Less Talk and More Action in Treatment Courts
Treatment Court work is challenging, interesting, and rewarding. However, recovery is a long road, and it can take a long time before participants start to see lasting changes, as they work to acquire essential knowledge and skills. This can be frustrating for everyone. Frankly, all that listening that treatment court programming requires can get a bit, well, boring. What’s the best way to “supercharge” that process? Decades of research supports the Chinese proverb “I hear I forget, I see I remember, I do, and I understand.” The more we can engage participants not just through their brains but through doing, the more likely they are to understand, assimilate, and integrate recovery skills and knowledge. It’s not complicated: “Would you show me how you did that…” “Let’s practice that together…” and “Can you stand up and do…” are the kinds of prompts that ALL members of the team can integrate into their interactions with participants. While therapists are generally tasked with teaching participants essential recovery knowledge and skills, the entire team is responsible for helping to keep those skills active, to provide opportunities for practice and feedback, and to offer encouragement. The payoff is substantial, as research shows that infusing action into our encounters with participants boosts the acquisition of knowledge and use of skills.
New Veterans Treatment Court Innovations Program
Justice for Vets (JFV), in collaboration with the Bureau of Justice Assistance (BJA), has developed a Veterans Treatment Court Innovations Program. JFV seeks applications to implement and enhance veteran treatment court services to ensure that programs are conducting and using validated risk and need assessment tools to determine eligibility, program track placement, supervision, and treatment program assignment and dosage.
The NDCRC Changes Name to NTCRC
The National Treatment Court Resource Center (NTCRC) has changed its name from the National Drug Court Resource Center (NDCRC), effective October 1, 2023. The name change reflects the breadth of courts supported by the center to include adult and juvenile drug treatment courts, adult and juvenile mental health courts, veterans treatment courts, DWI/DUI courts, co-occurring disorder courts, reentry courts and family treatment courts.
“We are excited to continue to serve the treatment court field as part of the Bureau of Justice Assistance (BJA) Training and Technical Assistance Collaborative. The National Treatment Court Resource Center more accurately communicates our mission and purpose – to provide resources such as research, data, interactive mapping, best practices, and training to the treatment court field,” said NTCRC co-Directors Dr. Kristen DeVall and Dr. Christina Lanier.
Parenting Adult Children while in Treatment Court
The negative impact of parental substance use on children’s well-being is well documented within the literature. Family Treatment Courts (FTCs) specifically aim to provide parents involved with the child welfare system with access to clinical treatment and recovery support services in an effort to enhance family functioning and help families stay together and thrive. However, a large percentage of participants in all types of treatment court programs have children (or serve in the role of parent/guardian). As a result, these participants could benefit from enhancing their knowledge and skills within the area of parenting.
Introducing Our Best Ideas of the Year
At RISE23, it was a special time to reflect on the growth and progression in the field of treatment courts through the years. One of the ways that progress comes about is through creative thinking and innovative ideas. While at RISE23, the NDCRC hosted an interactive session titled “The Great Exchange: My Best Idea of the Year” in which we encouraged attendees to share some of their best ideas of the year. This post marks the first in a series of posts sharing the many great ideas that were shared with us. Stay tuned in the following weeks to read about your other great ideas! Let us know what you think about these ideas in the comments, and we encourage you to share your own too.
Marketing Your Treatment Court
Need help marketing your treatment court? The NDCRC has developed a quick guide to help treatment courts develop focused communication strategies aimed towards specific audiences and goals. This guide will introduce you to the basics of integrated marketing communication (IMC) and walk you through a step-by-step communication plan template. We know it can be hard work to maintain consistent communication, especially for those who already have a significant workload when it comes to the daily operations of a program. Our hope is that this guide will alleviate some of the stress of not knowing where to start. After all, the awesome work that you do deserves to be shared with the world!
Available Now: Painting the Current Picture Full Report
During 2020, the NDCRC collected data on the state of the treatment court field in 2019. Fifty-two states and territories submitted information on their operational treatment courts. The NDCRC processed, analyzed, and condensed these data into one report which shows a full picture of treatment court operations in the US. The data collected are accompanied by a comprehensive literature review of peer-reviewed research for each treatment court type, identifying gaps for future research projects. Explore the national overview of data or the breakdown by court type with suggestions for best practices and development.
Who’s Your Audience? Communicating with Stakeholders to Market Your Treatment Court
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.
Available Now: Tribal Healing to Wellness Court Report
The NDCRC has published a report resulting from the Tribal Healing to Wellness Courts Inaugural Survey of the Field. This survey was the first of its kind to collect information on Tribal Healing to Wellness Courts (THWCs). Together with the Tribal Law and Policy Institute (TLPI), it was our goal to learn more about how these courts operate; specifically, how they use cultural practices for the success of their participants. Only about 14% of existing THWCs were represented in the survey responses, but we still learned a lot of valuable information about these courts. The full summary is available in the survey report.
OUD, MOUD, & Sleep Disorders
- 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?
- 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., 3rd shift will be different from 2nd 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.
NDCRC Newsletter Gets a New Look
The NDCRC is kicking off 2023 in full gear by giving a fresh face to our monthly newsletter. For starters, you’ll only get the newsletter every other month, beginning in January. In February, we’ll start sending Beyond the Field features every other month. The newsletter will look a little different: we’ll tell you about the latest NDCRC resources, you’ll get a word from our co-directors, and we’ll summarize a peer-reviewed study that bridges treatment court research and practice. The Beyond the Field features will look pretty much the same: you’ll still get valuable content related to non-jurisprudence aspects of treatment courts. All content will still be published to the NDCRC website if you miss it in your inbox! Additionally, please make sure that “ndcrc@uncw.edu” is on your “safe senders” email list. We want to make sure that all our good stuff gets to you, and we look forward to sharing it!
Happy New Year!
What Treatment Courts Should Know About Sleep, Trauma, & Substance Use
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.
The What, Who and Why of Trauma-Specific Therapies
- 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)
July RISE22 Announcement
It’s almost time for RISE22! Join NADCP for the biggest treatment court professionals’ conference in the country. Make your way to Nashville, Tennessee July 25-28 for networking, continuing education, inspirational guests, and the annual RISE Film Festival. Be sure to stop by the NDCRC’s booth and say hello!
Trauma-Informed Drug/Alcohol Testing
- 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.