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Question: who should know about treatment courts? Answer: everyone, right? While everyone should know about the work and benefits of treatment courts, how we communicate with specific audiences – which we call stakeholders – must be tailored to their role, location, and function. This means that a message to a legislator inviting them to a drug court graduation would be different than a press release announcing the treatment court graduation to the media. The logistical information may be the same but the “so what?” varies across stakeholder groups. According to Ulmer, Sellnow and Seeger (2019), “To communicate more effectively, organizations must determine the types of communication relationships or partnerships they currently have with primary stakeholders.” How do you identify your relationships and partnerships? We can help with that. The NDCRC will be releasing “Marketing your Treatment Courts” in May for Treatment Court Month to help you tell the story of the work of treatment courts.
 

• How many hours of sleep do you get each night (on average)? What time do you go to bed and wake up?
• Where do you sleep?
• Do you have trouble falling asleep? Do you have trouble waking up?
• On a scale of 1-5 (1=not at all rested to 5=very rested), how rested do you feel when you wake up?

• Pittsburgh Sleep Quality Index
• Epworth Sleepiness Scale
• Consensus Sleep Diary

• Ask about the environment and other protective factors: “I know you’ve been having sleep problems. Can we help you talk to your family/roommates about that so they can support you? How can we support you in getting safer/more stable housing?”
• Urge treatment for mental health challenges: “I hope you are getting help for problems like stress and depression and trauma – that can also help with sleep. And vice versa. Can we help you get the treatment you need?”
• Help them use cognitive reminders to assist with everyday tasks that may be negatively impacted by lack of sleep: “It’s easy to forget what you’re doing if you haven’t had good sleep. Let’s review how a planner or calendar can help you stay organized? You can set reminders on your phone. I can help show you how to use one…”
• Encourage them to decrease nicotine and alcohol use: “You wouldn’t think so, but tobacco, e-cigarettes, and alcohol can really mess with sleep. Is that something you want to think about or change?”
• Ask about how they engage in physical activity: “I know how hard it is to get good sleep too. Walking during lunch has really helped. What sorts of physical activity do you engage in? When could you incorporate physical activity into your weekly schedule?”
• Ask if clients are using any mindfulness apps or working on relaxation in therapy. “So, mindfulness and breathing differently really help some people relax and fall asleep. Have you talked about that with your counselor?”
• Free, evidence-based apps such as iBreathe may be helpful.
• Help clients develop a structured daily schedule that includes sleep. It will vary depending on employment (e.g., 3^rd shift will be different from 2^nd shift); parenting or other caregiving, etc.
• Ask about how they can make their sleeping space and bedtime routine more supportive of sleep: “Can you control the lighting or noise level where you sleep? Can you put away your phone a half hour before bedtime?”
• Offer cognitive behavior therapy for insomnia (CBT-i) as part of your menu of evidence-based treatment. Some of the above activities above are covered in more depth in CBT-i.
• The U.S. Department of Veteran’s Affairs (VA) has developed CBT-i Coach, a free app that supplements healthcare treatment but can be used on its own https://mobile.va.gov/app/cbt-i-coach

• Identify at least one medical doctor in your area with whom your team can refer individuals in need of routine medical exams, assessments for specific conditions, etc.
• Identify at least one pharmacist in your area with whom you can consult regarding medication interactions and general questions regarding medications.
• Build a relationship with a medical and/or pharmacy school in your area. Medical/pharmacy students could observe your treatment court planning and court sessions, as well as provide consultation.

This is the fifth in our Beyond the Field series of articles that explore trauma and its impact on treatment court work. Treatment court participants can face challenges including complex health problems, poverty, discrimination, substance use, trauma, just to name a few. As a result, poor sleep may not rise to the top of the list of issues to address with individuals. Yet sleep disturbances underlie many of the physical, cognitive, and emotional struggles that can derail recovery. Over 80% of people who have been diagnosed with post-traumatic stress disorder (PTSD) also have a sleep disorder, and adding substance use to the mix compounds sleep problems exponentially (Vandrey et al. 2014). Recognizing and targeting sleep problems as one dimension of treatment could not only improve health and well-being but may be key to helping people more fully engage in treatment court activities.
 

What are sleep disorders?
 

Sleep is essential to our ability to regulate our mood, make wise decisions, avoid accidents, encode and retrieve memories, and learn new things. Treatment court clients are expected to do all these tasks, and not doing so impedes their progress to graduation and blocks long-term recovery. Not all difficulties with sleep meet criteria for a sleep disorder, but sleep disorders affect people with PTSD at much higher rates than the general population. The most common sleep disorder is insomnia, which includes problems with falling asleep, staying asleep, and returning to sleep after waking. Other sleep disorders that commonly occur with trauma are nightmares and obstructive sleep apnea (Coloven et al., 2018).
 

How are sleep, trauma, and substance use related?
 

The relationship between substance use and sleep problems is fairly well studied, and treatment court practitioners and providers should be aware of the importance of addressing sleep problems within the process of recovery. Use of stimulants, alcohol, opiates (e.g., too much sleep and insomnia rebound), and marijuana withdrawal all can cause or exacerbate sleep disturbance. The self-medication hypothesis is well supported as well, as people who struggle with sleep may turn to substances to help. Much more research is needed to determine best treatment practices, and the Substance Abuse and Mental Health Services Administration has published a useful resource to learn more (SAMHSA, 2014; https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4859.pdf)
 

The impact of trauma on sleep is powerful. Re-experiencing traumatic events often occurs in the form of nightmares, and people become hypervigilant, or intensely on guard against future dangers. Depending on the nature of the trauma, people may have come to associate nighttime, darkness, and sleepiness with extreme vulnerability. We are never more defenseless than when asleep, and people who have experienced trauma form negative expectations and cognitions related to the inevitability of future harms.
 

There is growing evidence that PTSD, substance use disorders, and sleep disorders are bi-directionally linked (Vandrey et al. 2014).
 

For example, disordered sleep can make people more susceptible to trauma (e.g. accidents) and more likely to use substances to help them sleep; people with PTSD have symptoms that directly interfere with sleep (e.g. nightmares), and may misuse substances to get relief from both; and people who use or are withdrawing from substances find their sleep is disturbed and can experience heightened PTSD symptoms. Substance use offers quick relief from their distress, but then withdrawal from the same substances leads to sleep disturbance. These are just a sample of the dynamic relationships among these factors, but more research is needed to understand the interplay among them and find effective treatments to address all three factors in concert.
 

Assessing sleep problems
 

Whether an individual reports “trouble sleeping” or has a diagnosable sleep disorder, it is important for providers to assess sleep disturbances. While parasomnias (e.g., sleepwalking) and obstructive sleep disordered breathing may require specialists and technologies (e.g., polysomnography) to diagnose, there are validated self-report measures of insomnia that can identify triggers in order to promote use of coping skills direct sleep interventions (see Colvonen, et al. 2018). Sleep diaries are another tool that asks the individual to track their own sleep, recording bedtimes, wake times, sleep latency, night awakenings and total amount of sleep. The data collected can inform not only diagnoses but provide a road map for developing treatment plans. As sleep disturbances do not occur in a vacuum, it is essential also assess trauma symptoms and substance use at the same time.
 

Treatment of sleep disorders as they co-occur with trauma and substance use
 

Research shows that treatment of trauma does not necessarily lead to improved sleep, and the same is true for treatment of substance use. Identifying and addressing sleep problems early in treatment may provide several benefits for people with trauma. Since disordered sleep is widely accepted as a common problem, providers may focus on sleep as a “foot in the door” to express empathy for their distress and begin the winding therapeutic pathway forward toward.
 

Pharmacological interventions can be effective in treating sleep disorders, however there is a risk of misuse that should be considered. Obstructive sleep apnea, narcolepsy, parasomnias, and restless leg syndrome need to be addressed by specialists and generally are not relieved by talk therapies alone. Non-pharmacological therapeutic interventions, at least for insomnia, have been found to be more effective than medications in people with PTSD and substance use disorders (SAMHSA 2014; Colvonen et al., 2018; Vandrey et al., 2014).
 

Cognitive behavioral therapy for insomnia (CBT-I), is a brief (6-8 sessions) approach comprised of well-supported behavioral interventions like restricting sleep, stimulus control, such as structuring the environment to be more conducive to quality sleep. It also integrates cognitive therapies that target negative thoughts about sleep and other dysfunctional beliefs that interfere with sleep. The approach is heavily researched and is endorsed by the Department of Veteran’s Affairs (VA) and the American College of Physicians as a first line of treatment for insomnia-even as it co-occurs with PTSD. The manualized intervention can be administered with individuals or groups, and there are mobile technologies such as apps that supplement in-person treatment (e.g., the VA’s CBT-i Coach). Imagery Rehearsal Therapy, or IRT has shown promise in the treatment of nightmares in PTSD. A cognitive therapy, IRT involves “re-writing” of recurrent nightmares to make them less distressing and repeatedly imagining and rehearsing the new scenarios to make them less potent (Colvonen et al., 2018).
 

What Treatment Courts Can Do
 

• Assure that the whole team is educated about the complex relationship among mental health, substance use disorders and sleep.
• Ask participants about sleep troubles and have empathy for some of their cognitive and emotional struggles in this context.
• Locate and contract with providers who are trained to assess sleep disorders and who can offer non-pharmacological, cognitive, and behavioral treatments. Although online programs and self-help books have been shown to help, the complexity of co-occurring disorders and treatment court clients are at high risk, high need symptoms.
• Don’t expect sleep to get better just because mental health symptoms and/or substance use improves. Consider offering treatment for sleep, especially insomnia, separately but as an integrated part of treatment for other mental health and/or substance use disorders. If all treatments are not integrated, there is a real risk of playing a winless game of “Whack-a-Mole.”
• At minimum, offer participants sleep hygiene information as part of their health and self-care and recovery services. While this information may not fully address many of the complexities of the trauma-substance use-sleep disorder cycle, sleep hygiene skills overlap and reinforce other skills participants are already learning in treatment, including mindfulness, relaxation training, exercise, and changing self-talk to be more accurate and self-compassionate.

Improving sleep in treatment court participants can potentially impact the cognitive, emotional and physical impairments that interfere with recovery. Participants could engage more fully in treatments for PTSD and other mental health struggles, as well as substance use interventions, improving the chances of successful recovery.
 

• Trauma therapies are too harsh ”they could relapse and they won’t graduate.
• Better to treat the substance use first, THEN address the trauma.
• Whatever trauma-focused therapy is available, that will be good enough.
• It is expensive (for providers) to learn trauma-focused therapies, and they are too complicated.

• The Trauma History Screen (THS)
• Life Stressor-Checklist (LSC-R)
• Life Events Checklist for DSM-V (LEC-5)

• Posttraumatic Symptom Scale (PSS-I) (request from author)
• Posttraumatic Diagnostic Scale (PDS) (request from author, can serve as both a screen and diagnostic assessment)
• Clinician Assisted PTSD Scale for DSM-5 (CAPS-5) (online request form, child version available)

 
• Give participants written AND verbal information about what to expect during a UDS each time a screen is required
• Have signage available in the restroom such as where to place the sample, when it is OK to flush and wash hands. Do not rush.
• Close off restroom when in use and be sure it is clean and free of hazards
• Ensure alternative means of testing, e.g. mouth swabs

 
• Inform participants and provide documentation explaining why the UDS is being conducted, and when/how participants can access results
• Allow participants to observe the sample being closed and labelled
• Ensure participants know who to contact if they have questions, complaints or want to follow-up

 
• Provide a checklist of options about decisions they can make (if available) regarding use of a hat, whether or not they want to have conversation or quiet, soft music, or have water running.
• The tip sheet provides a sample information sheet that along with the above options, lists the purpose, substances tested for, and includes the statements “We understand this can be an uncomfortable process and want you to feel as safe as possible
• Provide a way for participants to offer feedback.

 
• Give participants a choice of which trained staff is giving the UDS.
• Ensure participants are aware of their rights as a service user, and provide in writing
• Avoid stigmatizing language dirty UA).

 
• If peer support is requested during the UA, ensure this option is available.

• Require staff to participate in trauma-informed care, cultural humility, and equity training as part of onboarding process.
• Ensure UDS staff represent the population being served.
• Ensure easy access to menstrual products.

• Attention: intentional focus to the present moment
• Acceptance: recognition of the truth of what is happening in the mind and body (note: this is not resignation, simply acknowledging what is true at this time)
• Allowance: making space for the full experience of what is happening without pushing it away (unless it is skillful in the moment to have such boundaries)
• Attitude: bringing qualities of curiosity, non-judgment, openness, and kindness to witnessing and holding the inner experience
• Action: choosing deliberative responses (rather than automatic, habitual reactions) that are grounded in awareness of the present moment

• Mindfulness is about escaping, emptiness, zoning out, or “nothingness.” In actuality, mindfulness is about “falling awake” to the life that you are actually living, versus escaping, numbing, or erasing parts of it (Kabat-Zinn, 2018). Instead, mindfulness is the gentle noticing and befriending of all of the thoughts, feelings, and sensations that make up our inner world.

• Mindfulness is “woo-woo” and is only useful for certain people. Mindfulness is not woo-woo; it is a tradition that spans thousands of years and a variety of traditions. Over the past 40 years, a vast body of research has emerged and bares out the benefits of mindfulness-based interventions for wellbeing in a number of ways, including related to common experiences such anxiety, depression, and chronic pain (Khoury, Sharma, Rush, & Fournier, 2015). Mindfulness has been introduced in healthcare, clinical, educational, business, and legal settings to explore its usefulness; and research shows benefits for both clinical and non-clinical populations (Visted, Vøllestad, Nielsen, & Nielsen, 2015). The vast majority of people can potentially benefit from paying attention to their experience without judgement and with kindness, and the scientific community continues to explore mindfulness-based interventions.

• Mindfulness involves having a blank mind and no thoughts. The mind wanders, and this is completely natural—even during formal mindfulness practices like meditation. The practice of mindfulness is actually about the steady, consistent practice of bringing the attention back to the present moment when we’re lost in or overidentified with thinking. Overidentification is when we merge with our thinking in such a way that we don’t recognize thinking is happening. For example: “I am a terrible worker” is an example of being fused with a thought. A more mindful approach would be the observation “I am having the thought ‘I am a terrible worker.’” This observational stance can be incredibly helpful de-intensifying the impact of that thinking. Observation creates a pause that makes space for the awareness that thoughts aren’t facts.

• Mindfulness requires you to meditate. Formal meditation is the practice of concentrating on an “object;” examples can be the breath, sounds, thoughts, the body, or even the entire field of whatever arises in awareness. Formal meditation is an incredibly helpful approach to support your capacity to practice mindfulness in everyday moments of living. However, formal meditation is only one mindfulness practice. Any activity can actually be engaged in mindfully—driving a car, walking down the hallway, giving a friend a hug, or brushing your teeth. Bringing non-judgmental attention to any moment is a practice that is always available to us.

• Mindfulness will erase stress and discomfort. While it is true that the practice of mindfulness may at times result in less stress or discomfort, mindfulness is not centered around “arriving” to any particular state of being (e.g., calm, stress-free, happy), though arguably the practice does cultivate a greater overall sense of wellbeing over time. The practice is truly about being with whatever is here, which paradoxically can, in fact, help us experience the transient nature of all thoughts, feelings, and sensations. Yet, it is helpful to avoid beginning a mindfulness practice attached to particular outcomes; such an expectation to lead you to think you’re “doing it wrong,” if certain experiences are not different. Mindfulness will not erase stress and discomfort; mindfulness will support you having a different relationship with stress and discomfort.

• Mindfulness is a “cure-all.” Though the practice has become increasingly popular in various settings, it is important to note that mindfulness is not a panacea, and further research is needed to better understand where, how, and with whom it can be most helpful. While there is strong evidence to support its use, certain practices may be unhelpful or in need of modification if someone is experiencing certain symptomology (e.g., trauma symptoms). More research is needed about the mindfulness-based interventions and certain populations or mental health concerns (e.g., schizophrenia) in service of prioritizing safety and effectiveness with those with whom we are working. Facilitators of mindfulness-based interventions also do need to be trained in the intervention, and education about trauma-sensitive mindfulness practice is helpful regardless of the nature of the intervention (i.e., clinical or non-clinical).

• What does that mean for how much energy you have to create the life you want?
• What does that mean for your wellbeing?
• What does that mean for your relationships?
• What does that mean for how you engage in your work?
• What does that mean for staying in connection with those you serve in your work?

• Attention: intentional focus to the present moment:
  • “I am having the thoughts that ‘He doesn’t event care. So disrespectful. Why do I even try? I’m tired of working harder than he is.’ I notice I feel frustrated. I can sense heat in my body and my heart rate rising.”
• Acceptance: recognition of the truth of what is happening in the mind and body (note: this is not resignation, simply acknowledging what is true at this time):
  • I don’t like it, but judgement, frustration, and internal heat really is around for me right now.
• Allowance: making space for the full experience of what is happening without pushing it away (unless it is skillful in the moment to have such boundaries)
  • giving permission for judgmental thoughts, the frustrated feeling, and the bodily sensations to exist; letting them be here instead of trying to push them away through distraction or busyness
• Attitude: bringing qualities of curiosity, non-judgment, openness, and kindness to witnessing and holding the inner experience
  • “It’s interesting I’m having these thoughts;” remembering judgment, frustration, and an activated physiological response are all normal; noticing with as much kindness towards yourself as you can
• Action: choosing deliberative responses (rather than automatic, habitual reactions) that are grounded in awareness of the present moment
  • deliberative responses such as taking a short walk before interacting with anyone, reminding yourself you do not have all of the information about the participant’s absences, reminding yourself of the participant’s strengths and the difficulty of the change process for all of us, active listening and asking questions to see understanding when meeting with the participant.

• When are you most mindful at work? What helps that to happen?
• When are you least mindful? What gets in the way?
• When in your day could you commit to pausing for a short meditation? (e.g., when you first sit down to your desk, when transitioning between meetings, before potentially stressful interactions)

• Connecting with yourself:
  • Engage in 5 minutes of formal meditation per day. If you are new to meditation, guidance is very helpful. A wealth of free resources exist online, and you can also choose to explore guided meditations using apps (e.g., Waking Up, Headspace, Calm).
  • Engage in an “everyday practice” of mindfulness per day. Choose an activity that you regularly do—brushing your teeth, walking the dog, washing the dishes, etc. As best you can, try to notice the experience of the activity (versus thinking about the activity), choosing to anchor your attention on physical sensations. When the mind wanders, as it will, gently escort your attention back to the body. Use your senses to connect to the raw, direct sensations of the experience.

• Connecting with others:
  • Choose one conversation per day to practice mindfulness. You do not need to mention you’re practicing to the other person. As best you can, focus your attention on the other person—what is being said, their body language, the emotional tone of what is shared. Notice when thoughts arise (e.g., planning what you want to say), and gently bring your attention back to the speaker. When you notice a thought, you might practicing “noting;” that is, simply saying to yourself  “thinking,” which helps to avoid getting lost in the narrative the mind if creating.  After noting, return to listening when the other is talking. Practice pausing and considering your words carefully.

By design, the judicial system wields disconnection as a tool to gain compliance, police behavior, and execute punishment. Rules are standardized, personal histories often remain unconsidered, change is sought through punitive means, and people are, quite literally, numbers. Arguably, the dehumanization inherent in this approach perpetuates, at least in part, the very social problems it seeks to address.

• How can treatment court practitioners stay in connection with themselves to be able to engage with participants skillfully?
• How can treatment court practitioners stay in connection with participants?
• How can treatment court practitioners support participants to stay in connection with themselves?
• What does a connected treatment court team look like? How can connection be cultivated and reflected in practices, processes, and policies?
• What does a connected criminal justice system look like? How can connection be cultivated and reflected in practices, processes, and policies?

Which clients in your treatment court have a history of trauma? How can you find out? Why does it matter? While the conversation about the prevalence and devastating effects of trauma has become increasingly open in justice settings, many treatment courts may be blind to it in their own programs or simply hope that good intentions will prevent further trauma. Perhaps now is the time to self-reflect as a treatment court and to take small, but meaningful actions right now.
 

According to SAMHSA, “Individual trauma results from an event, series of events, or a set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being, (2014a, p. 7).” Trauma experiences can diminish the ability of treatment court participants to engage in programs and long-term recovery. So, what does it mean for organizations to be trauma-informed? First, in order for treatment court programs to fully embody a trauma-informed system of care, all program staff must:
 

1. Have a basic realization of the origins of trauma and the impact this can have on individuals, families, groups, and communities.
2. Be able to recognize the signs of trauma in individuals.
3. Continuously assess the ways in which policies, procedures, and practices should be revised in order to allow staff to respond to individuals appropriately.
4. Resist engaging in action(s) that may result in re-traumatization.
 

In addition, SAMHSA (2014a) identifies six key principles that should serve as the foundation for developing your trauma-informed systems of care.
 

1. Safety (this is #1 for a reason) – above all else, participants’ physical & emotional safety should be promoted in all settings & through all interactions. Individuals (i.e., staff and participants) who do not feel safe will not fully engage.
2. Trustworthiness & Transparency – treatment court operations should be transparent and conducted with an eye toward developing and maintaining mutual trust between and among stakeholders and participants.
3. Peer Support – incorporating peer recovery support specialists into your treatment court program is an effective way for individuals with lived experience to assist participants in their recovery.
4. Collaboration & Mutuality – recognizing and acknowledging that all treatment court team members and participants have unique roles/responsibilities is key to developing collaborative relationships based on mutuality and respect.
5. Empowerment, Voice, & Choice – treatment court team members look for opportunities to empower participants to make decisions and have a voice in their recovery.
6. Cultural, Historical, & Gender Issues – the treatment court program provides participants with access to clinical and recovery support services that are responsive to their cultural, racial/ethnic, and gender needs.
 

A good place to start moving toward being a trauma-informed treatment court is to screen participants for trauma exposure to determine which individuals are in need of a more thorough assessment and trauma-specific services. Several screening and assessment tools have been validated with justice-involved populations; a sample list is attached. This is by no means an exhaustive list, and note that separate tools have been developed for youth (Collaborative for Change, 2016) and adults (SAMHSA, 2015). Many of these tools are free, while some charge a nominal fee.
 

To conduct a screen sensitively that will yield valid responses, it is recommended that programs “take the time to prepare and explain the screening and assessment process to the client gives him or her a greater sense of control and safety over the assessment process.” (SAMHSA, 2014b, p. 94). Be prepared to reassess individuals as they grow more willing to disclose information over time.
 

In the coming months, Beyond the Field entries will periodically highlight literature on trauma-informed practices for different components of treatment courts, including drug testing, courtroom set-up and structure, team dynamics, use of language, and providing participants opportunities to have a voice and make choices.