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Beyond The Field

Trauma-Informed Spaces and Courtrooms

When you go into a court you don’t know what’s going on because you’re terrified. There are guns, they’ve got you chained up, and you’re under the influence. All these things are happening at once. — Trauma Survivor (SAMHSA et al., 2013).

 
People who have experienced trauma can be easily and suddenly overwhelmed, hypersensitive to sounds, confined spaces and objects. They may reflexively respond to these as life-threatening and can’t attend to or remember essential court proceeding or treatment-related information.
 
The field of Environmental Psychology studies how the physical environment, such as building design, floorplans, signage, and other features of buildings impact our behavior. Designs that provide privacy and a sense of safety are ideally suited for people who have experienced trauma (Garcia, 2020).
 
Of course, few courts, probation departments, treatment providers, etc. have the luxury of designing their own buildings. However, SAMHSA and other collaborators (2013) compiled tips for treatment court professionals that can help prevent or offset negative impacts of these often-intimidating spaces and promote a sense of safety and respect in participants. They highlight aspects of the physical environment that treatment courts can consider without great expense or delay.
 
Does your courtroom have seating that provides easy access to aisles and exits? If not, can seats be reserved near aisles? Where does the judge sit? DO they loom above the court, making eye contact and respectful connection difficult? Are people placed in handcuffs and shackled where all in attendance can see? Are the bathrooms where drug tests take place well lit? Is there a space where people can get some privacy if they need a space to calm down? Is the signage posted respectful? OR does it just instruct people what NOT to do?
 
The article provides a table that describes potential triggers in the environment, the possible reactions of a trauma survivor, and a more trauma-informed approach that treatment courts may take. According to Garcia (2020), “The goal of trauma-informed design is to create environments that promote a sense of calm, safety, dignity, empowerment, and well-being for all occupants. These outcomes can be achieved by adapting spatial layout, thoughtful furniture choices, visual interest, light and color, art, and biophilic design.” It would behoove treatment court teams to assess the physical spaces where participants engage in program-related activities with a critical eye toward minimizing trauma.
 

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Beyond The Field

Trauma-informed Treatment Courts: Translating Knowledge into Action

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.
 

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Beyond The Field

Branding your Treatment Court

Associating the word “brand” with treatment courts may seem to be a mismatch. Taking a closer look at what branding is, however, opens up possibilities for how we talk about the work of treatment courts with professionals, clients, and the larger community. In communication studies and rhetoric, one of the most prominent scholars who explains narratives and story is Walter Fisher. According to Stache (2017), “In 1978, Walter Fisher proposed a theory of narrative communication, which advances the idea that humans inherently tell stories and like to have stories told to them.” The idea of branding and brands comes from this human need for stories. In the commercial, business-to-consumer sense, brands function as a way for humans to create relationships with consumer goods (Twitchell, 2004). We sometimes call these “brand narratives.” Organizations tell stories in order to gain their stakeholders’ attention and every communication interaction between an organization with its audiences has an impact. In addition, Fisher explains that stories ideally have narrative coherence and narrative fidelity. Narrative coherence means that the story makes sense, and narrative fidelity means that the story rings true to the audience’s experience (Stache, 2017).
 

What does this look like for treatment courts? It means that the responsibility for communication falls on every member of the treatment court team, because every interaction is an opportunity to create a new reality – a new story – that builds on the mission and vision of your program. Does this mean every interaction must be perfect? Of course not. That’s neither realistic nor human. However, it does mean that open, honest, and authentic communication that aligns with a program’s mission and purpose can create a strong brand story. This strong brand story also means that the inevitable messiness of human communication happens within the context of a coherent story with fidelity. The process of developing your program’s brand can also build goodwill and trust with your intended audience, which will serve you well in times of both crisis and celebration.
 

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Beyond The Field

How do We Know if a Therapy is Culturally Relevant?

Innovations like NADCP’s Equity and Inclusion Tool make it easier for treatment courts to “Do Better” to determine if their policies and procedures reduce racial, ethnic, and cultural disparities. But what about therapies? Are evidence-based interventions, say motivational interviewing (MI), equally relevant and effective for diverse populations?
 

No. The field has been slow to address this problem, but researchers have attempted to adapt existing, effective therapies to make them relevant for diverse clients. For example, Karen Chen Osilla and colleagues developed a web-based MI intervention in English and Spanish to improve the outcomes of Latino first-time DUI clients, (Osilla et al., 2012). They used a strategy called formative iterative evaluation, a multistep process, to assure the MI intervention content and delivery were responsive to linguistic and cultural needs.
 

First, MI researchers and health literacy experts for Latino & Spanish populations created an in-person MI intervention tailored to first-time DUI clients. Next, they conducted focus groups with clinicians and clients to determine what changes were needed. Then, they adapted the in-person MI intervention to an interactive web format in both English and Spanish. Finally, they tested it again to gather more feedback about its usability and cultural fit.
 

The developers made changes, such as translating idioms (“getting high”) and adding examples of ways that drinking could negatively affect family and friends. They integrated feedback on social and family values-related themes, adding “drinking with friends” as a reason to drink, “being a good role model” as a reason to stop drinking, and “not meeting family responsibilities or disappointing family/children” as negative consequences of drinking (p. 197). At the final test of the web-based format, clients who spoke only Spanish (compared to English-only and bilingual clients) “reported feeling less embarrassment, shame and discomfort with the web-MI” (p.199).
 

A later study of the intervention found it was likely not long or intensive enough to make a lasting impact, at least on its own. However, the study provides a sound example of a systematic, collaborative approach to developing effective multicultural therapies. Clearly, treatment court staff and providers cannot afford to wait for intervention research to catch up with the demand for culturally relevant therapies. In the meantime, we can remember that treatments are not “one-size fits-all,” and ask clients–especially those from diverse backgrounds–whether they feel respected, a sense of belonging, and if the therapy is actually helping, throughout their treatment court experience.
 

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Beyond The Field

Evidence-Based Relationships: The Science of Relationships that Work

How many hours per week do you spend in meetings? Is it time well spent? Do you leave meetings with a sense of a way forward? Frustration? Could your team use a meetings “tune-up”? Workplace meetings are a mainstay of all organizations. For treatment court teams, regular pre-court staff meetings are required as a Best Practice (NADCP, 2018). But teams engage other meetings as well, including those with community stakeholders, program evaluation and planning, and others.
 
The NADCP Adult Drug Court Best Practice Standards champion the use of evidence-based practices, based on the best available research. While research can tell us what models and interventions work, the how of their delivery is less often discussed. The most effective treatment court teams go beyond the “what” of their program’s offerings (evidence-based practices) and relate to participants in ways that support and promote recovery (evidence-based relationships).
 
A Task Force on Evidence-Based Relationships was formed by the American Psychological Association to analyze the best available research to identify the core components of effective therapy relationships (Norcross & Wampole, 2011). The Task Force concluded that the therapeutic alliance, empathy, and gathering client feedback are clearly linked to positive outcomes. The therapeutic alliance entails mutually agreed upon goals, agreed upon tasks, and a sense of collaboration and relational bond between the two parties. Multiple rigorous studies also indicate that therapists who can express empathy (understand and acknowledge the client’s perspective) and who actively monitor client’s perceptions and responses to treatment are more effective. Relationship behaviors deemed ineffective and potentially harmful include a confrontational style, therapist comments that are hostile or blaming, judging the person versus their behavior, and applying a one-size-fits-all approach that ignores individual and cultural differences.
 
Relevance to Treatment Courts
 
While most members of treatment court teams are not therapists, the Task Force’s findings detail what works and doesn’t work in relationships that target lasting personal change. The following can apply to every court team role: 
 

  • To enhance the relational alliance, treatment court team members should frequently discuss participants’ personal values and motivations, and collaboratively review program and client expectations.
  • While these relationships must remain professional, expressing genuine caring for participants can help form bonds that are healthy, respectful and meaningful.
  • Directly asking clients for feedback about the program and their experiences provides opportunities to improve collaboration, to modify approaches as needed, and prevent premature termination.
  • Confrontation has historically been a problem in the addictions field. Interactions that are infused with motivational enhancement elements, such as rolling with resistance, reflective responding and active listening serve as antidotes to these all-too-human, but toxic reactions.
  • Individualized treatment plans that consider the individual’s unique and diverse identities are a hallmark of treatment court Best Practices, and the Task Force’s findings confirm this. “Fair treatment” does not equal “identical treatment.” It means tailoring the program and services to match the evolving needs of each individual.

 
Treatment court involvement is essentially a series of human interactions, so relationships between participants and the team are central to recovery. Substance use and criminal behavior can be viewed as rooted in disturbed relationships, disconnection and alienation, and treatment court professionals have the opportunity to make lasting impacts–not only via evidence-based techniques and operational models–but through meaningful, evidence-based connections.

 

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Beyond The Field

The Science of Conducting Successful Meetings

How many hours per week do you spend in meetings? Is it time well spent? Do you leave meetings with a sense of a way forward? Frustration? Could your team use a meetings “tune-up”? Workplace meetings are a mainstay of all organizations. For treatment court teams, regular pre-court staff meetings are required as a Best Practice (NADCP, 2018). But teams engage other meetings as well, including those with community stakeholders, program evaluation and planning, and others.

Industrial/organizational (I/0) psychologists Joseph Mroz and colleagues reviewed over 200 empirical studies of meetings in their article “Do we really need another meeting? The science of workplace meetings” (Mroz, Allen, Verhoeven & Shuffler, 2018). They identify worthy goals and provide specific recommendations for conducting successful meetings.
 
Nationally, they note, the average employee spends 6 hours per week in meetings, and that half of those meetings are rated as “poor” by those who attend. For most organizations, there is a clear need to revisit current practices and consider improvements. Mroz and colleagues identify four primary purposes of meetings:
 
1) Information Sharing;
2) Problem solving and decision making,
3) to develop and implement organizational strategies, and
4) to debrief a team after particular events.
 
They recommend that care should be taken before, during and after meetings to facilitate positive outcomes. For example, before a meeting, attendees should have read the agenda, be prepared and arrive on time. The agenda should list clear goals and outcomes and be realistic in terms of allotted time. During meetings, leaders should make the meeting short, and relevant. Humor and laughter can stimulate positive behaviors, but complaining leads to poor performance. Leaders should also intervene when communication becomes dysfunctional or off-track. A clear agenda as described above can go a long way toward mitigating these issues. By the same token, leaders should attend to perceptions of fairness and encourage participation from all attendees. After meetings, effective leaders send out action items and minutes and seek feedback about how others perceived the meeting, to improve the process.
While many of these recommendations seem obvious, researchers have objectively analyzed the costs, interpersonal conflicts, and inefficiencies that arise when these recommendations are not followed. The authors describe a problematic dynamic noted in a study by Simone Kauffeld and Nale Lehmann-Willenbrock, that many readers may find familiar:
 
When one person starts to complain in a meeting by expressing so-called “killer phrases” that reflects futility or an unchangeable state (e.g., “nothing can be done about that issue” or “nothing works”) other meeting attendees being to complain, which begins a complaining cycle that can reduce group outcomes (p. 488).
 
This “cycle” is common among professionals in human services fields, and while realism and pragmatism are valuable, pessimism can be contagious and toxic. This is one of the major challenges in treatment court work—even when participants behave in ways that look like “giving up,” staff would do well to convey a sense of hope in how they conduct themselves in meetings.

 

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Beyond The Field

Microaggressions

  • An African American client stops attending intensive outpatient groups. He explains, “I was the only Black person there-I wasn’t comfortable.” He asks for individual therapy instead but is told “No, group is always best for the intensive treatment people need early in the program. Besides, there is only one race-the human race.”
  • A young Latina who is affiliated with a gang is not referred to treatment court, while a young white woman who is also gang affiliated is referred and admitted, “because she’s not as hard core.”
  • A transgender client tells her counselor about violence she has faced. The counselor says: “I understand. As a woman, I experience discrimination too.”

 
Decades of research in cognitive and social sciences show that categorizing, stereotyping, and even discrimination is part and parcel of being a human being. All of us process information and aim to make judgments as quickly and efficiently as possible. We’ve needed to, in order to survive as a species. But a byproduct of this process is that we form implicit biases. Automatic and unintentional, implicit biases are “mistakes” that can lead us to discriminate against others and cause lasting harm.

 
Microaggressions flow from implicit biases. In the article Racial microaggressions in everyday life: Implications for clinical practice, psychologist Derald Wing Sue defines microaggressions as “brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative messages to (marginalized) people,” (Sue et al., 2007; p. 279). The person committing the microaggression can usually “explain it away” by seemingly nonbiased and valid reasons.

 
Sue and colleagues would consider the first scenario above as an example of colorblindness, or denying a person of color’s racial or ethnic experiences. The message is “You are not a racial/cultural being. You must assimilate/acculturate to the dominant culture.” The second example represents assumption of criminality, when a person of color is presumed to be more deviant on the basis of their race. The third scenario seems well intentioned but reflects a denial of biases. The therapist implies, “Your oppression is no different than mine. I can’t be biased. I’m just like you.” While the therapist is unaware of their mistake, the client feels diminished and misunderstood, adding to their suffering.
 
Recognizing and confronting implicit biases and microaggressions in ourselves takes courage and humility. Sue and colleagues (2007) offer a model that invites us to be more aware and intentional in each of our personal and professional actions.

 

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Beyond The Field

Traumatic Brain Injury and Treatment Courts

A client continually misses appointments, drug tests and curfews. Another has no insight into their problems and repeatedly puts themselves in dangerous situations. Another can’t focus in group treatment and interrupts with off-topic, embarrassing comments. Another is irritable and gets angry quickly. Are these signs of long-term substance use? Mental illness? Traumatic brain injury (TBI)? It could be any and all of these, as they frequently co-occur.
 
Treatment courts target people with mental health and substance use challenges, but TBI and its long-term impacts are often “off the radars” of court professionals and providers. Lasting effects of TBIs can be easily mistaken for “personality problems” or intense resistance to treatment. The prevalence of TBIs among treatment court clients is unknown, but they are common in the justice system, resulting from accidents, falls, fights, domestic violence, and military service (CDC, 2010).
 
So, can people with a TBI benefit from treatment court programs? The structure, predictability and case management support that treatment courts provide can make it a good fit, especially if the team is knowledgeable and adapts their practices to meet client needs. Veteran’s Courts are especially aware of these issues, and trainings are periodically offered (check the calendar).
 
But you don’t need to wait: three online guides for substance use treatment, criminal justice, and mental health professionals are listed below and offer strategies for assessing the impact of TBIs and for adapting daily practices and services. Adaptations include using visual aids, patiently repeating information, slowing down interactions, demonstrating self-regulation skills, and tailoring clients’ environments for reminders. Trauma-informed care in this case requires that teams be aware of the cognitive, emotional and behavioral challenges that can persist well beyond the initial injury, and a willingness to respond with compassion–even though it can be very challenging.
 

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Beyond The Field

Self Determination Theory and Internal Motivation in Treatment Courts

Participant #1: “I entered Treatment Court because I want treatment and a better life for my kids and myself.”
 

Participant #2: “I entered Treatment Court because I am sick of jail.”
 

Do clients freely choose to enter a treatment court? The answer is far from simple. Is it a “choice” when the criminal justice system relies on external motivators like incarceration and resulting cascade of losses? Ideally, the choice to enter a treatment court would be an autonomous one that reflects a participant’s internal motivations to live a healthier, more meaningful life. Deci and Ryan’s Self Determination Theory (SDT) holds that internally motivated behaviors are stronger, longer lasting, and produce better outcomes than those that are externally motivated (Deci & Ryan 1985). SDT provides the framework for a number of studies of the impact of treatment courts and other legally mandated programs (e.g. Morse et al., 2014; Wild et al., 2016).
 

According to SDT, three psychological needs must be met to foster internal motivation and self-determined behavior: Autonomy, Competence and Relatedness. To the extent that treatment courts support these inborn, intrinsic needs, clients are more likely to engage in treatment and maintain gains.
 

Autonomy is enhanced when clients feel they have options and take responsibility for choices. At intake, staff must make clear the voluntary nature of treatment court programs, especially because the consequences of refusing are often swift and aversive. Does the court notice and consistently praise and encourage values-driven choices, or does it emphasize missteps and sanctions, which detract from autonomy? Motivational Interviewing is a NADCP Best Practice designed to maximize autonomy and minimize coercion.
Competence develops through a focus on skills development, repeated practice, and environmental support. Evidence-based practices such as relapse prevention training and stress management equip clients to face the challenges of recovery. Lapses are viewed as opportunities to refine skills and increase competence.
Relatedness is the need to interact and be connected with others. Through treatment groups and treatment court membership, clients give and receive support, which is both healing and crucial to problem solving and competence.
 

While Client #1 seems more internally motivated and ready to engage, research indicates that Client #2 also has the potential to succeed in treatment court. SDT holds that over time, externally motivated behaviors can transition to become internally motivated. This process is at the heart of therapeutic jurisprudence.
 

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Beyond The Field

The Neurobiology of Substance Use Disorders

This month, NDCRC Director of Clinical Treatment and UNCW professor of psychology Dr. Sally MacKain discusses how an understanding of the neurobiology of substance use disorders can inform treatment court practices. Treatment court clients struggle with significant cognitive, emotional, behavioral, and social problems. Understanding some basics of the neurobiology behind these difficulties may help court team members tailor their interactions and services more effectively.
 
Dr. MacKain breaks down the article “Neurobiologic Advances from the Brain Disease Model of Addiction” by Nora Volkow, George Koob & Thomas McLellan (2016) which reviews scientific evidence supporting the view that substance use disorders are rooted in changes in how our brains are structured and function. The authors contend that a brain disease model of substance use has facilitated a movement away from shaming, stigma and incarceration. Volkow and her colleagues have made an important contribution in helping those of us who are not brain scientists understand more about the neurobiological changes associated with substance use disorders, how a disease model of addiction fits the evidence, and why recovery can be so challenging.
 

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