Trauma-Informed Care in Mental Health Courts Wednesday, March 30, 2016 New York, NY
Š 2016 Council of State Governments JusDce Center
Presenters Alyssa Benedict, MPH
The NaDonal Resource Center on JusDce Involved Women
Hon. Marcia Hirsch
Presiding Judge, Queens Treatment Courts
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Overview Mental Health Courts: The Essen@al Role of TraumaInformed Care Managing a Trauma-Informed Court Room Ques@ons and Answers
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Mental Health Courts: The Essen@al Role of Trauma-Informed Care 5
SeEng the Context
• Growth in the number of offenders with mental illness • Persons with mental illness over-represented in criminal jusDce populaDons • Support for programming and services targeDng offenders with mental illness • The criDcal role of mental health courts 6
Jus@ce and Mental Health • Balancing tradiDonal objecDves with innovaDve responses • The mental health court model – looking back and looking forward • The SequenDal Intercept Model and traumainformed care 7
Enhancing MH Court Processes and Outcomes: The Essen@al Role of Trauma-informed Care • Trauma as a universal experience among people who are jusDceinvolved. (NCTIC) • TraumaDc experiences connected to mental health and substance abuse challenges. • Survivors are not likely to seek treatment for trauma-related symptoms. (Schreiber, Renneberg, & Maercker, 2009)
• Survivor’s experiences in the criminal jusDce system can deepen traumaDc wounds and create new traumas. (SAMHSA) 8
Moving from Understanding to Collabora@on & Implementa@on
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Some Barriers… • Trauma can get “lost in the weeds” • Over-specializaDon • Lack of integraDon • Stakeholders may not share the same awareness of trauma and its impacts • OperaDonalizaDon is hard!
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MH Coordinators: Managing the Interface of Criminal Jus@ce and Mental Health • • • • • • • •
Raising awareness about the impact of trauma and the importance of trauma-informed approaches among key players (judges, POs, providers, PDs) Awareness of local, trauma-based services and supports for clients/offenders CollaboraDng with other agencies to facilitate client/offender access to trauma-informed care Addressing trauma as part of court-based assessment FacilitaDng client/offender access to trauma-based services/treatment FacilitaDng client/offender access to advocacy (e.g., regarding vicDm rights, protecDve orders) ImplemenDng trauma-informed pracDces in the courtroom (i.e., as part of court processes) Managing the complexiDes of co-occurring issues/ disorders 11
The Neurobiology & Ecology of Trauma Neurobiology
Ecology • Trauma responses and recovery occur in a relaDonalsocial contexts • InteracDons with partners, family & friends, community, insDtuDons & systems and society MATTER. • PotenDal for healing and growth biggest in the context of relaDonships 12
The Principles of Trauma-informed Care (Harris & Fallot, 2006) • • • • •
Safety Trust Choice CollaboraDon Empowerment
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Bringing Stakeholders Together to Address Trauma Important Ques@ons • • • • • • •
*What is trauma and its impact? *What are the principles of traumainformed care? What is the mission of this court? Goals? Where and how does trauma-informed care fit? How can we improve our respec;ve and collec;ve prac;ces? How can we iden;fy challenges? Successes? What is our plan for self-reflec;on, quality assurance and ongoing improvement and innova;on?
Forums ü Dedicated meeDng(s) ü Summits ü Brown bag lunches ü Conferences ü Workshops
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The Team
15 Judge Dee Anna Farnell and the Pinellas County Drug Court
Key Elements Safety – Trust – Choice Collabora@on – Empowerment
• • • • • • • •
The team as the foundaDon Who and how Shared philosophy Honoring roles and perspecDves Clear team process Managing complexity Frequent check-ins Self-care* 16
Self Care – The Three R’s (Benedict, King, & Van Dieten, 2014)
• What is happenoing with me right now? • NoDce somaDc (body) experinces, feelings, thoughts • Acknowledge
Recognize
Regulate • What can help me feel more anchored? • Breathe • Orient • Ground • Create Calm
• How can I respond effec8vely? • CulDvate non-judgment • Proceed with purpose
Respond
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The Courtroom
18 Judge Dee Anna Farnell and the Pinellas County Drug Court
Key Elements Safety – Trust – Choice Collabora@on – Empowerment • The courtroom as an extension of the treatment space - selng the condiDons • The team brings its philosophy into the courtroom • AdapDng to what arises • Everyone in the room counts • Physical & emoDonal safety are essenDal • Trauma-informed communicaDon and procedures
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Crea@ng Regula@on and Resilience (Benedict, King & Van Dieten, 2014)
Regula@on Ò
Ò Ò
Tolerate difficult thoughts, feelings, and sensations Connect with self and others Engage in effective action.
Resilience Ò
Ò
Ò Ò
Access and utilize our skills and strengths Cope with day-to-day stresses and burdens Explore solutions to problems Set and achieve goals
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Examples • Increasing regula@on and resilience
– Reduce crowding through dedicated days – Selng a tone
• Visual space
– Bringing life into the courtroom – Offering hope and celebraDng success
• Rela@onal space
– Who is present – Where keys persons sit
• Communica@on
– Nonverbal messages – Trauma-informed language and micro skills • Empathy, reflecDve listening, affirmaDons
– Balancing support and accountability
21 Judge Dee Anna Farnell and the Pinellas County Drug Court
The Treatment • • • • • • • • •
Safety – Trust – Choice Collabora@on – Empowerment Philosophy Facility/Space Management and OperaDons Staffing and Training Culture Offender/Client Management Assessment and ClassificaDon Programs, treatment Case and TransiDonal Planning
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“This court saved my life. My rape was underneath everything I was doing. I was in chains. Those chains are broken now. I am free. I can breathe again.” -Client “I never realized how this work was affec;ng me. Being trauma-informed is not just about the [clients]. It’s about us too. We all have experienced some kind of trauma. This approach helps all of us. I’m beRer at my job and I’m beRer at life.” -CorrecDons Professional 23
Managing a TraumaInformed Courtroom 24
Managing a Trauma-Informed Courtroom Hon. Marcia Hirsch, Presiding Judge, Queens Treatment Courts Research Provided by; Dr. Pamela Linden, Assistant Professor, Stony Brook University and Dr. Shelly Cohen, Stony Brook Research & Evalua;on Consul;ng
Trauma Project Collaborators • Treatment Court Teams – Court staff from five felony treatment courts in Queens (QTC, QDWI, QMHC, QVTC, QDDC) – Queens District Aqorney’s Office – Defense Bar (Legal Aid, QLA, Private Aqorneys) – Queens TASC – NYS Departments of ProbaDon and EducaDon & US Department of Veterans Affairs
*Special Thanks to Policy Research Associates 26
Trauma Project Collaborators • Treatment Agencies – Samaritan Village, Inc – Counseling Services of the Eastern District of New York – Elmcor Youth and Adult AcDviDes
• Program Evaluators – Stony Brook Research & EvaluaDon ConsulDng, LLC
*Special Thanks to Policy Research Associates 27
Queens Trauma Project (QTP) • Funded by grant from the Center for Substance Abuse Treatment (CSAT) for three years – from October 1, 2010 through September 30, 2013
• Goals of QTP – Provide enhanced screening and assessment of all parDcipants in the five felony treatment courts in Queens County, NY (approximately 200/year) 28
Queens Trauma Project (QTP) • Goals of QTP (cont.) – Provide trauma specific treatment services to parDcipants that are idenDfied as potenDally benefilng from these services (approximately 40/year) – Conduct evaluaDon of fidelity of implementaDon of program acDviDes and success of acDviDes in achieving intended outcomes 29
Trauma-Informed Care • WHY? • WHO? • WHAT?
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Why Do We Learn About Trauma? • • • • • •
Develop understanding Increase awareness Recognize signs Learn how to respond Improve courtroom interacDons Create successful outcomes
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Goal: Trauma-Informed Responses • • • •
Increase safety Reduce recidivism Promote recovery Acknowledge the presence and impact of trauma
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Goal: Trauma-Informed Responses • Be aware of possible “triggers”—smells, sounds, or sensaDons—that provoke memories of past traumaDc experiences • Responses may be more effecDve if they: – Are specific to the individual’s gender – Integrate trauma-specific treatment with mental health and substance abuse treatments – UDlize group environments to build trust and enhance healing 33
Trauma-Informed Judicial Prac@ces • Trauma-informed judicial interacDons begin with dignity and respect • EffecDve communicaDon is essenDal and takes into account the percepDon of the trauma survivor • Express concern and give posiDve feedback, rather than use negaDve or puniDve language • The courtroom environment can be inDmidaDng – make sure that parDcipant is not retraumaDzed
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Trauma@c Events • • • • •
Physical abuse Loss Combat or vicDm of war Community trauma Sexual abuse
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Trauma@c Events • • • • • •
DomesDc violence Witness violence or other traumaDc event Historical trauma Terrorism Natural disaster Betrayal of trust by a person or insDtuDon 36
Trauma Is… • A psychological response to: – Events that are physically or emoDonally harmful – Experiences that have negaDve long-term effects on an individual’s physical and mental well-being
• Causes feelings of constant powerlessness, fear, hopelessness, and a state of alert
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Trauma Is… • • • •
Impact is pervasive It shapes the world view of the parDcipant Individualized experiences Many people cope or heal while others get stuck
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Impact of Trauma • Short-term effects of trauma can include substance abuse, interpersonal violence, gambling, and other risky behavior • Long-term effects can include arrest, incarceraDon, and recidivism • High ACE (Adverse Childhood Experiences) scores are associated with depression, suicide aqempts, hallucinaDons, and various diseases (i.e. liver disease, heart disease, autoimmune disease, etc.) 39
Childhood Trauma • TraumaDc experiences during childhood affect behavior during adulthood in two ways: – Increase likelihood of smoking, drinking excessively, overeaDng, self-injury, and engaging in risky sex—behaviors known as coping mechanisms – Adversely affect brain development, hindering its ability to respond to stress
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Process of Trauma
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Trauma Instruments Adverse Childhood Experiences (ACE) N=270 • 74% reported score of 0-2 • 13 % reported score of 3-4 • 13% reported score of 5 or more
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Trauma Instruments Trauma Symptom Checklist-40 (TSC-40) N=249 • 63% reported score of 0-30 • 20% reported score of 16-30 • 18% reported score of 31-97
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Trauma Instruments PTSD Checklist - Civilian Version (PCL-C) N=50 • 32% reported score of 17-22 (no clinical concern) • 28% reported score of 23-31 (symptoms of some clinical concern) • 40% reported score of 32-57 (likely presence of PTSD) 44
Trauma Instruments Trauma History Screen (THS) • Not formally scored, but used to gather more details about traumaDc events 45
Trauma in Veterans (N=36) Adverse Childhood Experiences (n=25) – 36% ACE score of 5 or more items endorsed – 20% ACE score of 3-4 items endorsed – 44% ACE score of 0-2 items endorsed
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Trauma in Veterans (N=36) Current Trauma Symptoms – 100% indicate likely presence of PTSD on PCL-C (n=5) – 50% score 31+ on TSC-40 (n=24)
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Program Status and Trauma
Adverse Childhood Experiences (ACE) 25% 20%
21% 17% 17%
15% 10% 5% 0%
11% 3% 0 % graduate % fail Low ACE Moderate High
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Phase Advancement and Trauma (Median Number of Days)
Adverse Childhood Experiences (ACE) 140 135 130 125 120 115 110
136 129
129 122 122
Phase 1 Low ACE
121
Phase 2 Moderate High
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Types of Reported Trauma (n = 39) • Loss of close family member through death (16) or separaDon (2) • Military Combat experience (3) • Sexual abuse as a child or adult (5) • Auto accident (4) • Work accident with injury (1) • Witness family violence (4) • Natural Disaster/Hurricane (1) • Witness stranger’s death (1) • Assault (2)
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Treatment Interven@ons Three (3) Trauma Case Managers hired in three Queens County treatment agencies and trained in three trauma treatment group models: • Trauma, AddicDons, Mental Health and Recovery (TAMAR) • Seeking Safety • Helping Men Recover
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TAMAR • The TAMAR Program is designed to educate and treat those who have a history of physical and/or sexual abuse and a recent treatment history for a mental health condiDon as well as an alcohol or drug use or abuse disorder. • Structured, manualized 15-week intervenDon combining psycho-educaDonal approaches with expressive therapies 52
Seeking Safety • Offers coping skills to help clients aqain greater safety in their lives • Highly flexible and can be used for group or individual format; women, men, and adolescents; all levels of care (e.g., outpaDent, inpaDent, residenDal); all types of trauma and substances; and any clinician.
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Seeking Safety • 25 treatment topics, each represenDng a safe coping skill relevant to both PTSD and SUD. • Used broadly with clients who need improved coping skills; they do not have to meet criteria for PTSD and substance abuse as the skills can be generalized.
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Helping Men Recover • Helping Men Recover integrates a theory of addicDon, a theory of trauma, and a theory of male psychosocial development. • Program materials consist of a facilitator manual and a parDcipant workbook
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Helping Men Recover •  18 sessions in four modules: Module A: Self Module B: RelaDonships Module C: Sexuality Module D: Spirituality
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Par@cipant Feedback “Trauma services saved my life.” “I am very grateful for this experience. Though it has been difficult at ;mes, I know it will beRer my life and my future.”
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Par@cipant Feedback “I was lost before and all this experience helped me improve my life and emo;onal issues that has led me to the wrong paths.” “I recommend it to those who really need it and would benefit from it. I enjoyed it.”
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Recovery • A process of change through which individuals improve their health and wellness, live a selfdirected life and strive to reach their full potenDal. • Depends on the empowerment of the individual and the creaDon of healthy relaDonships
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Resilience • Recovering from trauma requires resiliency • The 10 Factors of Resiliency: 1. OpDmism - maintaining a posiDve altude while being aware of the challenges you face 2. Flexibility 3. Core value system - staying true to strong personal morals and beliefs
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Resilience • The 10 Factors of Resiliency (cont.):
4. Faith - both dependent and independent of religion 5. PosiDve role models 6. Social support - a safety net for support and communicaDon
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Resilience • The 10 Factors of Resiliency (cont.):
7. Physical fitness 8. CogniDve strength 9. Facing fears- fear is normal and can be used as a guide in overcoming life’s challenges 10. Finding meaning in struggles
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Ques@ons? Please contact: • Hon. Marcia Hirsch, Presiding Judge – mhirsch@nycourts.gov
• Dr. Shelly Cohen, Program Evaluator, Stony Brook Research & EvaluaDon ConsulDng, LLC – scohen@notes.cc.sunysb.edu
• Dr. Pamela Linden, EvaluaDon Consultant , Stony Brook Research & EvaluaDon ConsulDng, LLC – Pamela.Linden@stonybrook.edu
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References 1.
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AdministraDon for Children and Families. (2009). Understanding the effects of maltreatment on brain development. Retrieved from hqps://www.childwelfare.gov/ pubPDFs/brain_development.pdf Dennis Charney, Steven Southwick, Resilience: The Science of Mastering Life’s Greatest Challenges (New York: Cambridge University Press, 2012) What Every Judge Needs to Know About Trauma. Essen;al Components of TraumaInformed Judicial Prac;ce, SAMHSA, 1-9. Retrieved from hqp://gainscenter.samhsa.gov/ cms-assets/documents/128389-391390.essenDalDjudges.pdf Covington, S. S. (2008). Women and addicDon: A trauma-informed approach. Journal of psychoac;ve drugs, 5, 377-385.
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Ques@ons?
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Presenter Contact InformaDon Alyssa Benedict, MPH ExecuDve Director, CORE Associates Federal partner, NaDonal Research Center on JusDce Involved Women coreassociatesllc@comcast.net 401-837-CORE Hon. Marcia Hirsch, Presiding Judge, Queens Treatment Courts mhirsch@nycourts.gov
http://cjinvolvedwomen.org/ 66
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The presentation was developed by members of the Council of State Governments Justice Center staff. The statements made reflect the views of the authors, and should not be considered the official position of the Justice Center, the members of the Council of State Governments, or the funding agency supporting the work. Citations available for statistics presented in preceding slides available on CSG Justice Center web site. 67