Maryland’s T.A.M.A.R Project Trauma, Addictions, Mental Health, and Recovery

Presenters Darren J. McGregor, MS, MHS, LCMFT Director, Jail-based Mental Health Programs State of Maryland, Department of Health and Mental Hygiene David A Washington, LGSW, LCADC, AD/PC Supervisor, Program Coordinator, Washington County Health Department Alisha Saulsbury, LCSW-C, Trauma Specialist, Dorchester County Detention Center

Hypothesis Repeated and prolonged traumatic experiences, often occurring in childhood, may negatively impact mental health and result in maladaptive, risky behaviors resulting in incarceration. This sequence is likely to repeat unless treatment specific to the needs of the person with the trauma history are met and detention center staff are knowledgeable about the effects of trauma. We believe that unless traumatic experiences are addressed and the survivor honored and respected, the individual will seek maladaptive behaviors to cope with the psychological, emotional and often physical damages by engaging in risky behaviors: masking feelings through substance use, engaging in burglary and/or prostitution to support a drug habit eventually become involved in the criminal justice system.

Learning Objectives To understand the benefits of trauma specific care from the consumers’ perspective To know Maryland’s long term commitment to trauma care and the development and implementation of the T.A.M.A.R. model. To be introduced to trauma treatment through a discussion of the 15 treatment modules presented in the T.A.M.A.R. project. Review the connection between trauma and criminal activity and the need for jail-based mental health care Obtain knowledge on provider self care and managing compassion fatigue See the connection between trauma, criminal activity, and jail Accept the benefits that a trauma informed staff will bring Be introduced the TAMAR model Value the importance of continuing treatment from jail to the community Appreciate the onerous task of measuring what works

What needs to happen to turn a life around? Panel Discussion What needs to happen to turn a life around?

15 Minute Break

TRAUMA

Trauma Impact Loop We hope this model will better illustrate our hypothesis. Of course we will come across some resilient individuals who will work through trauma, find trustworthy people, and lead productive lives, but for many unless we intervene on their behalf they will be stuck in their traumatic experiences.

What is Trauma? Definition (NASMHPD, 2006) The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters DSM IV-TR (APA, 2000) Person’s response involves intense fear, horror and helplessness Extreme stress that overwhelms the person’s capacity to cope Just so that we are on the same page, lets look at a couple of definitions on trauma: The National Association of Mental Health Program Directors who work hand in hand with the National Center for Trauma Informed Care define trauma as the (read slide) The DSM IV adds that trauma involves intense fear, horror, and helplessness so much that it overwhelms the person’s capacity to cope. In trauma informed care systems, we want to integrate these principles into all our clinical interventions. We want to include the survivor’s perspective. That’s so important as we move from our controlling environments, to collaborative supported environments. We recognize that coercive interventions are contraindicated for people who have been abused. It is re-traumatizing and recapitulates victimization.

What does trauma do? Trauma shapes a child’s basic beliefs about identity, world view, and spirituality. Negative beliefs and views require adaptations Symptoms are ADAPTATIONS Using a trauma framework, the effects of trauma can be addressed and a person can go on to lead a “productive” life. (Saakvitne, Gamble, Pearlman & Lev, 2000) Read slide

Consequences of Trauma Faulty control methods: Over-control Self-blame Passivity Addictive behavior Self-harm Impaired attachments: Warmth by friction Interpersonal skill deficits

Prevalence of Trauma Mental Health Population – United States 90% of public mental health clients in have been exposed to trauma (Mueser et al., in press, Mueser et al., 1998) 51-98% of public mental health clients in have been exposed to trauma (Goodman et al., 1997, Mueser et al., 1998) Most have multiple experiences of trauma (Mueser et al., in press, Mueser et al., 1998) 97% of homeless women with SMI have experienced severe physical & sexual abuse – 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997) Rosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to trauma Goodman, in a separate study, found that 51-98% were exposed. Meusar and Felitti identified that most have had multiple experiences of various types of traumatic stress Homeless women are particularly vulnerable to rape

Prevalence of Trauma Substance Abuse Population – U.S. Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000) Study of male veterans in SA inpatient unit 77% exposed to severe childhood trauma 58% history of lifetime PTSD (Triffleman et al., 1995) 50% of women in SA treatment have history of rape or incest (Governor's Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006)

What do the data tell us? The majority of adults and children in psychiatric treatment settings have trauma histories A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories (Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998) Traumatic exposure is epidemic among adults and children in the mental health system. Many clinicians in the US see PTSD as the only trauma-related diagnosis. Increasingly, we are appreciating that a range of other disorders can be directly related to trauma exposure or individuals might suffer from such co-occurring such as substance abuse, affective illness, personality disorders and psychotic disorders.

Trauma, Addiction, Mental Health and Recovery TAMAR The Trauma, Addiction, Mental Health, and Recovery program or TAMAR is another program offered through the Office of Special Needs Populations.

The History of TAMAR

TAMAR PROGRAM SAMHSA Women and Violence Site Maryland only site addressing the needs of incarcerated women Began in 3 local detention centers Currently serving 10 sites in Maryland Piloting in 2 Ohio detention centers Provides mental health, substance abuse, and trauma treatment for men & women in detention centers and State psychiatric hospitals 17

Tamar’s Story In the Old Testament, Tamar was a daughter of King David. Tamar’s half brother Amnon raped her. The author of II Samuel writes that afterwards she tore her clothes and retreated into her brother’s house. She is not mentioned in the Bible again. 18

Preparing for Implementation Trauma training for community agencies Trauma training for Correctional Officers and staff Correctional Cross-training for TAMAR clinical staff Symptoms and behaviors are adaptations 19

The RICH Model Respect Information Connection Hope (Saakvitne, et al, 2000) 20

R.I.C.H. Be an ally Safety and respect Boundaries work with survivors Use connection to help people manage their feelings and memories 21

TAMAR Program Components Administered by Master’s level, licensed mental health clinician Individual sessions Group sessions Linkage to case management and aftercare 22

How is TAMAR accessed? Screening administered at facility intake Trauma Specialist does in-depth assessment on those that screen “positive” for trauma Program is explained and offered to eligible individuals 23

Trauma Assessment Tools Trauma Symptom Inventory (TSI) by Briere Dissociative Experiences Scale (DES) by Carlson and Putnam Stressful Life Experiences Screening by Stamm 24

More Tools Traumatic Antecedents Questionnaire (TAQ) by van der Kolk Structured Interview for Disorders of Extreme Stress (SIDES) by van der Kolk Modified PTSD Symptom Scale by van der Kolk 25

More Tools – Child Specific Dissociative Features Profile (DFP) by Silberg Trauma Symptom Checklist for Children (TSCC) by Briere 26

TAMAR TAMAR is a 15 week program that delivers 30 trauma related topics or exercises to individuals 18 years of age and older who are detained in one of the participating detention centers. Modules incorporate psychodynamic therapy with expressive art therapy and psycho-educational techniques Eligibility requirements include having a history trauma and/or a history for a mental health condition and/or an alcohol or drug use or abuse disorders.

TAMAR Groups Meet twice a week for 90 minute sessions Groups of 12-15 individuals Voluntary, no good time or credit earned for participation 28

TAMAR Treatment Manual Module 1 – What is Trauma Module 2 - "What is abuse?" and "What is Emotional Abuse?" Module 3 - "What is abuse (sexual)/Female Sexuality" Module 4 - "Trauma and Addiction" Module 5 - "HIV/AIDS Education and Condom Skills" Module 6 - "Communication and Negotiation Skills“ Module 7 - "Containment- The Concept of Self-Regulation" Module 8 - "Grounding" and "Imagery" Module 9 - "Distress Tolerating Skills" and "Distress Tolerance Module 10 – Self-Soothing Module 11 - "Boundaries and Safety" Module 12 - “Trust and Intimacy" Module 13 - Parenting Module 14 - Life Story Module 15 - “Closing Ritual"

TAMAR: Module 1 (example) Session I Coming Together (Responsibility) WHAT IS TRAUMA? Meeting A Who cares, why bother, and what's in it for me? Materials Managing Traumatic Stress Through Art page xv Goal - each member will be able to demonstrate an understanding of the meaning of psychological trauma. Goal - each person will say at least one sentence about herself in the group. Meeting B Poetry therapy Creative re-structuring in trauma treatment Goal - members will complete exercise in group. Goal - members will take away one idea about how to keep safe.

Module 1 What is Trauma? Who Cares, Why Bother, What’s in it for Me? Recognition of traumatic reactions makes management of survivors’ much easier A little bit of trauma awareness goes a long way Ongoing trauma treatment across a continuum of care is a major contributing factor to reducing recidivism in this population 31

Module 2 What is Abuse? Physical and Emotional Goal is to recognize behaviors/actions that constitute physical and emotional abuse Recognize the impact of physical and emotional abuse on their lives 32

Module 3 What is Abuse? Sexual Abuse Goal is to recognize how sexual abuse has impacted their lives. Recognize self-defeating thoughts and behaviors and begin to develop their right to a healthy self-concept 33

Module 4 Trauma and Addiction Goal is to recognize addictive/compulsive behaviors as coping mechanisms Make the connection between addictive/compulsive behaviors and their trauma 34

Module 5 Facts on HIV/AIDS Goal is to provide facts about HIV/AIDS as well as discuss myths and misconceptions Demonstration of behavior skills to reduce the risk of HIV/AIDS transmission This module may be triggering to many women and needs to be presented in a trauma context (i.e. presentation of overt sexual materials introduced with permission to feel and voice upset) 35

Module 6 Sexual Communication and Negotiation Skills Discuss what constitutes sexual communication (both verbal and non-verbal) Provides an opportunity to role-play negotiation skills (includes sexual assertiveness, safe sex, and refusal of unsafe sex) 36

Module 7 Containment Why containment instead of disclosure? Goal is to help members describe levels of consciousness and understand the different parts of memory. Increases self-awareness 37

Module 8 Containment II - Grounding Goal is to identify different grounding techniques. Members will be able to practice grounding techniques daily, outside of group 38

Module 9 Tolerating Distress Each member will begin to distinguish the negative aspects of being unable to tolerate distress Each member will be able to recognize and verbalize benefits to learning how to tolerate distress 39

Module 10 Self-Soothing Members will identify existing methods of self-comfort Each member will begin to distinguish healthy ways of coping from harmful/damaging ways 40

Module 11 Boundaries and Safety Members begin to develop a sense of how much or how little control they have over what happens to their bodies Begin to understand how to set interpersonal limits. Boundary exercises (physical, verbal) 41

Module 12 Trust and Intimacy Members will be able to identify at least 1 barrier which inhibits their ability to trust other people Members will be able to identify intimacy and see how it is separate from sex 42

Module 13 Parenting Discuss how trauma, substance abuse, and mental health issues have affected their parenting choices and ability to parent How trauma affects attachment 43

Module 14 Life Story Group members are given the opportunity to share their life story with the group Members will understand how trauma has impacted their entire life 44

Module 15 Closing Ritual Members experience healthy closure Members will learn to delineate leavings and their importance to the group Helps members internalize messages from the group experience 45

While trauma may affect a person for the rest of his/her life, there are some criteria to assess recovery. Source: Harvey, 1996 46

Recovery Criteria Physical symptoms of PTSD are within manageable limits Person is able to bear feelings associated with traumatic memories. Memories don’t limit what he/she chooses to do Memory of trauma is linked with feeling Damaged self-esteem is restored Important relationships have been reestablished Person has reconstructed a system of meaning & belief that encompasses the story of the trauma 47

TAMAR Today

Treatment Population

TAMAR FY ‘08 Outcomes Total County 3 5 1 11 6 13 161 103 83 97 80 27 Female Male Classification Correctional Officer Family Friends Medical Other Staff Self Other Eligible Treated Anne Arundel 174 3 5 1 11 6 131 13 161 Baltimore 103 83 97 Mid Shore Region 80 27 37 72 70 Frederick 75 9 55 68 63 142 20 7 2 4 12 123 118 Garrett 31 8 15 30 Prince George’s 113 106 99 Washington 71 34 52 18 17 16 87 719 115 93 26 54 40 558 50 743 Gender Referral Source Male Table 1 illustrates utilization statistics for Maryland for Fiscal Year, 2008. Over 800 inmates were referred with 743 assessed. 719 participated at least once in the trauma focused group or individual settings. Self-referrals numbering 558 exceeded all other referrals with 93 referrals from corrections a distant second. The disparity between self-referral and classification can be traced to inmate failure to report original referral source to the program and providers not probing further. Accuracy in referral source allows us to better understand jail staff’s sensitivity to mental illness. Female

Breaking the Cycle RECOVERY rOAD tO New Life TRAUMA INFORMED _______________ Re-triggered TRAUMA INFORMED TREATED Depression Anxiety Jail Time rOAD tO New Life Arrested And Sentenced Substance Abuse And Dependence RECOVERY Illegal Activity To Maintain

Lunch Time Please Return in 1 Hour

Broken Child

Please return in 15 Minutes Break Time Please return in 15 Minutes

“What Every Caregiver Should Know About Compassion Fatigue” 55

Learning Objectives Develop a personalized self-care plan to prevent compassion fatigue. Identify sign and symptoms of traumatic stress. Understanding of counter-transference. Identify actions and behaviors that violate healthy boundaries.

Psychological First Aid When caring is more like labor, than a labor of love, take steps to heal the healer. American Academy Family Physicians, April 2000 57

Consequences of Counter-transference Compassion Fatigue Burnout Vicarious Traumatization 58

Counter transference A condition where the therapist/counselor, as a result of the therapy sessions, begins to transfer the therapist's own unconscious feelings to the patient. 59

Compassion Stress Enduring negative psychological consequence of caregivers exposure to the traumatic experience of victims in their care. Schauben and Frazier, 1995 60

Compassion Fatigue Is the emotional exhaustion that comes from “living” an individuals stresses, struggles, and fears day in and day out. 61

Burnout Depletion of physical and intellectual energy. Happens when overworked, stressed, and involved in demanding situations over a long period of time. May feel tired, rundown, overwhelmed, and irritable. Reduced sense of personal accomplishment and discouragement as an employee/volunteer. Burnout is the depletion of physical and intellectual energy that happens when you are overworked, stressed, and involved in demanding situations over a long period of time. As result you feel tired, rundown, overwhelmed, and irritable. Burnout also has been associated with a reduced sense of personal accomplishment and with discouragement as an employee. Burnout can happen concurrently with the emotional, spiritual, and sexual energy depletion indicative of compassion fatigue. This occurs in mental health workers who have unmanageably large caseloads, for instance. Individuals also may experience burnout in other professions, such as technical or business fields; however, they generally do no have their emotional and spiritual energy challenged or used up. Although these individuals may become tired, drained, and unmotivated, they are not inclined to begin wondering if people are basically good or evil, or if their world is safe, both of which may happen to those repeatedly exposed to violence. 62

Vicarious Traumatization Can emerge suddenly. Can happen as a result of hearing clients talk about their trauma’s. VT happens when you are actually traumatized during your job; for example, you have a traumatic reaction upon hearing a survivor’s account of the individuals assault that is particularly painful to you. 63

Compassion Fatigue vs. Burnout Personal Stress related compassion demands Internal factors Holistic (mental, emotional, physical, behavioral, etc. Burnout Organizational Stress related time demands External factors Holistic (physical, emotional, behavioral, etc. 64

Energy Domains Intellectual Physical Emotional Spiritual Sexual 65

Untreated Compassion Fatigue Decreases one’s ability to be empathetic and compassionate which can contribute to a cycle of self-destruction, escape and decreased sense of /for humanity. 66

What causes it? Exposure Empathy 67

Compassion Fatigue Process Figley, C.R., 2001

Why Are Caregivers Vulnerable Compassion, empathy and idealism Counter transference issues (Over identify with an individual, therefore you are unable to separate ourselves out from the individual) Rescue fantasies Unresolved trauma Lack of self-care 69

Who is at risk? ER Personnel Rape Crisis Workers Hospice Volunteers Child Protective Workers Domestic Violence Advocates Mental Health Professionals Fire Fighters, EMTs Police/Corrections Staff Disaster Relief Workers 70

Recognizing Signs and Symptoms “The Eater of Sin” Recognizing Signs and Symptoms 71

What are the signs? Physiological Emotional Cognitive Behavioral Spiritual Interpersonal 72

Examples of Compassion Fatigue Cognitive Emotional Behavioral Spiritual Personal Relationship Physical Somatic Work Performance lowered concentration powerless impatient question the meaning of life withdrawal shock low morale less self-esteem guilt withdrawn loss of purpose decreased interest in intimacy & sex sweating low motivation apathy anger/rage moody decrease self-appraisal mistrust rapid breathing task avoidance rigidity survivor guilt regression pervasive hopelessness isolation from others increased heart rate obsession about details disorientation shutdown numbness sleep disturbance anger at god overprotective as parent/spouse breathing difficult dichotomous thinking perfectionism fear nightmares question religious beliefs projective anger or blame joint and muscle aches preoccupation with trauma helplessness appetite changes loss of faith in higher power intolerance dizziness and disorientation negativity Figley, C.R., 1995;97 73

Physiological Reactions Increased Arousal Agitation Sleep Disturbances Headaches Stomach Aches Impaired Immune System 74

Emotional Reactions Irritability Uncontrolled Emotions Anxiety or Fear Anger, Rage, Hostility Detachment Shutting Down Boredom Feeling incompetent 75

Cognitive Reactions Diminished concentration Confusion Intrusive Traumatic Imagery Self Doubt Preoccupation with others’ trauma Perfectionist thinking 76

Behavioral Reactions Impatience with Others Sleep Disturbances Nightmares Startle Response Hypervigilance Use of Negative Coping Losing Things 77

Spiritual Reactions Loss of Purpose Sense of Meaninglessness Anger at God Questioning Prior Spiritual Beliefs Pervasive Hopelessness 78

How Do Caregivers Cope? Intellectualize Deny Minimize Over Identify Get Depressed Get Anxious Use Drugs and Alcohol 79

Prevention, Management and Treatment Compassion Fatigue Prevention, Management and Treatment 80

Management and Treatment Three tiers Prevention Self Care Management Coping Treatment Healing 81

Compassion Fatigue Prevention 82

Self Care It is unethical not to practice self care as a caregiver, because self care prevents harming those we serve. 83

Preventing Compassion Fatigue Have a recognition and awareness of the symptoms Restore a healthy balance in your life Adequate sleep Adequate nutrition Exercise Get medical treatment for those symptoms that are interfering with your daily functioning Balance work and your life outside of work. Utilize your positive supportive connections with others to process your feelings. Implement regular mini-escape in your life, like recreation, therapies or other healthy diversions from the intensity of your work. Do not self medicate with drugs or alcohol, or other self-defeating addictions 84

Develop Your Own Self-Care Plan Spend plenty of quiet time alone. Recharge your batteries daily. Hold one focused, connected and meaningful conversation each day. 85

Strategies of Self-Care Commit to replenishing yourself The alternative is to continue doing advocacy at an impaired level or leave the field Be aware of how well you are eating, sleeping, exercising, socializing, enjoying life, spending time with family, and participating in the hobbies and activities you love.

Compassion Fatigue Management 87

Coping Techniques Physical Exercise: walking, stretching, aerobics Minimize ‘bad nutrition” Emotional Support Share feeling/stories Spiritual Nature Readings: professional and personal 88

Compassion Fatigue Consequences 89

Consequences of Untreated Causes people to leave their jobs Fall into the throws of addictions Self-Destructive behaviors Suicide 90

Costs of Compassion Fatigue It becomes increasingly difficult to attend to survivors with empathy, hope, and compassion. It can result in caregivers changing roles from caregiver to victim. Caregivers often work in a culture in which it is largely unacceptable to talk about feeling exhausted, overwhelmed, or not connecting with clients. Pay attention to how you are affected by your work, and prioritize your own self-care. 91

Workplace Prevention Program Compassion Fatigue Workplace Prevention Program 92

Meet With a Supervisor Items to discuss: Difficult, new, or unusual cases. Cases involving vicarious trauma. Cases with boundary issues. Cases in which you are meeting with the victim more than once a week, or for a total of 12 sessions.

Workplace Prevention Program Proper screening for the work assignment. Orientation of the emotional cost. Educate about self care, wellness, compassion, fatigue. Proper self monitoring. Regular emotional debriefings, self-monitoring, and orientation to wellness and spiritual renewal. If you notice a colleague in distress, reach out to them. 94

Wrap-Up Questions

Thank You Darren McGregor 410-724-3170 mcgregord@dhmh.state.md.us David Washington 240-313-2159 davidwashington@dhmh.state.md.us Alisha Saulsbury 410-228-8102 tamars@bcctv.net