed services.
• The only time we are required to break this confidentiality in order to seek help is if we hear you intend to hurt yourself, child abuse or you have a homicidal plan toward someone else.

• Ask participant what, if anything, they have heard about the project and whether they have any questions or concerns about participating in the project.

Raising awareness of different types of IPV and GBV and their correlation  with drug use and HIV risks

• Introduce how relationship conflict and abuse can occur in loving, intimate relationships;
• Present the positive and negative aspects of intimate relationships.

• Most relationships have good times and bad times. Intimate relationships can be an important source of support, love, and purpose in life. Conflict can arise when partners have different needs or expectations or when difficult things happen that are outside of both partners’ control.
• While all relationships may have positives and negatives, we’d like to talk today about types of conflict and abuse, which sometimes occurs in intimate relationships. We would also like to point out that many women do not expect abuse or violence to happen in their relationships; sometimes things start off great, but over time their partners become more controlling and sometimes hurtful and abusive.
• As we talk about these issues we are not saying these all relate to you or even people in your network but some of the issues may sound familiar.

• Ask participant if they know women who have experienced loving relationships that turned violent or hurtful;
• Describe the Cycle of Violence handout.

The Cycle of Violence handout, in English, can be downloaded through this link:

• This chart shows what many women experience when in abusive relationships. First, there is a sense of tension that builds, and the partner exhibits more controlling behaviors. Following a period of tension, an abusive incident occurs, where the partner may feel he or she has lost control.
• After an explosive incident, the partner apologizes or behaves in apologetic ways (being sweet, bringing flowers etc.) and/or promises to change. The partner may also say things like they would not lose their temper if X, Y, or Z had been done.
• Often, in a situation like this, women have mixed feelings: they may feel like she has to try harder to not upset their partner / “walking on eggshells”, while others may feel like another incidence won’t happen again.

 

As in case with all other forms and handouts used in the session, a copy of this particular form / handout can be offered to the participant if she would like one and whether it is safe for her to take a copy home.

• Intimate partners may hurt each other in different ways. All of these types of violence or abuse are often related to power and control.

• Ask participant whether they know women in relationships, who experience tension and abuse.
• Describe the Wheel of Power and Control handout, and review all types of abuse presented there.

The English version of the Wheel of Power and Control handout can be downloaded through this link:

 

As in case with all other forms and handouts used in the session, a copy of this particular form / handout can be offered to the participant if she would like one and whether it is safe for her to take a copy home.

Violence can occur from intimate partners who are female or male, and within relationships that are long-term or casual. In Kyrgyzstan, sometimes, women may choose to give up a certain amount of control due to traditions and customary roles, but we are talking about a type of forced loss of control that can lead to harm.

• Together with the participant,review each type of violence in the handout, asking what the participant knows of them and how it impacts women in her community. 
• Describe what physical abuse may look like.
• Ask participant in what ways partners might physical hurt women.

• Yes, that’s right (fill in with examples below that the participant did not identify).
•  Physical Abuse: There are different ways husbands, boyfriends or other romantic partners can physically hurt women including shoving, pushing, slapping, hitting, kicking, pulling hair, choking, punching, binding, or burning women. Depriving women of their basic needs including water, food, a safe place to sleep etc., also constitutes physical abuse. Additionally, being forced to eat by yourself, against your will or having the excessive burden of doing household work may also be considered abuse. Further, pressuring or forcing a woman to use or take drugs is another form of abuse (participant can describe other ways they can think of about how partners may physically hurt women).

• Describe emotional or psychological abuse.
• Ask participant what she thinks of how boyfriends, husbands or partners can emotionally or psychologically hurt women.

• Emotional or psychological abuse occurs when a partner isolates a woman against her will from her friends and/or family or uses controlling behaviors like calling frequently to check where she is, doesn’t allow her to go outside, following her to see where she is going, telling her what to wear, who to talk to, or where she can go when she has not agreed to this relationship dynamic.
• Abuse may also occur when a partner tries to control the other partner by such behaviors as threatening to take their children away, threatening to leave the woman or to commit suicide, threatening to hurt their children or pets or threatening to report her to the police for criminal activity or to immigration if undocumented. Emotional abuse also includes verbal abuse, such as screaming, yelling, threats, name-calling, putdowns or other angry words that make someone feel hurt, ashamed, or unimportant/insignificant (participant can describe other ways they can think of about how partners may emotionally or psychologically hurt women).

• Describe sexual abuse.
• Ask participant what she thinks of how boyfriends, husbands or partners can sexually hurt women.

• Sexual abuse may include being forced to have sex or feeling pressured into having unwanted sexual activity by your boyfriend, husband or romantic partner. Some examples of sexual abuse are if a partner uses force or pressures you to have oral or anal sex or rough sex when you don’t want to or if a partner takes sexual advantage of you when you are under the influence of drugs or alcohol.   Sexual abuse also includes when a partner refuses to use a condom or allow the woman to use birth control when he has chosen to.  Some partners also force women against their will to have sex with other people and/or pressure women to sell sex for money or drugs so that they can supply them for drugs (participant can describe other ways they can think of about how partners may sexually hurt women).

• Describe economic abuse.
• Ask participant what she thinks or heard about ways that boyfriends, husbands or male partners can use economic stability to hurt women.

Economic abuse occurs when a partner attempts to make a woman against her will and customs, financially dependent. This can include taking her money without her decision, controlling the money or other resources without her best interest or agreement, limiting work opportunities, and/or forcing her to sell drugs or herself.

 

If project team was able to record a story of one of their beneficiaries that would be lasting for 3-5 minutes and focuses on any of the type of abuse described earlier, they can offer the participant to listen to it at this point.

• Describe ways that drugs and alcohol used by a woman and / or her partner, can increase the risk of experiencing different types of abuse;
• Ask the participant to share her thoughts on how substance use can cause or lead to increase of abuse.

• Yes, women often find themselves following the lead of their male partners hoping to please them and then the relationship starts to change. Some additional examples are: Encouraging a woman to be dependent on drugs or preventing her from getting drug treatment is also a form of abuse that can occur in intimate relationships.
• Pressuring women to sell sex for money or drugs or to deal drugs is also a form of abuse.
• When a woman and/or her partner are under the influence of drugs or alcohol they are more likely to get into arguments and physically hurt each other. Male partners may also feel like they can insist on sex if they have provided women with drugs or alcohol. Women are also more likely to experience sexual violence when they or their partners are under the influence of drugs.
• When physical or sexual abuse occurs when the male partner is under the influence of drugs or alcohol, women are more likely to excuse or disregard the violence blaming it on the drug or alcohol use for example “the vodka made me do it” and male partners are also less likely to remember or accept responsibility for hurting women. Unfortunately, this makes it only more likely that the violence will occur again.
• Male partners are also likely more likely to feel like they can verbally or psychologically abuse women because they use drugs and putting them down for being bad mothers or wives/girlfriends because they use drugs.
• Finally, women who experience psychological physical or sexual abuse are more likely to turn to alcohol or drugs to cope with or numb the emotional or physical pain from such abuse.

• Ask participant to share her thoughts of other ways that drugs or alcohol used by women or their partners, may trigger abusive behaviors in intimate relationships.
• Ask participants what she thinks of the ways that experiencing partner abuse may trigger problematic use or alcohol or drugs.

Raising awareness about gender-based violence, i.e. violence by other family members, police, bosses or pimps, drug dealers or strangers

• Now that you have reviewed some of the ways intimate partners may be abusive or violent, tell the participant that you are going to talk to them about how women may experience violence in other relationships including their family members, police, bosses or pimps, and drug dealers. Tell the participant that violence from these other groups may occur in the same way that it does from intimate partners. That is, it may take the form of physical, emotional/psychological, sexual, or economic abuse.
• Also note to them that one of the ways that women may experience violence differently is through bride-knapping or ala kachuu, where women are kidnapped or sold by their family members or others to other people against their will in exchange for money or other goods, associated with a dowry or “kalym”. Experiencing violence at the hands of others, especially family members and police may be especially traumatic and difficult to deal with.

• Ask participant what she thinks of the ways that people other than intimate partners, may be abusive to women.
• Ask her to share thoughts about and her attitude towards ala-kachuu (tradition of bride-knapping).
• After the participant reports different abusive and violent experiences outside of intimate partners, review the following to fill in where she has not listed them:

• Family Members: Women often report bride-knapping/being sold by family members and/or being physically and emotionally abused. Women may also experience sexual abuse by being forced to sell sex. Women who experience abuse by family members often report great conflict because of the contradictory supportive and abusive nature of the relationship.
• Police: Women who encounter abuse at the hands of the police often report being raped/sexually abused, especially when caught for using drugs and/or engaging in sex trading. Women can feel vulnerable due to illegal activities or undocumented status and find themselves losing control over their physical and emotional safety.
• Bosses or Pimps and Drug Dealers: Women who experience abuse from bosses/pimps often report similar experiences to women in violent intimate relationships. I.e. these people may provide support at times and violence at other times. Abuse also generally looks similar to abuse by partners. Women can feel they do not have a choice due to economic dependency (participant can describe other ways they can think of about how family members, police, bosses / pimps or drug dealers may abuse women).

Raising awareness about how wide-spread the problem of violence against women is

• Discuss prevalence of gender-based violence worldwide and in Kyrgyzstan.
• Ask participant what she thinks of how common violence against women is around the world and in Kyrgyzstan.

• Alarmingly, one in three women in the world will be raped or physically abused in her lifetime – that means there are 1 billion worldwide who will be forced endure such incredibly painful experiences. Experiencing physical or sexual violence by intimate partners, family members, police, clients or strangers is a devastating problem for women in every country.
• Unfortunately, there are no official government statistics on the prevalence of physical and sexual violence against women in Kyrgyzstan, but some studies which suggest that sexual and physical violence against women by their intimate partners and family members is widespread.
• As mentioned earlier, such violence can often start early on with women in Kyrgyzstan when they are forced to marry against their will or bride-knapped. Women in Kyrgyzstan as well as a number of other countries are also often physically or emotionally hurt by their own family members or family members of their husband or partner.

• Ask participant whether she is surprised by these high rates of physical and sexual violence against women.
• Ask participant whether among women she knows, there are ones who experienced such violence by their partners.
• Ask whether any of them were physically or emotionally hurt by family members of their partner.
• Download and review the Ministry of Internal Affairs’ Guidelines on Order of Protection management and their Guidelines on police management of domestic violence prevention activities.

The Russian version of the Kyrgyz Republic’s Government’s Guidelines on Order of Protection management can be downloaded through this link:

The Russian version of the Kyrgyz Republic’s Ministry of Internal Affairs Guidelines on police management of domestic violence prevention activities can be downloaded through this link:

• As it was within intimate partner relationships women who use drugs or alcohol and are with partners who use drugs and alcohol are at much greater risk for physical and sexual abuse. Women drug users experience 2-3 greater risk for violence than for women who do not use drugs or alcohol.
• The risk for IPV and GBV is magnified for women who use drugs in Kyrgyzstan. Women who use drugs in Kyrgyzstan face intense stigma and discrimination from their families and service providers which makes it difficult for them to get help and to stop the abuse they are experiencing.
• Women do not seek help from police as they fear discrimination or being arrested for their drug use even though sexual or physically assaulting women is considered a serious crime in Kyrgyzstan. According to the existing law, the abused women can even apply for the Order of Protection — such Order restricts the official husband’s opportunity to communicate with the woman that he is said to abuse, and assumes certain punishment towards the husband if he attempts communicate with the woman against her will (refer to and review the downloaded Ministry of Internal Affairs’ Guidelines on Order of Protection management and their Guidelines on police management of domestic violence prevention activities).

 

As in case with all other forms and handouts used in the session, a copy of this particular form / handout can be offered to the participant if she would like one and whether it is safe for her to take a copy home.

• Our recent discussions with women who use drugs and service providers from local NGOs also suggested widespread and severe IPV and other forms of GBV among their clients. Very few, if any, of these clients to date have pressed charges due to fear of consequences and police or family harassment, lack of legal protection from abusers, and the legal system that is often unresponsive.
• Moreover, police often target women who use drugs for bribes or for sexual favors or “community service” in return for dismissing arrest charges. One recent survey of women who use drugs found that 40% reported having experienced physical or sexual violence perpetrated by police officers.

• Ask participant what are issues that women she knows have experienced getting help to stop abuse or violence that they are experiencing;
• Ask participant what she thinks the WINGS of Hope project can do to help women in such situations;
• Let the participant know that the WINGS of Hope aims to (1) raise awareness about the different types of abuse and violence that women who use drugs and alcohol, as well as female sex workers, experience, and also to (2) advocate for better policies and services.

 

An optional 5-minute break can be arranged at this point so that the participant and the facilitator could use restroom, have some coffee etc.

Negative Consequences for Children

• Discuss negative consequences of abuse or violence for women and their children;
• Describe the consequences of experiencing emotional, physical or sexual violence on women’s health and well-being.

• Women who experience abuse by their partners or others may develop sleep disturbances, sexual dysfunction, depression, anxiety, traumatic reactions, eating problems, reproductive problems, become isolated, feel an intense loss of social connections, and may even attempt suicide. Such abuse may also make it difficult for women to negotiate condom use with their partners and protect themselves against HIV and other sexually transmitted infections (ask participant how experiencing violence has affected the health and well-being of any women she knows).
• Exposure to violence can also have lasting consequences for children. Children who see or hear violence often experience grief, fear, and anxiety. Their ability to trust and be connected in relationships or achieve in school can be severely challenged. Boys who witness violence between their parents are ten times more likely to abuse their partners when they become adults. Girls who witness parental violence are much more likely to be abused by their partners when they grow up.

Negative Consequences and Alcohol or Drugs

• Sometimes alcohol and drug use make the pattern of violence worse. People who use drugs and alcohol are more likely to commit acts of violence against their partners. Women who are under the influence of drugs or alcohol may be less likely to escape or resist abusive situations as they may feel they do not deserve a better situation. When an intimate partner keeps someone from attending treatment or threatens to hurt them if they use or don’t use drugs, this is a part of abusive behavior.

 

If project team was able to record a story of one of their beneficiaries that would be lasting for 3-5 minutes and describes correlation between drugs or alcohol use and violence, they can offer the participant to listen to it at this point.

Anger and Fighting Back

• Some women who experience violence in relationships may become angry and want to fight back. By fighting back, women may put themselves at risk for receiving criminal charges or going to jail or being physically maimed, injured or killed. Women who experience intense relationship conflict are also more likely to turn to drugs or alcohol to cope with the pain from the abuse. This may also increase their risk for being arrested for drug-related charges.

Talking About the Abuse

• Many women feel that their partner is not the normal abuser or that they are not the typical victim. Women sometimes also want to protect their partners or believe that no one else is going through what they are or will understand their situation.  For all these reasons and more, some women find it hard to talk about relationship abuse or to get help. Sometimes women accept the violence as a normal part of life and have difficulty imagining another way of living.

Internal / Private Couple and Family Issues

• Although in many communities fights between partners or family members are considered a private matter, it doesn’t mean the person causing harm or injury bears no responsibility. You may have heard proverbs like “don’t air dirty laundry in public,” “don’t wash dirty linens in public,” or “don’t show litter that was moved out of the house.” Have you heard of any other similar proverbs about keeping family issues at home? If you look at these sayings carefully, you’ll see that nowhere does it say that it is okay for someone to be injured or to cause injury. Women who are abused, have every right to move to a safer environment and the abuser has no right to justify his or their actions using these sayings. Abuse is considered a crime. The “internal/private” saying and “abuse” do not overlap. It is incorrect to use the concept of a “internal or private issue” to hide cases of abuse.

Religion Does Not Condone Violence

• Although we are not promoting any particular religion, many in this community do practice a religious faith, the most common being Islam and Christianity. According to the Quran and the Bible which notate these two most common religions in Kyrgyzstan, harming others should be avoided.
• Those who abuse others do so not because Islam or Christianity justifies it, but rather due to their own lack of the God in their hearts. The Quran states that Allah’s curse is upon the oppressors. Furthermore, another hadith states “do not oppress one another”. Additionally, the Quran teaches all Muslims to try to follow the Prophet in every aspect of their lives. Allah (The All-Mighty) sent the Prophet as the best interpreter of the Quran. His life was a practical demonstration of how the divine guidance was to be applied.
• The Prophet was affectionate to his wives and never hit his wives. The Prophet was well aware of the nature of some men to resort to abusing their spouses therefore he stressed good behavior towards women and emphasized this on numerous occasions.
• The Prophet has said “The best people from among you are those who are best to their wives”. Islamic law takes abuse and violence very seriously and does not tolerate it, rather the offenders would be punished in an appropriate manner. It is the Islamic duty of everyone who knows of abuse taking place to prevent it if they are able to do so.
• In the Bible, the Creator refers to a woman as a man’s helper – it is obviously that a helper should be taken care of and cured with love rather than abused. Therefore, family, relatives, friends and the community as a whole must take this very important responsibility very seriously, if they fail to do so they will be sinful in the sight of the God and will be accountable in that hereafter.

 

If project team was able to record a story of one of their beneficiaries that would be lasting for 3-5 minutes and further confirms that neither religious leaders nor religious interpreters condone violence against women.

Recognizing Relationship Conflict

• We’ll be talking about recognizing relationship conflict and different types of abuse now. What we talk about might be upsetting to you, especially if it touches on something that’s going on in your life. Please remember that we’re here to help.

Satisfaction with Relationship with Intimate Partner and Others

• Now you’re going to complete a screening on how safe and comfortable you feel in your relationship with your intimate partner(s) and others. In this next section I will be asking you just a few questions about your relationships with all the partners you have had recently and interactions you’ve had with others.

• Keeping what you discussed earlier in mind – that is, what violence can look like — ask the participant to answer several questions:

• SCR01. Have you been hit, kicked, punched, or otherwise hurt by someone within the past year?

__ Yes     __ No

• SCR02. Do you feel safe in your current relationships (e.g. with your partner(s), family, friends, etc.?

__ Yes     __ No

• SCR03. Is there a partner from a previous relationship or someone else who is making you feel unsafe now?

__ Yes     __ No

• If there is a positive answer to either SCR01, SCR02 or SCR03, you should ask the participant to check one or more options in the SCR04 for identifying one or multiple sources of violence posing risk(s) to her:

SCR04. (if “yes” to either SCR01, SCR02 or SCR03) You mentioned that you feel unsafe or have been hurt by an intimate partner or others, can you tell me who may hurting you or making you feel unsafe now (check all that apply)?

__ Husband

__ Boyfriend or male intimate partner

__ Other male regular sexual partner

__ Girlfriend or female intimate partner

__ Police

__ Family members of your husband or male intimate partner

__ Your family member(s)

__ Neighbor(s)

__ Drug dealer(s)

__ Pimp

__ Other option (please, specify): ______________

If there is a positive answer to either SCR01, SCR02 or SCR03, and at least one option is checked in SCR04, facilitator should inform the participant of a severe risk for relationship conflict or violence:

• Severe Risk for Relationship Conflict or Intimate Partner Violence: From your answers, it looks like there is a serious concern about safety in your relationship. I’d like to ask a few more questions about how you are influenced by the relationship, and then I’d like to go through some steps of safety planning to make sure that you are prepared in case conflict gets out of hand.

If all answers to SCR01, SCR02 and SCR03 are negative, and not a single option is checked in SCR04, facilitator should inform the participant of no risk for relationship conflict or violence and encourage her to stay in the project participant and keep participating in the session that would give her opportunity to learn of ways to help her family or friends who may be experiencing violence:

• No Risk: From your answers, it doesn’t look like you are experiencing serious relationship conflict, but we would like you to continue learning about how to help your family or friends who may experiencing serious conflict or violence by a partner or others.

Consequences of Relationship Conflict and Conflict with Others

• How does experiencing emotional, physical or sexual violence affect you? Experiencing emotional, physical, or sexual abuse by partners, family members, or others are common triggers for using drugs and alcohol to cope with the emotional and sometimes physical pain. Violence often causes women in recovery to relapse and drop out of treatment.

Negative Consequences of Relationship Conflicts

• Ask the participant to think through her relationship with her partner(s), family members, bosses, drug dealers, or others when conflict or abuse occurs and tell you of some negative consequences that she experience or is concerned about.
• Ask the participant to answer the following questions:

Does the relationship conflict or violence by others . . . (check a response option):

• Makes you feel sad or depressed?

__ Yes  __ Maybe  __ No

• Makes you feel anxious, stressed out, or on edge?

__ Yes  __ Maybe  __ No

• Makes you feel isolated from friends and family?

__ Yes  __ Maybe  __ No

• Makes you feel like using drugs or alcohol?

__ Yes  __ Maybe  __ No

• Makes you feel hopeless or helpless about your future?

__ Yes  __ Maybe  __ No

• Makes you feel bad about yourself?

__ Yes  __ Maybe  __ No

• Negatively affect your children?

__ Yes  __ Maybe  __ No

• Make you worry that you may end up fighting back or hurting your partner or others and risk getting charged with assault?

__ Yes  __ Maybe  __ No

• Make you worry that it is contributing towards physical problems that you are experiencing like headaches, stomach problems, body pains, female problems?

__ Yes  __ Maybe  __ No

• Make you worry that you may be injured in a fight?

__ Yes  __ Maybe  __ No

• Make you worry that you may be exposed to HIV or sexually transmitted infections because of unsafe sex?

__ Yes  __ Maybe  __ No

• Make you worry about becoming pregnant?

__ Yes  __ Maybe  __ No

• Other concerns that you have (please specify other concerns): _______________

__ Yes  __ Maybe  __ No

The next survey helps identifying reasons to reduce relationship conflict and improve safety, and supports facilitator’s effort to motivate participant to work on reducing risk of relationship conflict.

After considering the different negative ways that relationship conflict may be affecting your life and your family, what are some reasons why it would be important for you to reduce conflict? Please answer the following questions:

• Do you want to feel better about yourself and your future?

__ Yes  __ Maybe  __ No

• Do you want to feel less isolated from your family or friends?

__ Yes  __ Maybe  __ No

• Do you want to improve the quality of life for your kids or other family members who are affected by the relationship conflict?

__ Yes  __ Maybe  __ No

• Do you want to stop feeling scared or anxious when you are around your partner?

__ Yes  __ Maybe  __ No

• Do you want to improve the relationship you have with your partner?

__ Yes  __ Maybe  __ No

• Do you want to stop feeling trapped in the relationship?

__ Yes  __ Maybe  __ No

• Other reasons (please specify): ________________

__ Yes  __ Maybe  __ No

We hope this activity has been helpful to you in thinking through what role the relationship with your partner plays in your life and thinking through why you may want to reduce relationship conflict or reduce your risk for being hurt by your partner. It is possible to reach the goals that you set for yourself. While barriers may exist and feel overwhelming, there are ways to stay safe and work toward the future that you want.

Safety Planning & Mapping Introduction: Taking Steps to Increase Relationship Safety

• If you or a family member or friend is experiencing conflict, threatening behaviors or violence from a partner or others, there are steps you can take to reduce conflict, help to prevent being hurt. For the first step of the safety plan we’ll need to first identify who poses risk to you and who you can turn to for support.

Safety Strategy: Risk and Social Support Mapping

• All of us have people and places in our lives that we consider safer or more dangerous than others. If you’re feeling afraid that your partner or someone else might physically or sexually hurt you, it may be helpful for you to be able to reach out to particular family or friends who you can turn to for help, advice, and emotional support.
• There may also be times when it is safer for you to stay with a friend or family member. Your friends or family may also help you out by taking care of your children or pets or helping you financially if you need to leave.
• Understanding that at times, it may be family members or others who pose risk, we also need to identify who you can turn to or stay with, in those situations.
• Different people may be able to help you in different ways. For example, it may be easier to talk with a friend about your relationship problems, but ask your aunt for place to stay.

• Refer to the Risks and Social Support Map handout that was printed in advance, and build your conversation with the participant on the following questions:

The English version of the Risk and Social Support Map can be downloaded through this link:

• Can you tell me the names of one to five people who pose the most risk to threatening you or physically or sexually hurting you? Let’s write down their names, too (particular family members, partner, boss, police, drug dealer etc.). Out of these people, who are you most concerned about? (Mark on the list with a cloud).
• Can you tell me the names of one to five people you trust? Let’s write their names onto the birds on this tree (family, religious person, neighbor, people you work with, friends, partner, service providers).
• Which of these people can give you emotional support? We’ll mark these with a heart.
• Which of these people who can give you practical support, like giving you a place to stay, watching your pets, or lending you money? We’ll mark these with a star.

• If participant identified a particular person or set of persons as both, a risk and safety person, talk to them about under what circumstances they may pose a risk and threat and who to turn to in those situations.

 

As in case with all other forms and handouts used in the session, a copy of this particular form / handout can be offered to the participant if she would like one and whether it is safe for her to take a copy home.

Steps to Increase Support

Do you feel like you have adequate support from your family and friends?

What types of support (emotional support, advice, or practical help like babysitting children or borrowing money) do you feel like you may need?

Can you think of two things you can do to strengthen your support from family or friends or others in the next week?

This may be contacting someone who you like to spend time to get together for coffee/tea or go for walk so that you have a chance to connect with him or her. It may mean calling, texting, e-mailing, or sending a letter to someone who you have lost touch with but who you would like to reconnect with. It may mean choosing someone who you trust and respect to talk with about the relationship conflict or abuse that you are experiencing so that you can get their advice or support on how to deal with it:

• In the next week, I can do the following to strengthen my support: _______________
• In the next week, I can also do the following to strengthen my support: ______________

Strategies for Safety during a Violent Incident         

 Women cannot always avoid violent incidents. In order to increase safety, women may use a variety of strategies. You can use some or all of the following strategies to stay safe. It is a good idea to practice how to get out of your home. What doors, windows, elevators, stairwells, or fire escapes would you use? Consider which exits are safest. Below, write down how you would get out:

• This plan is for (type the participant’s name): ___________________
• If I decide to leave, I will: ________________
• In order to leave quickly, I can keep my purse, identification, and metro card (or bus/train fare) ready and put them (specify place): _____________

You can tell a person that I trust about the violence and request they call the police if they hear suspicious noises coming from my apartment.

• One person I can tell is: _________________________
• Another person I can tell is: _________________________

Do you have a cell phone or home phone that you can call the police or others if you feel that you are in a dangerous situation?

__ Yes __ No

(if the participant checks “no”…)

Do you have a neighbor, friend or family member who has a phone that you may be able to use?

__ Yes __ No

Are you comfortable calling the police if you are concerned that your partner or other family members may hurt you?

__ Yes __ No

You can use a code word with your children, family members or your friends so they can call for help. Code words should not raise suspicion from partner or others, but should not also be “every day” language that might confuse people. Some examples of code words are “Your aunt has not returned my phone call today”.

Code words for children need to be appropriate for their age. For example, a code word for a 13-year-old girl may be “Your cousin called you today and wants you to call her back today”. For a younger child it can be something like “Your grandmother called today and wanted to talk with you about something”.

Most children under the age of 5 will be too young to understand how to operate under code language, you will need to figure out who you can trust with this task.

• So, your code word will be: ____________________

• It’s a good idea to decide where you can go if you have to leave your apartment. Decide this even if you don’t think you will experience another violent incident.

• So, if you have to leave your home, you will go to: ______________________

Try to avoid arguments in the bathroom, and kitchens, near weapons or in rooms without access to an outside door.

• When you expect you are going to have an argument, you will try to move to a space that is lowest risk, such as: _______

You should use your judgment and intuition. If the situation is very serious, you may give some of what your partner wants to calm him/her down. You have to protect yourself until he or you both are out of danger. You will also get a list called ‘Items to Remember’ that provides a suggested list of things to take with you if you have to leave. Where can you keep this list?

• I will keep the list here: ____

Do you have a safe place to keep an emergency phone number and other important numbers?

__ Yes __ No

Safety When Preparing to Leave

A woman may have to leave the residence she shares with her partner, who is out of control. Leaving must be done with a careful plan in order to increase safety. A violent partner often strikes back if he or she believes that the woman is leaving a relationship. You can use some or all of the following safety strategies:

• To be able to leave quickly, money and an extra set of keys can be left with: ______________
• Copies of important documents (labor book, birth certificates, photocopies of ID) or keys will be kept at: _______

It’s important to become financially independent.

• To get help with becoming financially independent from your partner call: ______________
• To increase my independence, I will open a savings account by (specify date): ______________
• Other things I can do to increase my independence include: ________

Call 112 and ask for the Domestic Violence Hotline if you need counseling, legal assistance or emergency housing. If you are feeling threatened by your partner or in more immediate danger, call the police at 102.

If you use your cell phone, the following month the telephone bill will tell your partner those numbers that you called after you left. To keep your calls confidential, you must either use coins at a pay phone or use a calling card for a limited time when you first leave.

It is important to find people who will let you stay with them or lend you some money. You may want to check with the following people to see if you can stay with them or borrow money: _______________________

• Leave extra clothes with: _____

It’s important to review your safety plan occasionally. When do you think you’ll sit down and review your safety plan? (specify the date):___

• Ask a trusted friend or advocate to help you review your plan. The person you will ask is: _______________

If you feel it makes sense, review and rehearse this safety plan with your children.

Safety During a Violent Incident Outside of the Home

• You can discuss with the participant various steps that she can apply for increasing her safety. If you follow the questions below and check the participant’s answers, you can adjust the conversation accordingly:

• I will make sure to walk with a supportive friend on streets or neighborhoods where I do not feel safe.

__ Yes __ No

• I will avoid being in closed spaces with individuals who I do not know or have some reference with.

__ Yes __ No

• If I need to meet with someone I do not know I will let a friend know where I am.

__ Yes __ No

• When I expect I am going to have an argument with someone outside the home, I will try to move to a space that is lowest risk.

__ Yes __ No

• I will take a self-defense course.

__ Yes __ No

In addition to trying to stay safe during a violent incident, it is important to know what your options are in terms of reporting violence you may experience. As we discussed at the beginning of this session, it is against the law to abuse people and according to the Constitution, women and men are equal.

• Ask participant whether she knows what her legal rights are in terms of violence and how to report violence, if she chooses to.
• Regardless of whether they know or not, provide the participant with the booklet designed by the Voice of Freedom Foundation that explains the law and action steps they can take.

The booklet designed by the Voice of Freedom Foundation that describes what victims of police violence can apply, can be downloaded through this link:

• It is within your right, if you so choose, to report an incident of violence and/or seek a protection order. This handout explains it in more detail, but briefly, you may go to a local NGO for support or go to the court for assistance. You may also file for a protection order.

 

As in case with all other forms and handouts used in the session, a copy of this particular form / handout can be offered to the participant if she would like one and whether it is safe for her to take a copy home.

Safety Planning: Violence by Police

• Now that we’ve discussed your legal rights and have talked about safety planning in and outside of the home, it’s also important to go over safety planning in case there’s a violent incident with a government official, like the police. Our data indicates that women sometimes experience violence by the police, are threatened or are blackmailed into giving them money. Have you heard about such cases?
• In some cases, police report that women, when stopped for questioning, lash out at them by spitting on them or tear their clothes, which sometimes results in them to using physical force. In other cases, women are assaulted by the police even when they have been respectful towards them. Have you heard of similar stories?

• Ask participant whether she heard of the cases when women experienced violence by police staff, even though they didn’t commit anything wrong.
• Ask: Can you think of some ways you can stay safe during a violent incident by the police? What are some ways to avoid violence by the police?

• Thank you for sharing your ideas. Like violence by a partner, if you experience violence by the police, there are steps you can take to file a complaint, if you so choose. The same handout I provided also explains the action steps you can take, but briefly, the first step is often to go to the officer’s immediate supervisor. You may also choose to go to the Service of Internal Security, instead. Finally, a woman can also go to the prosecutor’s office if you are not satisfied with the outcome of the first two options. One important piece of information in filing a complaint is having evidence. A woman filing a complaint may not have any, but if they do, they may want to consider bringing that in if they feel comfortable. If they don’t, they can still file a complaint.

Review once again the handout designed by the Voice of Freedom Foundation that explains the law and action steps the participant can take.

The short animated video that summarizes steps that victims of police violence can apply, in Russian, can be downloaded through this link:

The same video, in Kyrgyz, is available through this link:

During the session I was taking notes and entering and checking your responses. You will be given a copy of this safety plan if you have a safe place to keep the safety plan at home or with a friend. Or, would you prefer to have these sent by email, mailed to you, or mailed to another address?

Let’s identify the goals you most want to pursue. If you could choose the best outcome, one or several, for you and your partner, what would it be? You can select all that apply:

__ My partner and I stay together, with no change.

__ My partner and I stay together. Stop emotional abuse.

__ My partner and I stay together. Stop physical abuse.

__ My partner moves out and we have no further contact.

__ My partner moves out, but continues to be involved with me.

__ My partner moves out, but continues to be involved with my children.

__ My family and I stay together, with no change.

__ My family and I stay together. Stop emotional abuse.

__ My family and I stay together. Stop physical abuse.

__ My family or I move out and we have no further contact.

__ My family or I move out, but continues to be involved with me.

__ My family or I move out, but continues to be involved with my children.

__ I continue working for and staying in contact with my boss, pimp or drug dealer, with no change.

__ I continue working for/contacting my boss, pimp, drug dealer or other person, but take steps or stop or reduce their emotional, physical and/or sexual abuse.

__ I stop working for or staying in contact with my boss, pimp or drug dealer.

__ I have to work to reduce risk posed.

__ I have to reduce or stop drug use.

__ I have to work on improving sexual safety.

__ I have to get an HIV/STI test.

__ I have to get treatment for HIV or an STI.

__ Other goal (please specify and add to the options above): __________

Ask participant to answer some questions about the types of issues that can trigger conflict for her and her partner or family members or put her in a dangerous position. It will help to identify services and organizations that might be able to help her with her particular needs.

• What are the main issues that may trigger conflict or abuse with your partner, family members and/or put you in danger with others? You can choose all applicable options from the list below, or specify other one(s) that apply to your situation:

__ Partner’s mental health issues or problem

__ Family member’s mental health issues or problem

__ Partner’s unemployment

__ Family member’s unemployment

__ Partner’s drug or alcohol issue

__ Family member’s drug or alcohol issue

__ Partner’s legal problems

__ Family member’s legal problems

__ Lack of communication with my partner

__ Lack of communication with family

__ Conflict over financial problems

__ Conflict over children

__ Conflict over family and friends

__ My drug or alcohol use

__ My mental health issues or problem managing anger

__ My legal and/or documentation problems

__ Housing problems

__ Other issues (please specify — e.g. experience violence by others, including bosses, pimps, drug dealers, police etc.): _______

Ask participant to specify services that might help her work towards these goals with her partner.

• What services might help you work towards these goals with your partner? You can check all options that apply):

__ Job training for self or partner

__ Help Getting Housing

__ Legal assistance (i.e. assistance getting restraining order, divorce or child custody)

__ Counseling from a religious organization (pastor, priest, rabbi)

__ Couples/Marital counseling

__ Education/Go back to School/GED

__ Recreation/Social Activities

__ Safety day care for children or a baby-sitter

__ Mental Health Counseling for self or partner

__ Alcohol Drug Abuse Counseling for self or partner

__ Anger management or batterer’s treatment program for partner or self

__ Counseling or group support to deal with partner abuse

__ Emergency domestic violence shelter or residential program

__ Other services that might help you (please specify):

• Out of these services, which one is the most important, or addresses your most immediate or life-threatening issues?

Together with partners’ coalition and consultants, you should prepare in advance a Service Manual with contact information, directions and working hours of all applicable organizations, government, municipal and non-government, that can appear helpful in providing appropriate services to the project participants.

• Here is a selected list of organizations that provide the service you just selected as the most important to you. You can keep this booklet if you want.

 

As in case with all other forms and handouts used in the session, a copy of this particular form / handout can be offered to the participant if she would like one and whether it is safe for her to take a copy home.

• If you prefer, we can email this list to your email address right now.

Discuss with the participant action plan, helping her to identify steps, one by one, to address her most important service needs.

• What are you going to do in the next week to address your most important service needs? (write down the participant’s response to the same sheet where the safety planning tips are written).
• What are you going to do in the next week to take time for yourself? Some ideas including going for a walk in the park, writing in a journal, creating some art, visit a friend or (fill in additional items): (write down the participant’s response to the same sheet where the safety planning tips are written).

Summarize the session, emphasize the parts and issues that are utmost applicable to the participant’s context.

• Thank you so much for meeting with us today and taking the time to discuss this important issue that affects many women. We hope that the information we have shared will be helpful for you and for other women you know who face relationship challenges.
• Reducing conflict is not easy. Sometimes people can work together to make changes and ensure their relationship will be respectful and safe. Sometimes one person needs to end the relationship in order to keep herself or her children safe. This is a personal decision, but having support can help women spread their wings and choose safety.
• We hope you can find support and power within yourself, and also be a support to others. Thank you again for your time and your participation.

At the conclusion of the service session, offer the participant optional HIV testing and referral.  

• Now that we’ve reviewed your goals and safety plan, I’d like to talk to you about optional testing for HIV. HIV is a widespread health issue and thus, we are encouraging all clients to get tested, if they haven’t already. This was one of the areas addressed during the consent process. Have you been tested for HIV recently? If yes, when were you last tested? If you are comfortable sharing your results with me, I’d like to refer you to any services that you may need and update your safety plan, accordingly.

• If the participant did not receive HIV test recently, offer her to set up an appointment for receiving an HIV test, and tell her what to expect.
• If participant declines testing, provide them with the referral contact information so that they may seek testing at a later time, if they choose. Ask permission to inquire about how they decided not to be tested and offer support and clarification about the process if needed. This may be a moment with your support can assist them in working through particular anxiety about the test or potential results. Also, inform the participant that in the pre-test counseling there will opportunities to ask questions and to confirm their decision for testing.
• Refer to HIV testing protocol to provide more information about the HIV pre/post test and what to expect. If the client is interested in receiving an HIV test, it’s important to discuss safety concerns if partner/family violence is a concern.

• Since we are making a referral/appointment for you to receive HIV testing and since you expressed concerns about your safety from X, Y, or Z people, let’s talk a little about what safety concerns you may have about getting tested. How safe do you feel about getting tested?
• Do you think any of the people we’ve previously talked about will pose a danger to you in getting tested?
• What if your results are positive? Who can you talk to about getting tested? That is, who do you feel safe/comfortable with?

Update the participant’s safety plan, explain how it can minimize her risks, and provide appropriate referrals.

 

If participant discloses her HIV status as positive, discuss her current access to and engagement in HIV treatment and care.

• Are you currently receiving treatment for HIV? Are you receiving any services for HIV?

If participant is currently receiving HIV treatment and care services, let her know how important is that she stay in HIV treatment and praise for taking care of herself.  

 

If participant is HIV positive, but not in HIV treatment, ask her about the main reasons that are keeping her from getting HIV treatment and care. If she has trouble expressing reasons, you may ask her if any of the following barriers is keeping them from receiving HIV care:

• Transportation
• No time
• Don’t want friends or family to know she is HIV positive
• Don’t want to be registered as HIV positive, concerns about confidentiality
• Don’t want to take any medicine for HIV
• Worried that she will be treated badly by staff at HIV care center
• Afraid to go to HIV care by herself
• Has too many other problems in her life
• Other barrier (encourage her to specify)

For each barrier that participant identifies, encourage her to come up with a possible solutions that can help her address the barrier. If she has concerns about HIV medication and treatment, point out the positives of starting HIV treatment early.

• People who get diagnosed early, and start antiretroviral medication when recommended and adhere to their medication can live longer and stay healthier than the ones who declines treatment or is not adherent enough. If you are receiving ARV medication, you are also much less likely to transmit the virus to other.

If participant lacks motivation to get treatment, ask her about reasons that she would like to stay healthy and have a better quality of life (e.g. “to stay health for children and family”, “it would upset my parents”, etc).

It is also important to discuss whether the participant’s HIV status poses any danger to her. For example, if she has disclosed her status to anyone, does she feel safe or unsafe about the response(s). Update her Risk and Social Support Map and safety plan to address any safety concerns.

Further, it is also important to connect or refer the participant to any other supportive services she may need or want in relation to her HIV status. e.g. support groups.

If a participant expresses any stigma or discrimination because of her HIV status, reflect and empathize with her experience. This can be highlighted as an important reason to seek a support group and counseling. Help her connect to available support groups and/or people in her life who can support her. Add these people to her Risk and Social Support Map.

After working through barriers with the participant, make a referral to HIV care and treatment. If possible, call HIV care center and make an appointment while participant is in the office. Ask her to come up with a concrete plan about when and how she will go to the appointment and who she will go with, and, if possible, navigate her to the HIV center.

• Discuss with the participant options for time and location for the next session, and make an appointment.
• Confirm whether it would be all right for the outreach recruiter to call or text message her with a reminder before the next session, and discuss ways to make the reminder as safe as possible. 

• Welcome participant, appreciate her commitment to continue being a part of the project.
• Provide brief review of last session and overview of follow-up session.

Thank you for coming in. When we last met, two weeks ago, we talked about different threatening behaviors and violence that you or friends/family members may be experiencing in and outside of the home, identified people who pose a risk for you as well as who are safe to be around, and set some goals. The goal of this activity was to motivate you and build your confidence to address abuse.

• Provide a summary of what you covered in last session.
• Highlight positive aspects of the session and any progress or gains the participant made or any challenges she identified and worked through. The goal of this summary is to build motivation and confidence of the participant to address abuse.

Today, we are going to review some of the threatening or violent behaviors from others that you identified, those safety/risk maps, the goals you set out, and the services we discussed that may be of help to you to see if you were able to connect with them or what barriers/issues you had in getting connected. Finally, we will be talking about the importance of HIV testing and introduce some methods to prevent and respond to a potential drug overdose.

• Review risks and different types of threatening and abusive behaviors from each perpetrator that the participant identified at last session.
• Ask the participant whether there have been any other threatening or abusive behaviors from others that occurred or that she remembered since last session.

• Since we met, have there been any additional incidents, where you felt threatened or hurt by your partner or others? Can you tell me more about what happened? Are there any other threatening or abusive behaviors from others that you have experienced and remembered after we met, that we didn’t talk about? (enter the participant’s answers and refer to them in the follow-up discussion).

• Assess how building motivation and confidence for addressing abuse were managed in last session.

• Last session, you identified the following reasons (go over reasons) why it was important to you to take steps to reduce or stop the abuse you were experiencing. Since last session, have you thought about any other reasons that would be important for you to stay safe?
• On a scale of 1 to 10, how important is it for you to do something about the violence or threatening behaviors that you are experiencing?

If the participant didn’t identify any threatening or hurtful behaviors, skip to next section.

If the participant identified such behaviors, here is the legend so that you can easier interpret the score the participant is coming up with:

• 0-2   Pre-contemplation or Not ready
• 3-4   Contemplation or Unsure
• 5-6   Preparation or Ready
• 7-8   Action or Trying
• 9-10 Maintenance or Trying

If the participant indicates a high rating, ask her, what makes it important for her to address the issue.

If the participant indicates a low rating, ask her what makes it a low priority.

Summarize reasons for addressing violence or hurtful behaviors. 

• What are some reasons that might make you want to take steps to reduce your risk or experience of abusive and threatening behaviors? (enter the reasons here, then summarize reasons back to the participant to build motivation for addressing this issue).
• We just talked about how important some of these things are for you, now we’ll talk about whether you feel you are able to address them.
• How confident are you on a scale from 1 to 10, that you can take steps to reduce your risk of experiencing threatening or violent behaviors?

Here is the legend so that you can easier interpret the score the participant is coming up with:

• 0-2   Pre-contemplation or Not ready
• 3-4   Contemplation or Unsure
• 5-6   Preparation or Ready
• 7-8   Action or Trying
• 9-10 Maintenance or Trying

If the participant indicates a high rating, ask her, what makes her feel confident about addressing the issue.

If the participant indicates a low rating, ask her what makes her feel not confident about taking steps to reduce abuse or threatening behaviors.

Summarize reasons to help the participant build confidence and self-efficacy that she can take steps to reduce her risks of experiencing abuse and threatening behaviors from others.

Summarize reasons back to the participant and validate any difficulties she faces for not being able to reduce risk or not feeling confident. Let her know that the purpose of the current session is to help her to identify small steps and strategies she can take to reduce her violence. From here, you want to help her figure out what would help her feel more confident so that she can address this issue.

• You rated yourself as a X, what makes you rate yourself a X and not a Y? What would help make you feel more confident? We recognize that it can be really difficult sometimes for women to takes steps to protect themselves from being hurt by others. Our goal today is to identify ways and small steps that you can take to reduce your risk of abuse.

• Review copy of the safety plan with the participant. For each step of the plan, ask her if she was able to implement any, some, or all of it. If yes, then specify the parts that were implemented.
• If the participant indicates she implemented the step, praise her for doing so and building her wings to protect themselves.
• If the participant indicates she didn’t implement the step, ask what made it difficult. For each barriers identified, ask what are some of the ways the barrier may be addressed. Then help her come up with a concrete plan of next steps to implement plan.

• Were you able to take your materials home or to another place and keep them somewhere safe?

If the participant says that she was not able to do that, appreciate her effort and confirm that you know women sometimes face difficulty doing this.

• What were the reasons that made it difficult or challenging to do this? You mentioned that don’t feel safe leaving it home, in case your partner or another family member finds it. This is a very important and legitimate concern. The last thing we want you to do is to put yourself at greater risk for abuse. Can you think of any other safe places that you can leave the plan? Okay, you mentioned that you can leave it at your neighbor’s place. That’s great when do you think you can do this?

• Review each step to enhance social support from their network that the participant identified from last session.
• Ask her whether or not she was able to take each step. If she succeeded in taking step, ask her how it went. Highlight and praise gains that she made in reaching out, connecting to, and securing support from people on her Risk and Social Support Map.
• If the participant was not able to take steps to reach out and connect with people on the Map, let her know that it is often difficult for women to ask for support or help from family or friends especially when they are experiencing abuse or using drugs.

Ask the participant what barriers or challenges she faced in addressing the abuse. For each barrier that the participant lists, ask about what are some of the possible ways she can address the barrier. Go over possible solutions and ask the participant to come up with steps she can take in the next week to reach out and connect to people on their Map. Summarize barriers, solutions, and next steps that they can take to strengthen their support network.

• Last time we met, you identified different family members or friends you can turn to for support, advice or help. Let’s go over the Map. Is there anyone else you would like to add to the Social Support Map? Is there any one you would like to take off from the Map?
• We also discussed ways you can strengthen your Social Support Map. Do you remember what ways we discussed? Were you able to take the steps you indicated to improve your support? What made it difficult? Are there other steps you can take to reach out to people on your Map? Are there people you would like to add to the Map?
• When we last met, you identified the following goals as important things to work on (go through goal setting). Let’s go over each goal and see how it went for you and whether you want to make any changes to your goals for the future.

Review steps the participant took toward each goal. If she successfully was able to take steps to achieve a/some goal(s), highlight and praise those steps to build confidence and self-efficacy. If she was unable to implement steps towards identified goals, acknowledge and normalize difficulties. Ask her to identify barriers and challenges she encountered, and ask her to think about what ways she can address each barrier. For each barrier that the participant lists, ask her of possible ways she can address the barrier.

Also, ask the participant if she wants to make any changes to their identified goals. Summarize goals and next steps that she can take to implement them. Ask when, and how, she plans to implement each goal. Help the participant to visualize exactly how she is going to go about taking each step towards the goals. List goals and next steps on a sheet of paper.

• Help the participant if she wants to make any changes to the identified goals. Summarize goals and next steps that she can take to implement them.
• Ask when, and how, they plan to implement each goal.
• Help the participant to visualize exactly how she is going to go about taking each step towards the goals.

Remind participant that goal setting is an ongoing process. There will always be challenges and it’s important to identify barriers and strategies when working to achieve their goals. It’s important for her to praise and reward herself for each little step she takes towards her goal(s).

• Review and revise the Service Referral Plan compiled at the last session. If the participant successfully was able to follow the plan, highlight and praise those steps.

• Last week we identified some places you can connect with to get some help, and some service referrals. Were you able to connect with any of these places? If yes, which ones? How helpful were they? If they were not helpful, what happened? How did you feel you were treated? What barriers or challenges did you experience in going to these services?

For each barrier they mention, ask client how she can address the barrier. Go over possible solutions and work with them to come up with steps they can take in the next week to connect with service. List barriers, solutions, and next steps on service plan.

• Is there anything we can do to help you right now to connect you to services, like calling service providers to set up appointments or even go there together with you?
• Are there any other services that you need at this point that we didn’t list on your service plan last time we met? Let’s summarize service plan and next steps. Please remember that our organization is available to help if you are facing difficulties getting into services or if you need help.

• Ask participant what progress she thinks she has made toward improving her personal safety and well-being that she has made since the first session.
• Praise her for protecting themselves and identifying specific positive steps she has taken so far to improve her personal safety and well-being.

Review highlights of the session, acknowledging challenges the participant faces, underscoring  the reasons for protecting herself and identifying specific positive steps she has taken so far to improve her personal safety and well-being. The goal of this summary should be to strengthen the client’s motivation and confidence for addressing abuse.

Remind participant about the importance of taking care of herself while she is dealing with these challenging issues and to reward herself for any small steps she takes towards change.

• What are you going to do in the next week to take time for yourself? Some ideas including going for a walk, creating art, making something, cooking something special etc?

Review materials that the participant is going to take home – revised Safety Plan, Risk and Support Map, Service Referral Plan, list of goals. Ask participant if she has any concerns, and let her know that you and your organization are available to help her achieve her goals. Also, provide contact card if available.

• This training course is optional and should be applied with the WINGS of Hope participants who feel overdose applies to their situation.  
• This module has been developed by Dr Timothy Hunt at Columbia University Social Intervention Group, and builds on guidelines and materials designed as a part of Project ADVANCE  by Attika Foundation and Kyrgyz Harm Reduction Association team led by Sergei Bessonov whose efforts we very much appreciate.

• Discuss with participant overdose in Kyrgyzstan.
• While discussing, use and refer to overdose statistics collected as a part of the WINGS of Hope project.

• Before discussing overdose in details, let’s talk briefly about overdose in Kyrgyzstan. It is difficult to estimate the true number of overdose patients and the number of fatal overdoses in Kyrgyzstan, but overdose is the leading cause of death among people who inject drugs in Kyrgyzstan and many other countries. Experiencing overdose “ever” was reported by 46% of the participants, and 6% overdosed in the past 3 months. About 32% of project participants stated that they were able access Naloxone through NGOs. In the framework of study, the respondents (n=213) also shared that they knew approximately 465 people who experienced overdose in the past 3 months. According to the participants’ estimates, out of 465, at least 208 persons (44,7%) died from overdoses.
• One of the biggest problems with treatment of overdose patients in Kyrgyzstan is the lack of appropriate medical facilities and qualified toxicologists. Often, people are embarrassed or fearful about seeking help, as well.
• Drug treatment in Kyrgyzstan remains hard to access for injection drug users and is even less accessible to women who use drugs because of public stigma, which discourages them from seeking help. Actually, treatment is limited mainly to paid and costly detox programs. Methadone service is available and free, but requires being officially registered in medical records as drug user. This requirement scares people and discourages them from joining methadone therapy as they are uncertain about negative consequences of this registration in a longer run. A total of number of women who use drugs enrolled in methadone program is 94. It is approximately 20.8% of the number of registered WDU or 4.8% of the estimated number.
• Therefore, it is important for us to learn skills how to minimize the risk of an overdose and know what to do if a friend or a partner is overdosing. There are medications that can help in the immediate response to an overdose while getting emergency help. We will be introducing you to an option called Naloxone and how you can obtain it as part of this project.

• Briefly review what and how opiates work.
• Provide examples of opiates.
• Describe the effects of opiates on brain and central nervous system.

• Opiates are a type of drug that comes from the opium poppy or are synthetically made by a drug company. All opiates act the same way on the brain. Opiates are depressants, which mean they slow down your central nervous system, including breathing.
• Can you think of an example of an opiate? Examples of natural opiates include heroin, morphine and codeine. Examples of synthetic (or manufactured) opiates include methadone, oxycontin, percodan, percocet, and vicodin.
• Opiates differ in both their strength and in the length of time they act on your body. For example, heroin is a strong opiate that produces effects for 6-8 hours. Methadone is a strong opiate, too, but acts much longer in your body – between 24 and 32 hours. Codeine is a weak opiate whose effects last for 3-4 hours:

?

• Discuss causes of an opiate overdose.
• Provide examples to better understand the causes.

• What is an overdose and how do they happen? An overdose is when your body has more drugs in its system than it can handle. People can overdose on lots of things, including alcohol, cocaine/crack, opiates or a mixture of drugs. Opiate overdoses happen when the amount of opiates and/or other central nervous system depressants (downers) in your body causes your brain to shut down your breathing. If you can’t breathe, then you can’t get oxygen to your brain and after a little while your heart stops, which leads to death or permanent brain damage.
• As you know, there are a lot of things that can lead to overdosing on opiates. One important thing to consider is tolerance. This means the amount of drug that your body is used to and can handle. When you do opiates on a regular basis, your body begins to develop a tolerance to this and can handle more of the drug than someone who is not used to taking opiates regularly. A lot of people overdose when they use after taking a break for a while, and thus reduce their tolerance (because they were in drug treatment or jail for instance).
• Another factor that leads to opiate overdose is mixing opiates with other drugs, especially downers like Benzos (Valium Relanium, Seduxen, Clonopin) or Alcohol. When you combine downers you don’t just get an added effect, you get a multiplied effect. This means that when you combine these drugs the overall effect of ALL the drugs is increased. The more alcohol and/or downers you have in your system, the less heroin you will need to overdose.
• Physical state, that is the state your body is in, can also have an impact on the likelihood of overdose. If you are feeling sick or weak, your body may not be able to handle this usual amount of drugs that you are used to using.
• Another important thing to realize about opiates is that if you are buying them on the street you never really know how strong they are. A bag of heroin, for instance, can vary a lot in purity. If your body is used to dope that is only 10% heroin and you score really good stuff that’s 60% heroin, doing one bag of this is like doing 6 bags of the dope that your body is used to.

• Assess participant’s experience with overdose.

• What is your experience with overdose? If you experienced an overdose, why do you think it happened? What do you think is your current biggest risks for overdose? If you have not experienced overdose, why do you think that is? Have you witnessed an overdose? How did you respond?
• If you decide to inject drugs, here are some tips that may reduce the harm to you and maybe prevent an overdose.
• Know your tolerance. The more often you use opiates, and the greater the amounts you use, the higher your tolerance level, or the amount your body can handle. If you take a break from using for a few days or longer, your tolerance goes down drastically. This means that it will take less of the drug for you to get high when you use again. It also means that it will take less of the drug to cause an overdose. Therefore, if you take a break from using for a while, it’s important that you start out again slow; you can’t pick up where you left off.
• Know your supply. Because heroin is illegal, there is no way to know exactly how pure the heroin you get is. If you’re buying from a new source or getting a new batch of product, it’s important to test it out first to assess how good it is.
• Control Your Own High When someone else fixes your drugs for you or hits you off, you do not have complete control of what is going into your body. Try to fix your own drugs so you know exactly what’s going into the syringe. If you haven’t learned how to hit yourself, talk with a staff member of the Trust Point so they can give you some tips on how to inject yourself safely.
• Follow proper injection techniques, don’t slam the shot, especially if it is from a source you’re not used to or part of a new batch. Instead, after you register give several small pushes to “taste” the quality of the drug(s). Remember, once it’s in, you can’t get it out.
• Be aware of the risks of mixing drugs. Mixing heroin with other downers like alcohol, “benzos,” or prescription opiates can be especially dangerous. The drugs interact and can create a much more powerful effect than when they are used by themselves. If you are going to mix heroin with other downers, you may want to do the heroin first – especially if you are injecting because this gets the drug into your system very fast.
• Alcohol and pills come on more slowly and you may not get the full effects for a while after ingesting them. Also, alcohol and pills can interfere with your judgment and may result in you doing more heroin than you intended or not being as safe when using. The important thing is to be aware of what you’re taking and how different drugs can interact. Remember to pace yourself.
• Try not to use alone. If you are using alone and overdose, there is nobody there to call for help or to try and revive you. If you are going to use alone, it is especially important to follow the guidelines above, so you minimize the risk of overdosing. And if you find yourself along in an overdose situation and have called an ambulance, remember to unlock your door so that medical personnel can get inside your house.

• Introduce this section on recognizing the signs of overdose by drawing what the participant already knows.
• You may need to clarify any misinformation that is shared by using the following key points.

Recognizing the signs when someone is overdosing is critical in responding in enough time. Overdose rarely happens suddenly but most often comes on during a period of 1-3 hours. There are a number of signs that someone has overdosed on opiates. Can you name any of them?

Sometimes it may seem difficult to tell if someone is overdosing or they are just really high. Let’s review overdose signs with the following list:

• Passing out unconscious
• Awake but unable to talk
• Slow breathing (less than 12 breaths per minute)
• Choking or gurgling sounds
• Limp body
• Pale complexion
• Cold, clammy skin
• Turning blue (fingers and lips turn blue first)
• Vomiting
• Slow heartbeat/pulse

Let’s review difference using the following chart:

• If you are with someone who you think is overdosing, there are some steps that you can take to help them recover. There are also some strategies that people typically use which are not advised. Let us first go over what not to do:

• Don’t inject them with anything — it won’t work any more than physical stimulation and can waste time or make things worse depending on what you inject. An injection of salt water, for instance, could cause someone to go into cardiac arrest if they already have high sodium levels in their system. Injecting them with other drugs such as cocaine or speed may make the worse.
• Now let’s talk about what to do when someone is overdosing

Ask the participants to review the signs of an overdose: 

• Deep snoring or gurgling (death rattle)
• Less than 12 breaths per minute
• Pale, clammy skin
• Heavy nod
• Slow heart beat/pulse, not responsive to stimulation

• After assessing the signs, if the person is unconscious or “out of it”, try to wake them up. Call their name and shake them. If this doesn’t work, try to wake them by causing mild pain like pinching them or rubbing your knuckles into their sternum, the place in the middle of your chest where your ribs meet (demonstrate and have the participant try rubbing knuckles in the middle of their chest).
• If this causes them to wake up, try to get them to focus. Can they speak to you? Try to get them to stand up and walk around, even if you have to support them. Check their breathing.
• If the person does not respond to stimulation and remains unconscious or their condition appears to get worse, follow these advise:

• Call for help (but don’t leave the person alone)
• Apply rescue breathing
• Administer Naloxone if trained to do so – if not trained, just break the ampoule and drop the solution to the victim’s mouth

• Ask participant what they have heard about Naloxone.
• Acknowledge correct responses and cover the following points about Naloxone:

• Naloxone is an injectable medication that reverses the effects of opiates like heroin. It is not a replacement for calling for emergency assistance but can save a life while getting help. We will give an introduction to when and how to use it in the next section.
• Regardless of your training, it is recommended that you call for an ambulance in the case of an overdose because it is important to have trained medical professionals assess the condition of the overdose victim. People who survive any type of overdose are at risk of experiencing other health complications as a result of the overdose, such as pneumonia and heart problems. Getting someone to be checked out by a medical professional is an important part of reducing the harms associated with overdosing.

• First, let’s talk about your thoughts regarding calling an ambulance in this situation. What are some of the reason why an ambulance may not be called during an overdose? You are right, some common responses you may hear are fear of police involvement, or delayed response, or stigma associated with drug users.
• When you call an ambulance, stay calm and ask those present to stay quiet. Have the address or location handy. If you don’t want to say it’s an overdose, tell the dispatcher that “the person has collapsed” and tell them whether or not they are breathing and whether or not they have a pulse.
• Focus on the symptoms rather than causes or diagnosis. Ambulance prioritizes cases of people who are not breathing, so if they aren‘t breathing or are barely breathing, make sure to emphasize that they aren‘t breathing.
• Ambulance personnel are more likely to contact police if the victim is found outside or in the entry way of a building. If victim is found in an apartment or a house, authorities are not contacted until the victim is taken to the hospital. Police is also contacted when there is a fatality or at the request of medical personnel. In these cases, police investigate if another person was responsible for the injection.
• If you have to leave the person at all, even for a minute to call ambulance, make sure you put them in the Recovery Position, which means laying the person slightly on their side, their body supported by a bent knee, with their face turned to the side.

• Refer to the Attika Foundation’s booklets during the conversation;
• Refer to Attika’ Foundations images of Recovery Position and explain that it can prevent the victim from choking on their own vomit if they begin to throw-up;
• Review steps in rescue breathing.

Download the Russian version of the booklet with overdose prevention guidelines applicable for situations when Naloxone is available:

Download the Russian version of the booklet with overdose prevention guidelines applicable for situations when Naloxone is not available:

• Now, we will talk about having access to and using Naloxone for an overdose of your family member, friend or someone you have witnessed in an overdose.
• Generally, Naloxone is an available medication used by doctors and nurses in emergency care for treatment of overdose, however, it has been shown to save more lives when available to injecting drug users and those that care about them. In Kyrgyzstan, Naloxone is available at NGOs who provide harm reduction services to those who use drugs. We will provide a list of locations for you today.
• Administering Naloxone does not require specific medical skills and can be provided by anyone who witnesses the opiate overdose, thus saving a great number of lives.
• Many countries around the world are currently using Naloxone to save lives. In the U.S. starting in 1999 it has been used to reverse the effects of opiate overdose while getting emergency care. Within three years of its use in non-medically administered programs deaths from overdose were reduced by between 30-42%.
• How does Naloxone work? Naloxone blocks the sedating and respiratory depressing effects of an opiate, like heroin. Naloxone replaces opiates on receptors and then blocks them for about 30-90 minutes causing sudden withdrawal. It does not get you high and has no addictive effects. You cannot overdose on Naloxone, and it has no effect if an opiate is not present.
• Naloxone is injected into a muscle and acts within 2-8 minutes, lasting 30-90 minutes. If no response is noticed with the first dose a second can be given with 2-5 minutes. Naloxone may also be available for nasal use at some sites.
• Naloxone should not be sold and should only be used with someone who is overdosing. There is no ability to get “high” from Naloxone and it will cause an immediate withdrawal for anyone using opioids.
• If you want, we will provide you with a supply Naloxone Kit with guidelines on when and how to administer Naloxone during an overdose.

• Ask participant if she has any concerns or foresees any barriers about using Naloxone.
• If the participant wants, give her Naloxone (make sure to pack the ampoules properly to prevent them from breaking), and help her to problem solve any barriers they identify that might prevent them from using the medicine.
• Summarize information about overdose.

• We provided you a lot of information about overdose today including what to do when someone else is overdosing. As we discussed, overdose does not have to be fatal. There are steps that you can take to prevent your own overdose, so if you do drugs, remember not to do them alone and do not use alcohol before injecting drugs.
• You will be safer if you inject first because it is easier to measure how much you drink than how much you inject. Lastly, if the steps to prevent overdose have not worked, we are very hopeful that through work with our collaborators we can offer this new option in preventing the death of your partner or those you care about.
• Before we move on, let’s brainstorm together and make a list of people in your community whom you could teach how to prevent overdose. Remember, we mentioned earlier that injecting drugs alone may be harmful to you. If you can teach these skills to someone in your community, you may be able to prevent your own overdose. I would also like to remind you to think of an individual(s) with whom you feel safe when doing drugs.

Through the link below you can download the short video with overdose prevention animated guidelines designed by Sergei Bessonov, the Executive Director for the National Harm Reduction Network Association — it is in 3gp format, “weighs” less than 8MB, so you can offer the participant to save it on their mobile phones and view when needed:

If you’d like to access the expanded version of the OD-prevention video guidelines designed and presented by Sergei Bessonov and his colleagues at Attika Foundation and the National Harm Reduction Network Association, and view it with the participant, just click the icon below and then save through the “save link as” command — it’s in MP4 format, the size it about 15MB: