Developed for the Massachusetts Statewide Drug Court Enhancement

Developed for the Massachusetts Statewide Drug Court Enhancement Project - BJA Award # 2012-DC-BX-0034 Produced by Advocates for Human Potential www.ahpnet.com Recovery from Trauma, Supporting Abuse and Exposure to Violence JUNE 2014 Design and original materials by Niki Miller Senior Program Associate [email protected]

INTRODUCTION there are no sufficient literary, psychological, or historical answers to human tragedy, only moral ones. . Just as despair can come to one only from other human beings, hope, too, can be given to one only by other human beings. -Elie Wiesel Our Purpose To convey that certain difficult, inexplicable, and even dangerous behaviors drug court clients may exhibit, are often related to past trauma.

Not to excuse Not even to explain To prevent or eliminate problems, reduce stress, and increase staff and client safety by using trauma-informed approaches whenever possible. 3 If we succeed, participants will Trust their good instincts, based on what they learn about trauma-informed approaches View self-care & good supervision as essential Try out some of the techniques with clients Think about how their program can implement trauma-informed practices Use the resource guide to learn more 4

Schedule Two part training with a 20 minute break Part 1- Impact, prevalence & relationship to addiction / criminal behavior Part 2 - Effective tools and strategies; what works and why This training endorses & encourages participant self-care! 5 PART 1 : UNDERSTANDING TRAUMA AND ITS IMPACT Our brains are sculpted by our early experiences. Trauma is a chisel that shapes a brain to

contend with strife, but at the cost of deep, enduring wounds. Teicher, 2000 In this segment we will: 1. Define trauma 2. Learn about the impact of trauma 3. Recognize responses that result from past trauma 4. Review trauma-informed principles/care/approaches 7 Why learn about trauma? Job Performance

Cost savings crisis and ongoing care Less effort, more results, lower recidivism Treatment engagement, less resistance Fewer health risk behaviors; healthier clients Job Satisfaction More humane communication Fewer violent and dangerous critical incidents Healthier staff - reduced stress and burnout Increased staff and client safety. 8 Results of Implementation Observations of ways clients respond: a. Noticed a recent client knew the court was a safe place, and displayed no resistance

b. When the team has information, clients are relieved that they dont have to keep repeating their story c. Now, clients tell the team they need a respite, before behavior accelerates, so teams can diffuse the situation. d. Report noticeable improvements for women: They do well in treatment. 9 MA Drug Court Staff The most humbling part of drug court is seeing the resiliency of spirit and watching them reclaim their lives. 10

What do we mean by Trauma? A state of extreme stress brought on by conditions, or by shocking, unexpected events, that overwhelm a persons capacity to cope resulting in feelings of helplessness, terror and violation. The individuals capacity to cope is so seriously overwhelmed that they experience complete powerlessness and loss of control An event may be witnessed or experienced as a threat to survival, or an intolerable violation of self or a loved one. May be experienced or witnessed Potentially traumatic exposures Childhood

Physical/mental/sexual abuse Neglect, abandonment Parental loss /separation Single Event Natural or man-made disaster Plane/train crash Gun violence, shooting War Witnessing atrocities or killing Combat and injury Torture Interpersonal Intimate partner violence Abduction/stalking Sexual assault/rape

Physical assault Hate crimes Robbery/mugging Ongoing or lifelong Oppression/discrimination Genocide Community violence Enslavement 12 High-risk exposures resulting from addiction People with drug and alcohol addiction Homelessness Prostitution

Witnessing or experiencing overdose Car accidents/Injuries IV drug use, withdrawal, DTs, convulsions Institutional seclusion & restraint Stigma, social isolation, loss of family Having close friends that die suddenly

Imprisonment, forced institutionalization 13 How has this affected your life? When people are dealing with the ongoing effects of trauma, the present can become more painful than the past. 14 Trauma memory There is evidence that trauma is stored in the part of the brain called the limbic system, which processes

emotions and sensations, but not language or speech. For this reason, people who have been traumatized may live with implicit memories of terror, anger, and sadness generated by the trauma, but with few or no explicit memories to explain the feelings. Sidran Traumatic Stress Foundation 15 Pams Story When I was on probation, I had to go to a group for drug offenders. I really dreaded it. Didnt say a word, took off as soon as it was over, missed as many groups as I could. The counselor said I was resistant and refused to participate. I had

no idea why I hated it, until I learned about triggers. There was another woman in the group, and six or seven guys. Four of them wore leather jackets. The smell of leather was what made me want to run, and the noises it made when they moved. When I was 15, I cut school for the first time, to meet up with some guy I met at a party at my older brothers dorm. He promised me a ride on the back of his bike. We took off on his motorcycle and rode way out of town, down winding country roads that got narrower and bumpier, as tobacco fields rose up on both sides. Then, he pulled off the road , drove up on the grass, about a mile deep into a field. As soon as we slowed down, four or five bikers came out from behind a patch of trees. 16

Traumatic Events & PTSD Percentage exposed who develop PTSD Rap 49.0% Severe b... 31.9% Other sexual a... 23.7% Serious accident or ...

16.8% Shooting or st... 15.4% Child's life-threatening i... 14.3% Sudden death of a close friend or rea... Witness killing or serious ... Natural di... (Bloom, 2011)

10.4% 7.3% 3.8% 17 Drug Courts in Massachusetts A juror remembers his own childhood abuse when he is called for jury duty on a child abuse case. An inmate with poor coping skills cant tolerate sitting for hours and waiting. As soon as bail is granted, his behavior escalates. A female inmate becomes highly reactive to males and sees every man as her father. Staff observe incidents of self-harm and witness violence. A client is startled when he gets a small pat on the back from a staff member, and cant tolerate being touched. 18

Pams trauma-informed story At the initial intake with Pam, I did a standard screening for domestic violence and current safety. She had a history, so we put together a safety plan. Pam was distrustful and reluctant to say much. We do not screen for trauma at intake, but assume women need single gender groups. Pam started in a womens group that focused on safety and learning new coping skills. She did well and built up a little trust. After her 3rd group, Pam and a peer asked to talk with me. Pam was crying and had disclosed her memory of a sexual assault to a peer. I reassured her that many women in early recovery have recalled similar experiences, and let her know how deeply sorry I was that she had to go through that. I reminded her that she had tremendous strength to have endured. I let her know that she had choices now, and asked if she wanted to schedule time with me the following day to look at some options that might be helpful.

19 Trauma-informed approaches Screening and referral Screens ask about event history, current functioning or current safety Does screening result in benefit to client; who should screen and when? Partners for referral to trauma-specific services

Universal measures Applied when a group shares the same general risk Applied without prior screening when the entire group can benefit Universal measures are harmless to those without trauma, so screening is not required. Integrated

treatments Interventions that target more than one issue; trauma + substance use Some cognitivebehavioral groups help with both; sometimes benefit clients w/depression or other mental health issues as well Some also address criminal thinking 20 Trauma & Mental Health

Characteristics of events that can lead to mental health problems: Begin in childhood or adolescence, during a critical developmental period. Victimization by a trusted person; betrayal that invokes deep mistrust. Intentional, prolonged, repeated or severe; involving interpersonal violence. Involve physical violation, and are sexually invasive or assaultive. 21 The body responds to the brains signals When a threat is perceived Heart rate and respiration increase, preparing the body for a survival response. Blood flows out of the thinking centers of the

brain and into the limbs to get them ready to run. Pupils dilate for better night vision; hearing is sharpened. Pain and hunger are temporarily dulled. 22 Trauma & The Brain: Cognition and Emotion Cortex- logical thinking and decision making Hippocampus puts stimuli in context from Slower past experience

Slower than normal Sensory Thalamus Faster than normal Very Fast wider than normal Amygdala Response

Response Trigger Cortisol (LeDoux, 1996, Bassuk 2007) Adrenaline Changes in arousal, attention, perception and emotion Arousal: Extreme excitability and responsiveness or numbing and detachment Hyper Arousal Numbing Attention: Inattentive, blocking out triggers or deeply focused upon them

Dissociation Hyper-focus Perception: Vision and hearing are sharpened or thinking is clouded and dull Heightened Dulled Emotion: Feelings are devastating and painful or detached from experiences Overwhelming Absent Trauma, cognitive development and health

Impact of chronic hyper-arousal: Can affect the architecture, development, and functioning of the brain. Chronic exposure to stress hormones increases the risk of health problems. Profound impact on belief system. 25 What is Post-traumatic Stress Disorder ? An anxiety disorder people can develop after seeing or living through a terrifying event, extreme abuse, or exposure violence and other horrendous conditions Most people exposed to danger and violence do not develop PTSD; they are affected, but only temporarily. Acute Stress Disorder: after a stressful eventa serious

automobile accident, for examplefor about a month. 26 Risk factors increase the likelihood of serious problems Before During After Past abuse or victimization Few resources or supports; social isolation Seeing others hurt or killed or being injured Prolonged or repeated abuse; multiple types

Being cut off from support; stigma Added stress such as loss of job or home 27 PTSD: 3 major symptom types; plus added diagnostic criteria Avoidanc e Suppression of memories Restriction of daily activities Intrusion Flashbacks

Nightmares Re-enactment Arousal Startle reflex Irritability Hyper-vigilance Sleep disturbance Negative changes in thinking and mood Changes in arousal and

reactivity Substance use 28 Resilience factors reduce the risk of lasting harm During After Protecting others during the event Feeling good about acting despite the danger Finding a way of coping and getting through Having support from friends, family or a group Finding a way to make meaning or learn from the

experience 29 Cultural trauma, disparities & healing Disparities limit access to services and supports in the communities most impacted by violence Protective factors are also limited. African American and Latino youth are more than 7x more likely to have someone close to them murdered than their white counterparts (Finkelhor et al, 2005) 30 Adverse Childhood Experience Study Abuse and household dysfunction seen by participants (17, 421 participants)

Types of abuse (by category) Sexual (by anyone) 22% Psychological (by parents) 11% Physical (by parents) 11% Types of household dysfunction (by category) Substance abuse

26% Mental illness 19% Mother treated violently 13% Imprisoned household mother 3% 31

ACE effects on women and substances: Women with 4 or more types of childhood trauma had a 78% attributable risk for IV drug use. Women who did not experience any of these instances had a .05% attributable risk for IV drug use. Women with histories of childhood sexual abuse were 60% more likely to abuse alcohol and 70% more likely to use illegal drugs. They were also most likely to experience further abuse. 32 ACE effects-men, addiction & alcoholism More on page 26 of your resource guide A male child who experienced at least 6 types of

adverse childhood experiences was 4,600% more likely to become an IV drug user Self-acknowledged alcoholism in men and women increased 500% in relation to adverse childhood experiences. 33 ACE events data for youth referred to Massachusetts Juvenile Court Clinics Six month data collected from 10/2/12 to 3/31/13 ACE Score from 1 to 10 possible Original CDC Study Sample Median

Score: 1 MA. Juvenile Justice Sample Median Score: 5 Proportion scoring 4+ 6.2 % Proportion

scoring 4+ 63 % Source: Massachusetts Alliance of Juvenile Court Clinics data report 2013 34 Both female & male drug court clients may have trauma histories Females Top exposure: -- childhood sexual abuse PTSD after exposure more likely - 20% Males -- witness to a killing or serious assault

Exposure more likely, PTSD less likely 8% About half use substances, and are less likely to More likely to use alcohol in response to the use alcohol effects of trauma Repeated sexual/violent victimization from intimates beginning in childhood Violence from strangers/enemies; sexual coercion/abuse in outside community More likely to have complex PTSD and accompanying depression Most common additional diagnosis is depression; not as common as in women

(Miller and Najavits, 2011) Substances, trauma and court involvement Childhood violent/sexual abuse Mental health consequences Vulnerability to violence Coping, surviving, running away

Selfmedication leads to addiction 36 Trauma-Informed Principles 1. Trauma recovery encompasses multiple aspects of peoples lives, involves changing deep beliefs and gaining knowledge and skills. 2. The assumption of a trauma history guides every encounter, whether

or not the participants disclose or even remember trauma. 3. Responses are reframed as survival strategies that served a safety function and are seen as evidence of strength and resiliency. 4. Creating safety is a primary task: the safer and more predictable the environment, the better the engagement. 5. Education and information about trauma is part of treatment.

6. Power sharing is the basis of helping relationships that are founded on respect, information, connection, and hope. 37 Preliminary Goals: Do no harm Increase safety Trauma-informed approaches can decrease the risk of: 1. Staff burn-out and stress 2. Low program engagement 3. Inaccurate mental health diagnoses 4. Relapses into substance use 5. Depression and suicide risk 6. Decreased self-efficacy; learned hopelessness 38

Exercise: Self-Care Check-In Trauma-informed approaches highlight self-care and safety for clients and staff beginning with you. Working with people with trauma histories can take a toll on caregivers (secondary or vicarious trauma or compassion fatigue). It is normal to have strong feelings when people disclose histories of abuse or exposure to violence. When we listen to stories about past trauma, or encounter workplace situations that feel overwhelming, we need to find ways to counteract stress and safeguard against burn out. Support, supervision and a sense of meaning make workplace stress more tolerable, but self-care is about escape, rest and fun! 39 20 MINUTE BREAK

PART 2: IMPLEMENTING TRAUMA-INFORMED APPROACHES Is intravenous drug use properly viewed as a personal solution to problems that are well concealed by social niceties and taboo? Is drug abuse self-destructive or is it a desperate attempt at self-healing the best coping device that an individual can find? ~Vincent Feletti, MD ACE Study In this segment we will:

1. Discuss risks for people working with trauma survivors and self-care for staff & clients 2. Look at ways trauma-informed principles could be implemented in drug courts 3. Learn more about trauma recovery 42 Trauma and the impact on staff More on page 27 of your resource guide Helping professionals can go through changes as a result of empathic engagement with trauma survivors. This is sometimes called vicarious trauma because changes may parallel trauma responses: Intrusive or obsessive thoughts or difficult emotions

Feeling over-responsible; overworking Physical health problems Feelings of distrust or excessive concern for loved ones Loss of hope or a diminished sense of control over ones fate Over-identification or disconnectedness, callousness and anger are common. 43 Self-Care: Model it, live it and teach it! Take breaks or rotate job duties Make time for supervision Find meaning Support from co-workers and outside support ESCAPE! REST! FUN!

For an excellent free online course on preventing secondary trauma from the Headington Institute visit: http://www.headington-institute.org/ 44 Resources: For help with vicarious trauma Contact your Employee Assistance Program or ask your family doctor. Others who can help: Family services, social agencies, or clergy Peer support groups

Health maintenance organizations Community mental health centers Social workers, counselors 45 Self-Care Exercise Sample Self-Care Plan: If I become exhausted, emotional, numb or angry: I can talk to __________ about my feelings. I can take a break. I can stretch or exercise or go for a walk. I can eat something nutritious. I can eat something not so nutritious (chocolate!) I can think of some of the successful clients I have helped. I can take a nap or lie down. I can watch something funny or entertaining.

I can play with my pet or my children. I can shoot baskets or play another sport. 46 Establishing Safety: The key to progress Survivors may experience intense fear even when there is no threat to their safety or become numb or frozen in the face of clear and present danger. The perception of threat and danger even when none exists makes defensive responses likely. It is important to address client safety if defensive actions seem imminent, whenever possible. 47

When small adjustments = big gains Texting reminders of appointment has helped clients when memory has been affected. Judges have opted to address inappropriate behavior in a sidebar with the attorney instead of publically sanctioning a client with PTSD. A judge stepped down from the bench to preside, upon realizing veterans were agitated when they had to face the front with their backs to the door. This allowed them have one side toward the exit when they spoke with the judge. A client with mental health issues and problems with authority wanted someone to listen to him when he was in lockup. The court officer knew it would go better if he sent in a non-uniformed staff. 48

Trauma and criminal behavior Emotional numbing can predispose survivors to thrill-seeking behavior, disregard for their own safety, difficulty empathizing with others, and can support criminal thinking. Lets hear an explanation from a veteran from About Face, online conversations about trauma and recovery from the VA National Center on PTSD. 49 Trauma Stabilization Trauma stabilization tools Grounding Selfsoothing

Self-care Strength-based 50 Trauma Stabilization: Grounding Grounding directs attention to the here-and-now and uses the senses as an anchor to the present I could feel myself starting to get crazy. I could feel a scream coming up my chest and into my throat. My fists were clenched. I began grounding. I counted the trees outside that lined the street. Then I counted how many colors were on each tree. Eventually, I wasnt so pissed off. I realized my anger was way too big for such a small thing. 51

Trauma Stabilization: Self-Soothing Self-soothing prepares and teaches comforting and calming procedures before a triggered response: I made the list to share in group of things that make me feel good: my daughter; my dog; riding my motorcycle; fishing; shopping for fishing rods and tackle and eating outside. The best thing for staff to do when I am agitated is to remind me how much I love my kid and about what we did the last time she visited. 52 Trauma Stabilization: Self-Care Self-care is learning to self-monitor emotional states, to evaluate choices and actions, and

actively pursue emotional, mental, and physical healing. I decided that I am not going to watch movies that have violence or rape scenes. I was watching Law and Order Special Victims Unit every week. I noticed I couldnt sleep on those nights, and I felt depressed. I like the show, but right now I am not going to watch it. 53 Trauma Stabilization: Strength-Based Strength-based approaches build self-efficacy by pointing out success, reinforcing the ability to change and to assert control over thinking and behavior. I never thought I could control myself when someone got in

my face like that. But, youre right, I did it for years around my stepfather. Even when I was 8 or 9 years old, I wanted to kill him every time he hit my mom. But, I had to control myself, and I guess the practice I got is helping now that Im sober. 54 Eliminating or reducing triggers Work with each client to answer the following questions: What kinds of reminders are difficult to deal with? What helps you calm down when you are triggered? What are the things staff can do to help when you are reacting to a trigger? 55 PEACE: An approach to avoidable triggers

Predict and prepare: When we go to court, your husband will be in the room. Tell me what steps would make you feel safest in court... What would you like to do to take care of yourself afterward? Enlist: What has helped you in the past not to drink when you had to deal with your mother yelling at your kids? 56 Acknowledge: Many people have difficulty sleeping in early recovery. I can understand why it makes you anxious. I probably would not be able to sleep easily either, if I were dealing with a lot of changes. Choice and control: We ask each person to provide a

urine sample. Would you like to go take care of it now, or would you rather come and get me when you are ready? Explain: We have to put everyone through the metal detector, even attorneys. We can make sure no weapons are in the building. It makes everyone safer. (Miller, 2010) 57 Sanctions and Rewards Research on sanctions tells us incentives are more effective at shaping behavior. BJA recommends incentives/rewards outnumber sanctions. Components of effective sanctions: certainty; speed; graduated progressively more intense; and drug court clients understand the result of each violation or achievement. But, some sanctions can remind survivors of past punitive abuse, and

this can derail their effectiveness. Rewards and sanctions, developed with trauma in mind Observe how clients respond to sanctions Increase the role of incentives. 58 RICH: Respect and Information This model states these elements form the basis for all trauma-informed communication: Respect: This may be a very different response than expected. It can be challenging to convey respect consistently. Clients may view staff and authority through the lens of past abuse from neglectful mothers and abusive fathers. Information: Let clients know what is going to happen and why. Provide education on the relationship between trauma

and substance use and how others have successfully overcome the effects of trauma. 59 RICH: Connection and Hope Connection: With the here-and-now and connections with people, as well as internal connections; between the mind, body and spirit, between actions and values. Safe connections with others re-write the patterns of abuse within relationships and ground survivors in today. Hope: Remind clients that they have many strengths, have survived many things. Recount their recent successes, small victories and strengths. The successes of others in recovery helps sustain hope for staff and clients alike. 60

Giving voice to survivors The more proactive we become by asking what helps and what makes things worse in times of crises, the greater opportunity we have to align with clients in their healing. - Laura Prescott (Prescott et al, in press) 61 Judith Hermans Stages of Recovery Stages of Trauma Recovery Establishing Safety Remembrance & Mourning Reconnection Safety means.

The survivor no longer feels completely vulnerable Has some confidence in the ability to protect her/himself Knows how to control his or her most disturbing reactions Knows whom to rely on for support 62 Types of trauma treatment Past Present Past - focused approaches primarily deal with the trauma memory Present - focused approaches deal

with current functioning 63 Trauma & Relationships Trauma affects the way individuals react, their relationships, and their belief system, whether or not they have a trauma-related mental health diagnosis. Often trauma or abuse happens in the context of a relationship. Healing also happens through relationships. Fairness Consistency Respect Empathy Responsibility Honesty

Predictability 64 Trauma & Recovery: Reasons to hope Trauma survivors in addiction recovery find their way back to varying degrees of health through: Practicing self-regulating and self-healing Using the strengths and skills many already possess

Trying different treatment approaches at various points throughout the course of their recovery Through alternative and expressive therapies, or cultural, altruistic and spiritual pathways Drug court teams can offer information on effective treatment and examples of others who are making it. All good reasons for hope. 65

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