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.

Apply now!

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

BestIdeaOfTheYear Blog Graphic

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!

Marketing Your Treatment Court PDF

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.

Painting the Current Picture: Full Report

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.

THWC Survey Report

OUD, MOUD, & Sleep Disorders

Statistics
Are you one of the 70 million people in the U.S who experience sleep problems? About one-third of adults get fewer than 7 hours of sleep and report symptoms of insomnia. About 10% of adults at any given time meet the criteria for insomnia disorder, reporting ongoing difficulty getting to sleep, staying asleep, and/or returning to sleep that results in problems with functioning. Another common sleep disorder is sleep apnea (about 10% of adults), in which the person stops and starts breathing again many times during sleep. Sleep apneas can lead to life threatening conditions and requires formal assessment and treatment by a medical provider. As we noted in the Beyond the Field article “Sleep, Trauma and Substance Use,” quality sleep is key to overall health, emotional stability, planning, and sound decision-making. Poor sleep is associated with accidents, heightened pain sensitivity, unemployment, and mental health problems. For treatment court participants, sleep problems can interfere with recovery, making it more difficult to engage in treatment, maintain employment, and use skills to cope with psychiatric symptoms.

People with opiate use disorders (OUD) are at much higher risk of sleep impairments than the general population. Researchers report that as many as 84% of people with OUD experience significant sleep disturbances. Opiate use can create and perpetuate a harmful cycle, in which sleep problems and pain sensitivity trigger opiate use, and opiate use in turn leads to poor sleep and greater pain sensitivity – especially as withdrawal becomes part of the cycle. Furthermore, people with OUD are at much higher risk of not only obstructive sleep apnea, but central sleep apnea when the brain stops sending signals to the muscles that control breathing. This is a condition distinct from the immediate impact on respiration that can follow opiate administration. Studies indicate that about 40% of people with OUD have some form of sleep apnea – four times as many people in the general population. The relationship between OUD and sleep is complex: there are many factors that contribute to poor sleep among individuals with OUD, including co-occurring psychiatric disorders, financial stress, unstable housing, living in unsafe areas, a history of trauma, as well as the use of alcohol, nicotine and other drugs. (Dunn et al., 2018).

Do Medication Assisted Treatments Address Sleep Problems?
While the benefits of medication assisted treatments for OUD (MOUD) are well documented (SAMHSA, 2021), better sleep does not appear to be one of them. Research indicates that sleep does not improve with MOUD. A large study of individuals using methadone found that most reported moderate to severe sleep disturbance at the start of methadone treatment and that their disordered sleep persisted throughout treatment (Nordmann et al., 2016). Likewise, patients treated with buprenorphine did not fare any better in terms of improved sleep (Dunn et al., 2018). Again, the roots of sleep disturbance in OUD are complex. For individuals using both methadone and buprenorphine, psychiatric impairments were the strongest predictor of disordered sleep. Researchers are exploring the possibility that the medication itself causes some sleep problems or makes pre-existing sleep problems worse. MOUD is a critical component of OUD treatment, so it is important that treatment court team members are aware of how common sleep issues are among their participants and find ways to support them.

An Action Plan for Addressing Sleep Disturbance in OUD and MOUD
So, what can you do to assist participants experiencing disordered sleep? An important first step to addressing this issue is to increase awareness among all team members as to just how common disordered/dysregulated sleep is among individuals with OUD and receiving MOUD. Furthermore, team members should be knowledgeable about the relationship between poor sleep quality and some problematic behaviors (e.g., poor attendance, disengagement, forgetfulness, etc.) they observe among participants. It is important to note that individuals may not be aware that their sleep quality is poor nor that it is negatively impacting other aspects of their lives.

Below are relatively simple (and free) steps your treatment court team can take to bring this issue into the forefront of your work with participants.

1.    As part of your enrollment/intake process, ask individuals about their sleep patterns.
  • 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?

2.    In addition to asking individuals these questions in casual conversation, you can add an empirically validated screening tool to your enrollment/intake process. While not a comprehensive list, the below-listed screening tools are free and can be administered by non-clinicians:

Each of these tools includes a scoring rubric which will determine if someone should be referred to a medical provider for a comprehensive medical assessment to rule out other high-risk conditions that may be affecting sleep (e.g., sleep apnea). When in doubt, refer an individual to a medical provider for an assessment as their condition could be life threatening.

3.    It is also crucial for participants to know that disordered/dysregulated sleep is a very common experience among individuals with OUD and receiving MOUD. Once serious physiological/biological conditions have been ruled out by medical professionals, treatment court team members can and should normalize the realities of sleep dysfunction and work with participants to identify strategies that will assist in mitigating the negative side effects associated with poor sleep. Moreover, it’s important that treatment court team members reaffirm the benefits of MOUD and together with the below-listed suggestions, sleep may improve over time and recovery will continue.

Below are several prompts that can be used by any member of the treatment court team. For example, a case manager during a case management session, probation officer during a reporting meeting, peer recovery support specialist during 1-1 interactions, or a judge during the court review session.
  • 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

Call to action:
Discussing disordered/dysregulated sleep is not practicing medicine. All members of the treatment court team should normalize disordered/dysregulated sleep, work to increase knowledge in this area, and actively work to support participants experiencing this issue.

Your treatment court team can take several steps to improving the program’s capacity to address the needs of participants. To this end, we would offer the following suggestions for specific action steps you can take:
  • 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

Perhaps you have heard these common misconceptions about trauma therapy for treatment court participants:
  • 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 National Drug Court Resource Center provides free resources to enable treatment courts to implement evidence-based practices and maximize the effectiveness of their programs. In this fourth article in our series on trauma-informed practices, we provide a brief overview of trauma-specific treatments that have the most scientific support, why these therapies are a good fit for many treatment court participants with trauma, and ways to facilitate greater access to these effective treatments.

 

Importance of integrating treatment for PTSD and substance use treatment
It is well known that trauma and substance use disorders co-occur at very high rates, and treatment courts are well positioned to provide treatment for both, concurrently. This integrated model offers outcomes that are far superior to the outdated, sequential approach that requires treating substance use disorder first, THEN the trauma (Flanagan et al., 2016). Integrated treatment allows clients to address PTSD symptoms that are directly linked to substance use, and vice versa. A sequential model that focuses on treating substance use first reduces the chances that trauma will ever be addressed before the treatment court participant either drops out or completes the program. Providers may fear that clients with PTSD are too fragile in that encouraging clients to face their trauma memories and intense emotions directly could lead to relapse or dropping out of treatment. Conversely, treatment court participants have greater supports and structure in place than in any other time in their lives, so treatment courts are encouraged to take advantage of this window of opportunity.

 

Trauma-focused therapies with the best outcomes
The following trauma-focused treatments have been rigorously studied and are recommended/strongly recommended by the American Psychological Association and the U.S. Department of Defense (Veterans Services). All are fairly brief (8-16 sessions), and share a direct focus on exposure to memories of the trauma. Some also emphasize changing clients maladaptive beliefs about the trauma and themselves. All the approaches involve temporary discomfort, as distressing memories are activated through exposure (imagined or real-life) and processed in a structured, systematic manner under the direction of the therapist (Watkins et al., 2018). Decisions about which treatment approach is the best fit will depend on nature of the trauma (e.g., combat-related, victim of sexual assault, witness to a violent event), the complexity of the trauma, client preference, and realistically, availability of clinical providers who offer the intervention.

 

Cognitive Processing Therapy (CPT).People who have experienced trauma try to make sense of the occurrence and can develop distorted beliefs about themselves and the trauma. These stuck points can keep the individual from healing, and include beliefs such as I have myself to blame and as long as I trust no one, I will be safer. Treatment extends over 12 sessions and involves activating the traumatic memory, which includes writing and reading a narrative account of the trauma. At the same time, the therapist helps the client to identify the maladaptive cognitions associated with the traumatic event and shift them to become more accurate and helpful (Resick, Monson & Chard, 2017).

 

Prolonged Exposure (PE).After educating the patient about the nature of PTSD and how PE works, the therapist uses exposure to both imagined and real-life situations, as well as people and places associated with the clients unique trauma. After repeated exposures, the client ultimately learns that the feared (avoided) consequence will not occur and is able to move forward and use more adaptive coping strategies as opposed to avoidance. The therapy typically takes 8“15 sessions (e.g., Foa et al, 2007).

 

Trauma-focused Cognitive Behavior Therapy (TFCBT). Many have heard of this as an evidence-based therapy for children. However, adults also benefit from the integration of behavioral (e.g., imaginal exposure to the distressing memory) and cognitive components. Clients learn to identify triggers of re-experiencing, practice discriminating between then vs. now, identify and dispute dysfunctional thoughts, as well as reshape beliefs about themselves, the trauma, and the world.

 

Eye Movement Desensitization Reprocessing (EMDR). In this treatment the therapist utilities exposure to the traumatic memory, coupled with eye movements (left and right) and sometimes tapping and sounds. EMDR differs from the other recommended approaches in that cognitions are not explored, exposure to the distressing memory is briefer, and there is no assigned homework. The therapy typically takes 6-12 sessions (Shapiro, 2017).

 

These therapies have been found to be very effective for people who are actively using substances, have thoughts of suicide (but low intent), are unhoused, or have minimal education. There are a few exclusions. Trauma specific treatment is not recommended for people who currently have unmedicated mania or psychosis, or who are at current high-risk for suicide, or who require immediate detoxification services.

 

Who should receive these therapies?
First, assessment of trauma symptoms is critical. Treatment court participants may not report or display trauma symptoms at the initial screening and assessment for admission to treatment court, as they may have normalized their experiences or may not be ready to disclose such sensitive information. However, members of the treatment court team should be on alert for signs of trauma and refer participants to trauma therapy providers for assessment. Providers should routinely assess participants for PTSD and continue to assess throughout treatment.

 

Valid and reliable trauma screening and assessment measures are available to licensed professionals free of charge (see the National Center for PTSD for more information https://www.ptsd.va.gov/professional/assessment/list_measures.asp#list1).

 

When working with justice-involved individuals with SUD or COD, SAMHSA (2015) recommends the use of the following trauma screening instruments:

 

PTSD Checklist for DSM-5 (PCL-5)

 

and

 

Select 1 of the following publicly available resources:

 

Similarly, SAMHSA (2015) recommends the use of one of the following trauma assessment instruments, which should be administered by a licensed clinician:

 

 

How available are trauma specific therapies to treatment court participants?
There are few studies on the use of trauma therapies in treatment court populations, and more work needs to be done to assess barriers to access as well as mental health and substance use outcomes. Veterans Treatment Courts (VTCs) are likely to be more familiar with and offer trauma specific therapies. The U.S. Veterans Administration has been a leader in funding the development, research, training and dissemination of these interventions. The therapies are applicable to non-veteran populations, and clinicians are encouraged to receive training to provide these interventions. All approaches are related to aspects of cognitive and behavior therapies, and most providers should already be familiar with the theories and be able to utilize the therapy manuals, handouts, and free phone apps for patients (e.g. PE Coach and CPT Coach).

 

Treatment Courts are encouraged to pursue training for providers in these strongly recommended trauma-specific approaches and to utilize the free and low-cost resources below to learn more.

 

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!

Register for RISE22

Trauma-Informed Drug/Alcohol Testing

This is the third in a series of articles regarding trauma-informed treatment courts. In December 2021, we offered an overview of SAMHSAs (2015) six principles of trauma-informed care and evidence-based strategies for the screening and assessment of trauma in participants. In January 2022, we explored literature on trauma-informed spaces and courtrooms and reviewed findings from environmental psychology. In this edition of Beyond the Field, we review work related to trauma-informed drug testing as it relates to the trauma-informed principles of safety, trust and transparency, collaboration and mutuality, empowerment/voice & choice, peer support, and cultural, racial/ethnic and gender needs.

 

According to Best Practice Standard #7, Drug and alcohol testing provides an accurate, timely, and comprehensive assessment of unauthorized substance use throughout participants enrollment in the Drug Court (NADCP, 2018, 26). Treatment court teams use drug/alcohol results to monitor participants use of substances to make decisions regarding appropriate treatment services, supervision levels, and the administration of both incentives and sanctions. To this end, the success of any Drug Court will depend, in part, on the reliable monitoring of substance use (NADCP, 2018, 27). Given the vital role of drug/alcohol testing plays within the treatment court environment and the frequency with which participants engage in this program activity (minimum of twice per week during first few months of enrollment is best practice), it is vital that testing protocols are trauma-informed and do not undermine other aspects of the program.

 

Review of trauma and its associated symptoms. SAMHSA defines trauma as resulting 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 individuals functioning and mental, psychological, social, emotional or spiritual well-being (2014). Because trauma is common among treatment court participants, teams will want to take action to minimize its negative impact on engagement in services, communication, problem-solving, decision making, and outcomes.

 

Symptoms of Posttraumatic Stress Disorder (PTSD) and related Acute Stress Disorder (ASD) include the following four clusters (American Psychiatric Association, 2013):
a) Re-experiencing the traumatic event, or having intrusive, recurring memories or dreams related to the event. Places, sounds, lighting, thoughts, objects, and even words can trigger re-experiencing.
b) Avoidance of situations, thoughts and feelings related to the event. Avoidance symptoms can cause people to resist instructions or escape to safety.
c) Disturbance in arousal and reactivity. People may be easily startled, on edge, irritable, or become angry or aggressive. They may have trouble focusing, sleeping, and paradoxically, may engage in risky or destructive behavior.
d) Numbing and/or other changes in cognition and mood. Numbing, emotional withdrawal or shutdown when triggered, negative thoughts, self-blame, feelings of isolation and apathy are common.

 

You can probably picture participants who exhibit these behaviors, but might not have considered them to be trauma-related reactions. Trauma-informed courts recognize that the people, places and things embedded in everyday treatment court operations can trigger and exacerbate PTSD and ASD, or even re-traumatize participants. They respond by altering policies and practices to minimize these risks, often at low or no costs.

 

The where, who and how of trauma-informed drug testing.
The National Center on Substance Abuse and Child Welfare (NCSACW) conducted a trauma-informed care assessment project, or walkthrough process, with five sites across the country (NCSACW, 2015). The site visits of child welfare, substance use treatment centers, and family treatment courts identified several common trauma triggers, including drug testing spaces and procedures. Restrooms tended to be noisy, uncomfortable, and located in high-traffic areas with little or no privacy.

 

A tip sheet, Trauma Informed Urine Drug Screens was developed by Trauma Informed Oregon (2019) that provides detailed guidance for programs aiming to reduce the impact of trauma on justice-involved individuals with substance use disorders (found at this link https://traumainformedoregon.org/wp-content/uploads/2019/05/Urine-Drug-Screen-tip-sheet.pdf)
The information and examples are wisely organized by the principles of trauma-informed care.
Some highlights include:

 

Safety
     

  • 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

 

Trust and Transparency
     

  • 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

 

Collaboration and Mutuality
     

  • 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.

 

Empowerment, Voice & Choice
     

  • 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).

 

Peer Support & Mutual Self-help
     

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

 

Culture, Gender & History

 

  • 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.

 

The UDS tips provided by Trauma Informed Oregon are not particularly expensive or difficult to implement, but they do require leadership and consistency. Drug/alcohol testing is a key component of the drug treatment court model and can/should be conducted with an eye toward minimizing the potentially traumatizing effects on participants. Treatment court teams should examine current policies and procedures and make necessary modifications where appropriate. Ensuring that all aspects of treatment court programs are trauma-informed will improve participant retention rates and increase the likelihood of participant success.