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

2. 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

3. 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.

4. 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

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

6. 15 Minute Break

7. TRAUMA

8. 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.

9. 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.

10. 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

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

12. 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

13. 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)

14. 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.

15. 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.

16. The History of TAMAR

17. 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

18. 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

19. 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

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

21. 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

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

23. 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

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

25. 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

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

27. 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.

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

29. 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"

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

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

47. 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

48. TAMAR Today

49. Treatment Population

50. 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, Over 800 inmates were referred with 743 assessed 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

51. 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

52. Lunch Time
Please Return in 1 Hour

53. Broken Child

54. Please return in 15 Minutes
Break Time
Please return in 15 Minutes

55. “What Every Caregiver Should Know About Compassion Fatigue”55

56. 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.

57. 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

58. Consequences of Counter-transference
Compassion Fatigue
Burnout
Vicarious Traumatization 58

59. 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

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

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

62. 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

63. 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

64. 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

65. Energy Domains
Intellectual
Physical
Emotional
Spiritual
Sexual 65

66. 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

67. What causes it?
Exposure
Empathy 67

68. Compassion Fatigue Process
Figley, C.R., 2001

69. 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

70. 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

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

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

73. 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

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

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

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

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

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

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

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

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

82. Compassion Fatigue
Prevention 82

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

84. 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

85. 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

86. 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.

87. Compassion Fatigue
Management 87

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

89. Compassion Fatigue
Consequences 89

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

91. 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

92. Workplace Prevention Program
Compassion Fatigue
Workplace Prevention Program 92

93. 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.

94. 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

95. Wrap-Up
Questions

96. Thank You Darren McGregor 410-724-3170 mcgregord@dhmh.state.md.us
David Washington
Alisha Saulsbury