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.
The information and examples are wisely organized by the principles of trauma-informed care.
Some highlights include:
- 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.