Trauma-Informed Care in Mental Health Courts

Wednesday,March30,2016NewYork,NY

©2016CouncilofStateGovernmentsJusDceCenter

Presenters

Hon.MarciaHirschPresidingJudge,QueensTreatmentCourts

AlyssaBenedict,MPHTheNaDonalResourceCenteronJusDceInvolvedWomen

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ManagingaTrauma-InformedCourtRoom

Overview

Ques@onsandAnswers

MentalHealthCourts:TheEssen@alRoleofTrauma-InformedCare

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MentalHealthCourts:TheEssen@alRoleofTrauma-InformedCare

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SeEngtheContext

•  Growthinthenumberofoffenderswithmentalillness•  Personswithmentalillnessover-representedincriminal

jusDcepopulaDons•  SupportforprogrammingandservicestargeDngoffenders

withmentalillness•  ThecriDcalroleofmentalhealthcourts

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Jus@ceandMentalHealth

•  BalancingtradiDonalobjecDveswithinnovaDveresponses

•  Thementalhealthcourtmodel–lookingbackandlookingforward

•  TheSequenDalInterceptModelandtrauma-informedcare

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EnhancingMHCourtProcessesandOutcomes:TheEssen@alRoleofTrauma-informedCare

•  TraumaasauniversalexperienceamongpeoplewhoarejusDce-involved.(NCTIC)

•  TraumaDcexperiencesconnectedtomentalhealthandsubstanceabusechallenges.

•  Survivorsarenotlikelytoseektreatmentfortrauma-relatedsymptoms.(Schreiber,Renneberg,&Maercker,2009)

•  Survivor’sexperiencesinthecriminaljusDcesystemcandeepentraumaDcwoundsandcreatenewtraumas.(SAMHSA)

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MovingfromUnderstandingtoCollabora@on&Implementa@on

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SomeBarriers…

•  Traumacanget“lostintheweeds”

•  Over-specializaDon•  LackofintegraDon•  Stakeholdersmaynotsharethesameawarenessoftraumaanditsimpacts

•  OperaDonalizaDonishard!

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MHCoordinators:ManagingtheInterfaceofCriminalJus@ceandMentalHealth

•  Raisingawarenessabouttheimpactoftraumaandtheimportanceoftrauma-informedapproachesamongkeyplayers(judges,POs,providers,PDs)

•  Awarenessoflocal,trauma-basedservicesandsupportsforclients/offenders

•  CollaboraDngwithotheragenciestofacilitateclient/offenderaccesstotrauma-informedcare

•  Addressingtraumaaspartofcourt-basedassessment

•  FacilitaDngclient/offenderaccesstotrauma-basedservices/treatment

•  FacilitaDngclient/offenderaccesstoadvocacy(e.g.,regardingvicDmrights,protecDveorders)

•  ImplemenDngtrauma-informedpracDcesinthecourtroom(i.e.,aspartofcourtprocesses)

•  ManagingthecomplexiDesofco-occurringissues/disorders

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TheNeurobiology&EcologyofTrauma

Neurobiology Ecology•  Traumaresponsesand

recoveryoccurinarelaDonal-socialcontexts

•  InteracDonswithpartners,family&friends,community,insDtuDons&systemsandsocietyMATTER.

•  PotenDalforhealingandgrowthbiggestinthecontextofrelaDonships

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ThePrinciples

ofTrauma-informedCare(Harris&Fallot,2006)

•  Safety•  Trust•  Choice•  CollaboraDon•  Empowerment

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BringingStakeholdersTogethertoAddressTrauma

ImportantQues@ons

•  *Whatistraumaanditsimpact?•  *Whataretheprinciplesoftrauma-

informedcare?•  Whatisthemissionofthiscourt?Goals?•  Whereandhowdoestrauma-informed

carefit?•  Howcanweimproveourrespec;veand

collec;veprac;ces?•  Howcanweiden;fychallenges?

Successes?•  Whatisourplanforself-reflec;on,

qualityassuranceandongoingimprovementandinnova;on?

Forums

ü  DedicatedmeeDng(s)ü  Summitsü  Brownbaglunchesü  Conferencesü Workshops

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TheTeam

Judge Dee Anna Farnell and the Pinellas County Drug Court 15

KeyElementsSafety–Trust–Choice

Collabora@on–Empowerment

•  TheteamasthefoundaDon•  Whoandhow•  Sharedphilosophy•  HonoringrolesandperspecDves•  Clearteamprocess•  Managingcomplexity•  Frequentcheck-ins•  Self-care*

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SelfCare–TheThreeR’s(Benedict,King,&VanDieten,2014)

• Whatishappenoingwithmerightnow?• NoDcesomaDc(body)experinces,feelings,thoughts

• Acknowledge

Recognize

• Whatcanhelpmefeelmoreanchored?• Breathe• Orient• Ground• CreateCalm

Regulate • HowcanIrespondeffec8vely?• CulDvatenon-judgment• Proceedwithpurpose

Respond

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TheCourtroom

Judge Dee Anna Farnell and the Pinellas County Drug Court 18

KeyElementsSafety–Trust–Choice

Collabora@on–Empowerment

•  Thecourtroomasanextensionofthetreatmentspace-selngthecondiDons

•  Theteambringsitsphilosophyintothecourtroom•  AdapDngtowhatarises•  Everyoneintheroomcounts•  Physical&emoDonalsafetyare

essenDal•  Trauma-informedcommunicaDonand

procedures 19

Crea@ngRegula@onandResilience(Benedict,King&VanDieten,2014)

Regula@onÒ  Tolerate difficult thoughts,

feelings, and sensations Ò  Connect with self and others Ò  Engage in effective action.

ResilienceÒ  Access and utilize our skills and

strengths Ò  Cope with day-to-day stresses

and burdens Ò  Explore solutions to problems Ò  Set and achieve goals

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Examples•  Increasingregula@onandresilience

–  Reducecrowdingthroughdedicateddays–  Selngatone

•  Visualspace–  Bringinglifeintothecourtroom–  OfferinghopeandcelebraDngsuccess

•  Rela@onalspace–  Whoispresent–  Wherekeyspersonssit

•  Communica@on–  Nonverbalmessages–  Trauma-informedlanguageandmicroskills

•  Empathy,reflecDvelistening,affirmaDons–  Balancingsupportandaccountability

Judge Dee Anna Farnell and the Pinellas County Drug Court 21

TheTreatmentSafety–Trust–Choice

Collabora@on–Empowerment•  Philosophy•  Facility/Space•  ManagementandOperaDons•  StaffingandTraining•  Culture•  Offender/ClientManagement•  AssessmentandClassificaDon•  Programs,treatment•  CaseandTransiDonalPlanning

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“Thiscourtsavedmylife.Myrapewasunderneath

everythingIwasdoing.Iwasinchains.Thosechainsarebrokennow.Iamfree.Icanbreatheagain.”

-Client

“Ineverrealizedhowthisworkwasaffec;ngme.Beingtrauma-informedisnotjustaboutthe[clients].It’saboutustoo.Weallhaveexperiencedsomekindoftrauma.

Thisapproachhelpsallofus.I’mbeReratmyjobandI’mbeReratlife.”

-CorrecDonsProfessional

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ManagingaTrauma-InformedCourtroom

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ManagingaTrauma-InformedCourtroom

Hon.MarciaHirsch,PresidingJudge,QueensTreatmentCourts

ResearchProvidedby;Dr.PamelaLinden,AssistantProfessor,StonyBrookUniversityand

Dr.ShellyCohen,StonyBrookResearch&Evalua;onConsul;ng

TraumaProjectCollaborators•  TreatmentCourtTeams

– CourtstafffromfivefelonytreatmentcourtsinQueens(QTC,QDWI,QMHC,QVTC,QDDC)

– QueensDistrictAqorney’sOffice– DefenseBar(LegalAid,QLA,PrivateAqorneys)– QueensTASC– NYSDepartmentsofProbaDonandEducaDon&USDepartmentofVeteransAffairs

*SpecialThankstoPolicyResearchAssociates

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TraumaProjectCollaborators•  TreatmentAgencies

– SamaritanVillage,Inc– CounselingServicesoftheEasternDistrictofNewYork

– ElmcorYouthandAdultAcDviDes

•  ProgramEvaluators– StonyBrookResearch&EvaluaDonConsulDng,LLC

*SpecialThankstoPolicyResearchAssociates

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QueensTraumaProject(QTP)•  FundedbygrantfromtheCenterforSubstanceAbuseTreatment(CSAT)forthreeyears–  fromOctober1,2010throughSeptember30,2013

•  GoalsofQTP– ProvideenhancedscreeningandassessmentofallparDcipantsinthefivefelonytreatmentcourtsinQueensCounty,NY(approximately200/year)

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QueensTraumaProject(QTP)•  GoalsofQTP(cont.)

– ProvidetraumaspecifictreatmentservicestoparDcipantsthatareidenDfiedaspotenDallybenefilngfromtheseservices(approximately40/year)

– ConductevaluaDonoffidelityofimplementaDonofprogramacDviDesandsuccessofacDviDesinachievingintendedoutcomes

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Trauma-InformedCare

•  WHY?•  WHO?

•  WHAT?

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WhyDoWeLearnAboutTrauma?

•  Developunderstanding•  Increaseawareness•  Recognizesigns•  Learnhowtorespond•  ImprovecourtroominteracDons•  Createsuccessfuloutcomes

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Goal:Trauma-InformedResponses

•  Increasesafety•  Reducerecidivism•  Promoterecovery•  Acknowledgethepresenceandimpactoftrauma

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Goal:Trauma-InformedResponses

•  Beawareofpossible“triggers”—smells,sounds,orsensaDons—thatprovokememoriesofpasttraumaDcexperiences

•  ResponsesmaybemoreeffecDveifthey:– Arespecifictotheindividual’sgender–  Integratetrauma-specifictreatmentwithmentalhealthandsubstanceabusetreatments

– UDlizegroupenvironmentstobuildtrustandenhancehealing

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Trauma-InformedJudicialPrac@ces•  Trauma-informedjudicialinteracDonsbeginwithdignityandrespect

•  EffecDvecommunicaDonisessenDalandtakesintoaccountthepercepDonofthetraumasurvivor

•  ExpressconcernandgiveposiDvefeedback,ratherthanusenegaDveorpuniDvelanguage

•  ThecourtroomenvironmentcanbeinDmidaDng–makesurethatparDcipantisnotre-traumaDzed

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Trauma@cEvents

•  Physicalabuse•  Loss•  CombatorvicDmofwar•  Communitytrauma•  Sexualabuse

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Trauma@cEvents

•  DomesDcviolence•  WitnessviolenceorothertraumaDcevent•  Historicaltrauma•  Terrorism•  Naturaldisaster•  BetrayaloftrustbyapersonorinsDtuDon

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TraumaIs…

•  Apsychologicalresponseto:– EventsthatarephysicallyoremoDonallyharmful– ExperiencesthathavenegaDvelong-termeffectsonanindividual’sphysicalandmentalwell-being

•  Causesfeelingsofconstantpowerlessness,fear,hopelessness,andastateofalert

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TraumaIs…

•  Impactispervasive•  ItshapestheworldviewoftheparDcipant•  Individualizedexperiences•  Manypeoplecopeorhealwhileothersgetstuck

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ImpactofTrauma

•  Short-termeffectsoftraumacanincludesubstanceabuse,interpersonalviolence,gambling,andotherriskybehavior

•  Long-termeffectscanincludearrest,incarceraDon,andrecidivism

•  HighACE(AdverseChildhoodExperiences)scoresareassociatedwithdepression,suicideaqempts,hallucinaDons,andvariousdiseases(i.e.liverdisease,heartdisease,autoimmunedisease,etc.)

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ChildhoodTrauma

•  TraumaDcexperiencesduringchildhoodaffectbehaviorduringadulthoodintwoways:–  Increaselikelihoodofsmoking,drinkingexcessively,overeaDng,self-injury,andengaginginriskysex—behaviorsknownascopingmechanisms

– Adverselyaffectbraindevelopment,hinderingitsabilitytorespondtostress

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ProcessofTrauma

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TraumaInstruments

AdverseChildhoodExperiences(ACE)N=270

•  74%reportedscoreof0-2•  13%reportedscoreof3-4•  13%reportedscoreof5ormore

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TraumaInstruments

TraumaSymptomChecklist-40(TSC-40)N=249

•  63%reportedscoreof0-30•  20%reportedscoreof16-30•  18%reportedscoreof31-97

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TraumaInstruments

PTSDChecklist-CivilianVersion(PCL-C)N=50

•  32%reportedscoreof17-22(noclinicalconcern)

•  28%reportedscoreof23-31(symptomsofsomeclinicalconcern)

•  40%reportedscoreof32-57(likelypresenceofPTSD)

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TraumaInstruments

TraumaHistoryScreen(THS)• Notformallyscored,butusedtogathermoredetailsabouttraumaDcevents

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AdverseChildhoodExperiences(n=25)– 36%ACEscoreof5ormoreitemsendorsed– 20%ACEscoreof3-4itemsendorsed– 44%ACEscoreof0-2itemsendorsed

TraumainVeterans(N=36)

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TraumainVeterans(N=36)

CurrentTraumaSymptoms–  100%indicatelikelypresenceofPTSDonPCL-C(n=5)

–  50%score31+onTSC-40(n=24)

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ProgramStatusandTraumaAdverseChildhoodExperiences(ACE)

0%

5%

10%

15%

20%

25%

%graduate %fail

21%

3%

17%

0

17%

11%

LowACE Moderate High 48

PhaseAdvancementandTrauma(MedianNumberofDays)

AdverseChildhoodExperiences(ACE)

110115120125130135140

Phase1 Phase2

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122

136

122

129

121

LowACE Moderate High 49

TypesofReportedTrauma(n=39)

•  Lossofclosefamilymemberthroughdeath(16)orseparaDon(2)

•  MilitaryCombatexperience(3)•  Sexualabuseasachildoradult(5)•  Autoaccident(4)•  Workaccidentwithinjury(1)•  Witnessfamilyviolence(4)•  NaturalDisaster/Hurricane(1)•  Witnessstranger’sdeath(1)•  Assault(2) 50

TreatmentInterven@ons

Three(3)TraumaCaseManagershiredinthreeQueensCountytreatmentagenciesandtrainedinthreetraumatreatmentgroupmodels:•  Trauma,AddicDons,MentalHealthandRecovery(TAMAR)

•  SeekingSafety•  HelpingMenRecover

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TAMAR

•  TheTAMARProgramisdesignedtoeducateandtreatthosewhohaveahistoryofphysicaland/orsexualabuseandarecenttreatmenthistoryforamentalhealthcondiDonaswellasanalcoholordruguseorabusedisorder.

•  Structured,manualized15-weekintervenDoncombiningpsycho-educaDonalapproacheswithexpressivetherapies

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SeekingSafety

•  Offerscopingskillstohelpclientsaqaingreatersafetyintheirlives

•  Highlyflexibleandcanbeusedforgrouporindividualformat;women,men,andadolescents;alllevelsofcare(e.g.,outpaDent,inpaDent,residenDal);alltypesoftraumaandsubstances;andanyclinician.

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SeekingSafety

•  25treatmenttopics,eachrepresenDngasafecopingskillrelevanttobothPTSDandSUD.

•  Usedbroadlywithclientswhoneedimprovedcopingskills;theydonothavetomeetcriteriaforPTSDandsubstanceabuseastheskillscanbegeneralized.

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HelpingMenRecover

•  HelpingMenRecoverintegratesatheoryofaddicDon,atheoryoftrauma,andatheoryofmalepsychosocialdevelopment.

•  ProgrammaterialsconsistofafacilitatormanualandaparDcipantworkbook

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HelpingMenRecover

•  18sessionsinfourmodules: ModuleA:Self ModuleB:RelaDonships ModuleC:Sexuality ModuleD:Spirituality

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Par@cipantFeedback

“Traumaservicessavedmylife.”“Iamverygratefulforthisexperience.Thoughithasbeendifficultat;mes,IknowitwillbeRermylifeandmyfuture.”

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Par@cipantFeedback“Iwaslostbeforeandallthisexperiencehelpedmeimprovemylifeandemo;onalissuesthathasledmetothewrongpaths.”“Irecommendittothosewhoreallyneeditandwouldbenefitfromit.Ienjoyedit.”

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Recovery

•  Aprocessofchangethroughwhichindividualsimprovetheirhealthandwellness,liveaself-directedlifeandstrivetoreachtheirfullpotenDal.

•  DependsontheempowermentoftheindividualandthecreaDonofhealthyrelaDonships

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Resilience

•  Recoveringfromtraumarequiresresiliency•  The10FactorsofResiliency:

1.  OpDmism-maintainingaposiDvealtudewhilebeingawareofthechallengesyouface

2.  Flexibility3.  Corevaluesystem-stayingtruetostrong

personalmoralsandbeliefs

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Resilience

•  The10FactorsofResiliency(cont.):4.  Faith-bothdependentand

independentofreligion5. PosiDverolemodels6. Socialsupport-asafetynetforsupportandcommunicaDon

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Resilience

•  The10FactorsofResiliency(cont.):7.  Physicalfitness8.  CogniDvestrength9.  Facingfears-fearisnormalandcan

beusedasaguideinovercominglife’schallenges

10.  Findingmeaninginstruggles

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Ques@ons?Pleasecontact:

•  Hon.MarciaHirsch,PresidingJudge– mhirsch@nycourts.gov

•  Dr.ShellyCohen,ProgramEvaluator,StonyBrookResearch&EvaluaDonConsulDng,LLC

–  scohen@notes.cc.sunysb.edu

•  Dr.PamelaLinden,EvaluaDonConsultant,StonyBrookResearch&EvaluaDonConsulDng,LLC

–  Pamela.Linden@stonybrook.edu 63

References1.  AdministraDonforChildrenandFamilies.(2009).Understandingtheeffectsof

maltreatmentonbraindevelopment.Retrievedfromhqps://www.childwelfare.gov/pubPDFs/brain_development.pdf

2.  DennisCharney,StevenSouthwick,Resilience:TheScienceofMasteringLife’sGreatestChallenges(NewYork:CambridgeUniversityPress,2012)

3.  WhatEveryJudgeNeedstoKnowAboutTrauma.Essen;alComponentsofTrauma-InformedJudicialPrac;ce,SAMHSA,1-9.Retrievedfromhqp://gainscenter.samhsa.gov/cms-assets/documents/128389-391390.essenDalDjudges.pdf

4.  Covington,S.S.(2008).WomenandaddicDon:Atrauma-informedapproach.Journalofpsychoac;vedrugs,5,377-385.

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Ques@ons?

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PresenterContactInformaDon

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Hon.MarciaHirsch,PresidingJudge,QueensTreatmentCourtsmhirsch@nycourts.gov

AlyssaBenedict,MPHExecuDveDirector,COREAssociatesFederalpartner,NaDonalResearchCenteronJusDceInvolvedWomencoreassociatesllc@comcast.net401-837-CORE

http://cjinvolvedwomen.org/

Thank You

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.

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FormoreinformaDon,contactSarahWurzburgswurzburg@csg.orgorvisitthewebsite:hqps://csgjusDcecenter.org/courts/

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