Tag: Beyond the Field

Beyond The Field

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 SAMHSA’s (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 individual’s 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 “e.g. “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.

 

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Beyond The Field

Criminals. Offenders. Participants. People.: The Role of Our Beliefs in the Work of Treatment Courts

 

Connection is a through-line in the operating philosophy of therapeutic jurisprudence. Yet, the anatomy of connection and that of therapeutic jurisprudence is complex, and precise roadmaps for either are debated among scholars. However, perhaps a helpful framing to best work toward living out this philosophy is to consider four elements: beliefs, values, attitudes, and behaviors.

 

Source: American Psychological Association: https://dictionary.apa.org/
 

In the last article, the concept of mindfulness was introduced and defined as paying attention to what is happening in this moment, without judgement or reactivity to the thoughts, feelings, and physical sensations that arise (Kabat-Zinn, 1994). As we untangle the anatomy of therapeutic jurisprudence and connection, mindfulness practice allows you to notice what is happening in your mind and body. What thoughts, feelings, and sensations arise when you agree with an idea? When you disagree? Feel bored? When you dislike the idea, have unpleasant feelings, or uncover a judgment of yourself? The foundational skill of mindfulness invites you to stay curious about whatever comes up for you. Curiosity can make way for you to be kind towards yourself and – importantly – persistent in examining and reflecting upon the ideas ahead.

 

In unpacking the anatomy of connection and therapeutic jurisprudence, we will first focus on the role of beliefs.

 

Psychologists define beliefs as the “acceptance of the truth, reality, or validity of something, particularly in the absence of substantiation” (APA, 2022). Before we examine the role of beliefs in treatment court work, we must first familiarize ourselves with our own thoughts that are pertinent. You are invited to consider the following questions carefully and honestly:

 

  • What thoughts arise when I think about people involved in the treatment court system?
  • It may be helpful to consider your ideas about their motivation, wants, needs, behaviors, capacity for / interest in change, etc.
  • What thoughts arise when I think about treatment courts?
  • It may be helpful to consider your ideas about their purpose, design, utility, approach, effectiveness, etc.
  • What thoughts arise when I think about my role in the treatment court system?
  • It may be helpful to consider your ideas about your knowledge, skills, preparedness, attitude, motivation, capacity to provide support / make change, desire to help, resources, etc.

 

Now that you have begun unfolding your own thoughts, we will outline beliefs that therapeutic jurisprudence invites practitioners to try on in treatment court work. These beliefs can include:

 

  • What do we believe about people involved in the treatment court system?
  • All people have strengths, gifts, and talents.
  • People are not their circumstances, conditions, experiences, or choices. People are in circumstances, experience conditions, have experiences, and make choices.
  • People have a complex life story we know only a fraction about. It may include but is not limited to their involvement in the justice system.
  • People have needs and wants as well as hopes for their lives.
  • People are complex, and understanding them takes time, energy, and interest.
  • People can change.
  • People deserve support in their efforts to change.
  • People will naturally make mistakes in the process of attempting to change their lives.
  • All people regardless of identity or circumstance deserve to be treated with dignity and respect.
  • All people – regardless of race, ethnicity, gender, sexual orientation, sexual identity, physical or mental disability, religion, or socioeconomic status deserve the same opportunities as other individuals to participate and succeed in treatment courts.
  • What do we believe about treatment courts?
  • The law can be leveraged to have a therapeutic effect, resulting in psychologically healthy outcomes.
  • A collaborative, non-adversarial approach is most effective to supporting people to change their lives.
  • Building relationships is necessary to positively impact treatment and court outcomes.
  • The opportunity for alcohol and other drug treatment and mental health services can make a meaningful difference in people’s lives.
  • What do we believe about practitioners’ roles in the treatment court system?
  • The treatment court system works best with a connected, collaborative team.
  • All members can learn from one another.
  • All members of the multidisciplinary team bring a unique, necessary perspective and play an important role in participant outcomes.
  • Transitioning to a team approach from an adversarial approach can take time, patience, and intention.

 

Why might honestly examining your own thoughts matter? Are your thoughts your actual beliefs? When do these automatic thoughts arise? Are the thoughts you had consistent with the beliefs outlined above? Where did your thoughts come from, and how might you challenge those that are inconsistent with those connected to therapeutic jurisprudence? Under what circumstances might your thoughts shift? (e.g., when you witness positive change, when your mood is low, when your body is activated, when your stress level is high, when you’re feeling really energized, etc.) And, when are you most generous thoughts about yourself around – when are the least generous ones pleasant?

 

Our beliefs about ourselves, others, and the world around us are deeply connected to our values, shape our attitudes, and influence our behavior—both personally and professionally.
In this way, we cannot solely focus on practitioners’ behaviors in cultivating a healthy, effective workforce. Yet, thoughts are not beliefs—unless we decide so.

 

We need to consider all aspects of the anatomy of therapeutic jurisprudence, starting with our actual beliefs about ourselves, others, and the work itself. Exploring our own thoughts means examining how we arrived at the ideas we have and the openness to challenges the ideas we hold. A part of the process also involves considering how our thoughts may automatically become beliefs without consciousness might affect our treatment of others.

 

Using the 5 A’s of mindfulness, you can distinguish thoughts from beliefs and uncover your actual beliefs with intentionality– a process that is critical to engaging skillfully and effectively in your work. For example, imagine you have thoughts that label those with whom you work as “offenders” and “criminals.” In using mindfulness, the following could unfold:

 

  • Attention: intentional focus to the present moment:
  • Noticing the labels of “offender” and “criminal” in your mind and conversations with colleagues
  • Noticing judgmental thoughts about actions and choices of those involved in the treatment court system
  • Noticing feelings of frustration, ambivalence, and an urge to disengage from helping
  • Noticing sensations of agitation in the body
  • Acceptance: recognition of the truth of what is happening in the mind and body (note: this is not resignation, simply acknowledging what is true at this time):
  • “This is just what is happening right now – judgmental thoughts, frustrated feelings, and the urge to disengage.”
  • Allowance: making space for the full experience of what is happening without pushing it away (unless it is skillful in the moment to have such boundaries)
  • giving permission for what is happening in the mind and to exist—taking a moment to breath and avoid “busyness” that is sometimes deigned to move us away from what is really happening
  • Attitude: bringing qualities of curiosity, non-judgment, openness, and kindness to witnessing and holding the inner experience
  • “It’s interesting I’m having these thoughts; It’s understandable to have these thoughts – because I’m feeling extra stressed today, and this is the language that I hear all the time in society, too. All emotions are normal to feel.”
  • Action: choosing deliberative responses (rather than automatic, habitual reactions) that are grounded in awareness of the present moment
  • Reminding yourself that thoughts aren’t facts and do not have to be representative of your actual beliefs because they arose in your mind. Our beliefs are our choices.
  • Reminding yourself that labels like “offender” and “criminal” are reductionistic, diminishing of someone’s humanity, and disconnecting; they are problematic because they label the entire person by a behavior and make us feel far and separate from that person (i.e., disconnected)
  • Choosing to reframe that language in your mind in speech—maybe even by simply thinking about the person by their name, dropping the label altogether. (i.e., Sam experienced a substance use relapse versus An offender in the program relapsed.)
  • Taking care of yourself in the best way for you in response to the frustration/agitation that is around and possibly connected to automaticity of labeling (e.g., talking with a supervisor about a challenging interaction with the person)
  • Taking a step to reconnect to that person, even if only in your mind and body (e.g., think of one thing you have in common with that person)

 

Thoughts are only mental experiences that we often mistake as facts or chosen beliefs; however, we can choose to buy into our thoughts or not. Beliefs are, in fact, choices. Bringing more consciousness to the ways in which with think about ourselves, others, and work positions us to stay connected—to ourselves, to others, and to our professional values, attitudes, and behaviors.

 

What we choose to believe directly impacts how we engage. How we engage directly impacts the lives of others.

 

And, we want to engage with the belief that those in the treatment court system are, in fact, criminals, offenders, participants people.

 

A Connection Call to Action:
This week, you are invited to engage in a connection call to action to try out the ideas discussed.

 

Connecting with yourself:
Examine your beliefs about yourself, focusing on your strengths. Take a few moments each day to make a list of 5 of the strengths you demonstrate in your work.

 

Connecting with others:
Examine your beliefs about those in a participant role, focusing on identifying their strengths. Take a few moments each day to make a list of 5 of the strengths you see in a person with whom you are / were working. Each day, choose a new person to think about. You are especially encouraged to focus on those people who brought up feelings of frustration for you or with whom you have / had a strained working relationship.

 

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Beyond The Field

Presence is the Foundation of Connection

In the introduction to the series, the role of connection to ourselves and others was offered as an essential practice to live out the philosophy of therapeutic jurisprudence that underpins treatment courts. But, how do we stay connected to ourselves and others?
 
Connection requires us to make conscious choices. Active listening, asking questions for understanding, and identifying a participant’s strengths are all examples of choices that can help us stay in connection with others. What keeps us from making these choices? How do we notice when we are in connection, and how do we sustain it? How do we notice when disconnection happens, and then, how do we take steps to reconnect?
 
The answers to these questions—and ultimately making deliberate choices—first relies on our capacity to notice what is happening in the mind and body. The quality of that noticing—how we do the noticing—is also important to balancing both effective communication with others and taking care of ourselves. The skill that supports us in this is called mindfulness.
 
What is Mindfulness? (And, What It is Not)
Mindfulness is paying attention to what is happening in this moment, without judgement or reaction to the thoughts, feelings, and physical sensations that arise (Kabat-Zinn, 1994). The practice invites us to adopt an attitude of openness and curiosity about what we are experiencing, with kindness towards ourselves, so that we are able to respond, versus react, to not only what is happening in us but also around us in the environment.
 
Said another way, mindfulness involves five A’s: attention, acceptance, allowance, attitude, and action (Lee, 2020, 2021):

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

 
Discussion of mindfulness is increasing culturally, which has resulted in the increased accessibility of learning and practicing opportunities. Yet, with the rise of attention to the practice comes, at times, misconceptions. These misconceptions include:
 

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

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

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

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

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

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

 
Why Mindfulness?
Research suggests we spend approximately 50% of our time lost in thoughts about the past or future (Killingsworth, Gilbert, D. T. (2010) instead of the moment-to-moment experience we are having.
 
Consider the consequences of not paying attention to at least half of the moments in your life.
 

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

 
While practicing mindfulness does not guarantee a particular “state” of being, noticing our experience with kindness and without judgement does position us to make more conscious choices. Those choices, if intentional, can better embody our values, meet our needs, reflect our knowledge, and allow us to exercise our skillsets.
 
So, What Could Mindfulness Look Like at Work?
We can practice mindfulness using formal practices (e.g., meditation) or informally through everyday activities. The purpose of formal practice is actually to support us carrying over what is learned to everyday life, both in personal and professional contexts. Everyday activities could include, for example, drinking your coffee in the morning at your desk. Using all your senses to bring you to the here-and-now, you may take time to notice its color, smell its richness, hear any noise it may make moving in the cup, and experience it through touch and taste when taking a slow sip. And, you can practice mindfulness when you interact with others.
 
Consider the following scenario: a participant has missed three sessions of a group treatment program you are running. What could be some of the automatic, habitual thoughts, feelings, and sensations that arise for you?
 
Let us say the following was your experience:
Thought: He doesn’t event care. So disrespectful. Why do I even try? I’m tired of working harder than he is.
Feeling: frustration
Sensations: heat in the body, increased heart rate
 
Now consider what reactivity to this internal experience might look like, remembering reactivity is not intentional, deliberate behavior but rather more automatic and habitual reactions.
 
Reactivity might look like:
Reactivity: assuming your thoughts are “true,” complaining to a coworker about the participant, being short the next time you see the participant, or failing to see the participant’s strengths due to ruminating on the “disrespectful” behavior
 
Were we to consider taking a mindfulness approach, how might you relate to the experience of the thoughts, feelings, and sensations outlined above? This might look like:
 

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

 
Certainly, many factors influence our automatic, thoughts, feelings, and sensations in response to the world around us. Perhaps our mood is low that day, we were just in an argument with a loved one two days before, the participant reminds us of a friend with whom we have a challenging relationship, or we have a pattern of interpreting participants’ absences as disrespectful to us personally—just as some examples.
 
No matter the explanation, we will experience automatic, habitual thoughts, feelings, and sensations. The key to being able to stay in connection with ourselves is to not abandon the experience we are really having. Connection with ourselves positions us to be able to take care of ourselves.
 
The key to being able to stay in connection with others is also not to abandon the experience we are having. Connection with others position us to make connective deliberate choices like listening, asking questions, and displaying empathy.
 
There is no greater sign of respect, no deeper signal of appreciation, no better gift than you can give yourself or others than you attention.
 
Each article in the Connection: The Essential Practice for Therapeutic Jurisprudence in Treatment Courts series will conclude by offering two features: Connection Questions to
Consider and Connection Calls to Action.
 
Connection Questions to Consider:

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

 
A Connection Call to Action:
This week, you are invited to engage in a connection call to action to try out using mindfulness practice to connect with yourself and others.

 

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

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

 

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Beyond The Field

Connection: The Essential Practice for Therapeutic Jurisprudence in Treatment Courts

By design, the judicial system wields disconnection as a tool to gain compliance, police behavior, and execute punishment. Rules are standardized, personal histories often remain unconsidered, change is sought through punitive means, and people are, quite literally, numbers. Arguably, the dehumanization inherent in this approach perpetuates, at least in part, the very social problems it seeks to address.
 
As a movement, the treatment court model is itself an answer to the ineffectiveness of disconnection in promoting behavioral change for those who experience challenges with substance use and/or mental health. The philosophy of therapeutic jurisprudence, which underpins the treatment court model, emphasizes the potential for psychologically healthy outcomes when the legal system is structured as a “restorative, remedial, and healing instrument” (ISTJ, 2022; Kawalek, 2020, p. 2; Stobbs, 2019). Therapeutic jurisprudence is concerned with “the human effects of the law” and the promotion of practices to benefit the “emotional, psychological, physical, relational, economic, and social personhood” of participants (Kawalek, 2020, p. 1-2). Treatment courts offer an important opportunity to leverage the legal system to make meaningful changes in people’s lives.
 
Collaboration is perhaps the hallmark of treatment courts. In identifying best practices, the National Association of Drug Court Professionals (NADCP, 2018b) emphasizes the importance of an interdisciplinary approach as well as complementary treatment and social services. Best practice standards also underscore the need for predictability, fairness, consistency, and evidenced-based principles for behavior modification in the operations of treatment courts—practices that cannot be actualized without both interdisciplinary and professional-participant collaboration. The NADCP standards further acknowledge the critical nature of attention to equity and inclusion for participant success; addressing historical patterns of discrimination and inequity certainly requires sincere collaboration (NADCP, 2018a).
 
The thread of collaboration can be traced back even further to NADCP’s earlier efforts to outline key components of treatment courts. NADCP names the “non-adversarial approach” as crucial to encourage collaborative, coordinated efforts to support participants (NADCP, 2004, p. 3). Another essential component is “ongoing judicial interaction with each treatment court participant,” a standard that explicitly highlights the need for an “active, supervising relationship” in service of increasing the likelihood of participant success (NADCP, 2004, p. 15). Emphasis is placed on early engagement with participants, interdisciplinarity, and “forging partnerships among treatment courts, public agencies, and community-based organizations” ­­(NADCP, 2004, p. 23).
 
Without question, intentional, focused, collaborative relationships are central to the mission of the treatment court model, and such meaningful collaboration requires connection.
 
While scholars within psychology offer various conceptualization, social connection may be simply described as a sense of belonging, which can be derived from the experience of acceptance, concern, empathy, and care (Seppala, Rossomando, Doty, 2013). Arguably, a uniqueness of the treatment court model is the opportunity for social connection including
between participants and direct service providers (e.g., case managers, therapists), participants and others professionals (e.g., defense counsel, probation authorities, judges), as well as among the entire team of professionals collaborating with the participant. Notable to the treatment court approach is another, albeit a less obvious, opportunity for connection for participants—connection with self. That is, mental health service provision as well as case management services offer participants pathways to cultivating a sense of belonging to oneself through self-acceptance as well as concern, empathy, and care for the self. Lastly, treatment court professionals benefit greatly from being in connection with the self, too, which is helpful for both their own wellbeing and positioning them to be present and skillful in working with participants.
 
Connection—whether it be with self, others, or larger systems—is the nexus of change.
 
When participants are connected with themselves, they are best positioned to understand the influence of the past upon the present, identify their needs and values, establish goals, and take meaningful, congruent choices to shape their lives. The connection between professionals and participants results in participants feeling seen, heard, understood, and supported—often catalysts to personal growth and change. A treatment court team member’s own capacity to stay in connection with oneself results in the ability to embody professional values, utilize knowledge from their training, and effectively engage with participants. Further, professionals do not operate in a vacuum; connected collaborations, systems, and institutions result in stronger collaborations, systems, and institutions. The practices, processes, and policies of these larger entities matter—they can either reflect an investment in connection or disconnection. The ultimate goal of the treatment court model is to reduce recidivism through substance use and/or mental health treatment, and the means by which this goal is achieved is, in fact, staying in connection—perhaps the most essential, yet most unrecognized, practice necessitated by the treatment court model philosophy.
 
If connection is the birthplace of behavioral change, five primary questions emerge:

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

 
In the Connection series, we will examine these questions as to untangle the rewarding, nuanced, and challenging aspects of working in treatment courts.

 

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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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Beyond The Field

The Science of Future Thinking and its Role in Recovery

Would you prefer a delicious piece of chocolate now or a whole chocolate bar tomorrow? A 3-day vacation now or a 7-day vacation in 5 months? To spend an extra/bonus $500 now, or put it in a savings account to accrue interest? Most people prefer immediate rewards over delayed ones. However, people with substance use challenges tend to find it especially difficult to imagine their futures and delay rewards. Research indicates that people with substance use disorders have a narrower “temporal window,” meaning their attention is focused on gaining near-future rewards, such as the next drink or next drug use opportunity. For example, studies show that when asked about their own future, the typical individual reports goals and activities about 5 years in the future. In stark contrast, people with heroin use disorders offered reports that extended only 9 days in the future, on average (Patel & Amlen, 2020).
 
Delay discounting is the term used to describe the rate at which future rewards are less valued over time. Higher rates of delay discounting are related to impulsivity and risky behaviors like drug and alcohol use. Research in Episodic Future Thinking (EFT) suggests that helping people to vividly imagine personally salient future events could help them learn to delay rewards in order to get a bigger payoff in the longer term (Bulley & Gullo, 2017). Applied to a treatment court context, clients could learn to forgo short term rewards such as relief from craving or feeling euphoric, in favor of long-term goals, like graduating from the program, freedom from probation, and regaining custody of children.
 
Several promising studies of EFT with people with alcohol dependence show positive results. For example, Snider, LaConte & Bickel, (2016) encouraged participants to expand their temporal windows by thinking about personally relevant future events and describing them in salient detail. Participants reported the most positive event that could realistically happen at each of 5 points in the future (1 day, 1 week, 1 month, 3 months, and 1 year). Researchers then probed: “What will you be doing?” “Whom will you be with?” “Where will you be?” “How will you be feeling?” “What will you be seeing?” “What will you be hearing?” “What will you be tasting?” “What will you be smelling?” (pp. 1160-1161). They also asked a comparison group of people with alcohol dependence to imagine PAST events in the same timeframes, with similarly worded probes. This method allowed researchers to assess the unique contribution of a future time orientation.
 
Each participant’s future or past personalized account was then integrated into a task in which they chose between hypothetical gains in money received now or after some delay (e.g., “Would you like $50 now or $100 in a year?” They also administered measures of alcohol use. They found that over time, people in the future-thinking/EFT group came to value future monetary rewards more highly and reduced their alcohol consumption. These improvements were also found in a study that involved a one-week, 4-session/practice protocol with people with alcohol dependence (Patel & Amlen, 2020). In addition to decreases in alcohol demands and delay discounting rates (i.e., they were more able to delay rewards), participants who had engaged in even 1 session also showed significant increases in mindfulness—an essential tool in supporting recovery.
 
More research is needed to determine whether EFT can effectively contribute to treatment of substance use disorders. But treatment court personnel and providers can easily incorporate these highly targeted, future-thinking questions to help clients visualize a future self that is healthier and more fulfilled. Repeated practice is essential to change, and the frequent contacts afforded to treatment court clients could provide ideal opportunities to engage them in this line of thinking.
 

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