Maryland s T.A.M.A.R Program

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Maryland’s

T.A.M.A.R Program

Trauma Addictions Mental Health Trauma, Addictions, Mental Health,

and Recovery

Presenter

 Alisha F. Saulsbury, LCSW - C

T.A.M.A.R. Trauma Specialist/Clinical Supervisor For All Seasons Mental Health Clinic

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Hypothesis

Repeated and prolonged traumatic experiences,

ft i i hildh d ti l i t

often occurring in childhood, may negatively impact mental health and result in maladaptive, risky

behaviors resulting in incarceration. This sequence is likely to repeat unless treatment specific to the needs of the person with the trauma history are met and detention center staff are knowledgeable about the effects of trauma.

Learning Objectives

1. To understand the benefits of trauma specific

care from the consumers’ perspective care from the consumers perspective

2. To know Maryland’s long term commitment to

trauma care and the development and implementation of the T.A.M.A.R. model

3. To be introduced to trauma treatment through a

discussion of the 15 treatment modules presented in the T.A.M.A.R. project

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Trauma Impact Loop

What is Trauma?

Definition (NASMHPD, 2006)

f

 The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters

DSM IV-TR (APA, 2000)

 Person’s response involves intense fear, horror and helplessness

 Extreme stress that overwhelms the person’s capacity to cope

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What does trauma do?

 Trauma shapes a child’s basic beliefs about identity, world view, and spirituality.

 Negative beliefs and views require adaptations

 Symptoms are ADAPTATIONS

 Using a trauma framework, the effects of trauma can be addressed and a person can go on to lead a be addressed and a person can go on to lead a “productive” life.

(Saakvitne, Gamble, Pearlman & Lev, 2000)

Consequences of Trauma

 Faulty control methods:  Impaired attachments:

 Over-control  Self-blame  Passivity  Addictive behavior  Warmth by friction  Interpersonal skill deficits  Addictive behavior  Self-harm

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Prevalence of Trauma

Mental Health Population – United States

 90% of public mental health clients in have been exposed to trauma

(Mueser et al., in press, Mueser et al., 1998)

 51-98% of public mental health clients in have been exposed to trauma

(Goodman et al., 1997, Mueser et al., 1998)  Most have multiple experiences of trauma

(Mueser et al., in press, Mueser et al., 1998)

 97% of homeless women with SMI have experienced severe physical & sexual abuse – 87% experience this abuse both in childhood and adulthood

(Goodman et al., 1997)

Prevalence of Trauma

Substance Abuse Population – U.S.

 Up to two-thirds of men and women in SA treatment report childhood abuse and neglect p g

(SAMSHA CSAT, 2000)

 Study of male veterans in SA inpatient unit

 77% exposed to severe childhood trauma

 58% history of lifetime PTSD

(Triffleman et al., 1995)

 50% of women in SA treatment have history of rape or incest

(Governor's Commission on Sexual and Domestic

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What does the data tell us?

 The majority of adults and children in

hi i i h

psychiatric treatment settings have trauma histories

 A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety

A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories

(Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

Trauma, Addiction, Mental Health

and Recovery

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The History of TAMAR

TAMAR PROGRAM

 SAMHSA Women and Violence Site

 Maryland only site addressing the needs of incarcerated women

 Began in 1999 in 3 local detention centers  Currently serving 10 sites in Maryland  Piloting in 2 Ohio detention centersg

 Provides mental health, substance abuse, and trauma treatment for men & women in detention centers and State psychiatric hospitals

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Tamar’s Story

In the Old Testament, Tamar was a

In the Old Testament, Tamar was a

daughter of King David. Tamar’s half

daughter of King David. Tamar’s half

brother Amnon raped her. The author of II

brother Amnon raped her. The author of II

Samuel writes that afterwards she tore her

Samuel writes that afterwards she tore her

clothes and retreated into her brother’s

clothes and retreated into her brother’s

house. She is not mentioned in the Bible

house. She is not mentioned in the Bible

again.

again.

Preparing for Implementation

 Trauma training for community agencies Trauma training for community agencies

 Trauma training for Correctional Officers and Trauma training for Correctional Officers and staff

staff

 Correctional CrossCorrectional Cross--training for TAMAR clinical training for TAMAR clinical staff

staff

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The RICH Model



R

Respect

espect



IInformation

nformation



C

Connection

onnection



H

Hope

H

Hope

ope

ope

((SaakvitneSaakvitne, et al, 2000), et al, 2000)

R.I.C.H.

 Be an allyBe an ally

 Safety and respect Safety and respect

 Boundaries work with survivorsBoundaries work with survivors

 Use connection to help people manage their Use connection to help people manage their feelings and memories

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TAMAR Program Components

 Administered by Master’s level, licensed Administered by Master’s level, licensed yy ,, mental health clinician

mental health clinician

 Individual sessionsIndividual sessions

 Group sessionsGroup sessions

 Linkage to case management andLinkage to case management and

 Linkage to case management and Linkage to case management and aftercare

aftercare

How is TAMAR Accessed?

 Screening administered at Screening administered at f ilit i t k

f ilit i t k facility intake facility intake

 Trauma Specialist does inTrauma Specialist does in--depth assessment on those depth assessment on those that screen “positive” for that screen “positive” for trauma

trauma

P i l i d d

P i l i d d

 Program is explained and Program is explained and offered to eligible individuals offered to eligible individuals

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Trauma Assessment Tools

 Trauma Symptom Inventory (TSI) by BriereTrauma Symptom Inventory (TSI) by Briere

 Dissociative Experiences Scale (DES) by Dissociative Experiences Scale (DES) by Carlson and Putnam

Carlson and Putnam

 Stressful Life Experiences Screening by Stressful Life Experiences Screening by Stamm

Stamm

More Tools

 Traumatic Antecedents Questionnaire (TAQ) Traumatic Antecedents Questionnaire (TAQ) by van der Kolk

by van der Kolk by van der Kolk by van der Kolk

 Structured Interview for Disorders of Extreme Structured Interview for Disorders of Extreme Stress (SIDES) by van der Kolk

Stress (SIDES) by van der Kolk

 Modified PTSD Symptom Scale by van derModified PTSD Symptom Scale by van derModified PTSD Symptom Scale by van der Modified PTSD Symptom Scale by van der Kolk

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More Tools – Child Specific

 Dissociative Features Profile (DFP) by SilbergDissociative Features Profile (DFP) by Silberg

 Trauma Symptom Checklist for Children Trauma Symptom Checklist for Children (TSCC) by Briere

(TSCC) by Briere

TAMAR

 TAMAR is a 15-week program that delivers 30 trauma related topics or exercises to individuals 18 years of related topics or exercises to individuals 18 years of age and older who are detained in one of the

participating detention centers 

 Modules incorporate psychodynamic therapy with Modules incorporate psychodynamic therapy with expressive art therapy and psycho

expressive art therapy and psycho--educational educational techniques

techniques techniques techniques

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TAMAR Groups

•• Meet twice a week for 90 minute sessionsMeet twice a week for 90 minute sessions

•• Groups of 6Groups of 6--8 individuals8 individuals

•• Voluntary, no good time or credit earned for Voluntary, no good time or credit earned for participation

participation

TAMAR Treatment Manual

 Module 1 – What is Trauma

 Module 2 - What is abuse?" and "What is Emotional Abuse?

 Module 3 What is abuse (sexual)/Female Sexuality

 Module 3 - What is abuse (sexual)/Female Sexuality

 Module 4 - Trauma and Addiction

 Module 5 - HIV/AIDS Education and Condom Skills

 Module 6 - Communication and Negotiation Skills

 Module 7 - Containment- The Concept of Self-Regulation

 Module 8 - Grounding" and "Imagery

 Module 9 - Distress Tolerating Skills" and "Distress Tolerance

 Module 10 – Self-Soothing

 Module 11 - Boundaries and Safety

 Module 12 - Trust and Intimacy

 Module 13 - Parenting

 Module 14 - Life Story

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TAMAR: Module 1 (example)

 Session I Coming Together (Responsibility)

 WHAT IS TRAUMA?  Meeting A

 Who cares, why bother, and what's in it for me?  Materials

 Managing Traumatic Stress Through Art page xv

 Goal - each member will be able to demonstrate an understanding of the meaning of psychological trauma.

 Goal - each person will say at least one sentence about herself in the group.

M ti B

Meeting BMaterials  Poetry therapy

 Creative re-structuring in trauma treatment  Goal - members will complete exercise in group.

 Goal - members will take away one idea about how to keep safe.

Module 1

Module 1

What is Trauma? What is Trauma? Wh C Wh B th Wh t’ i it f M Wh C Wh B th Wh t’ i it f M ??

•• Who Cares, Why Bother, What’s in it for MeWho Cares, Why Bother, What’s in it for Me??

 Recognition of traumatic reactions makes Recognition of traumatic reactions makes management of survivors’ much easier management of survivors’ much easier 

 A little bit of trauma awareness goes a long wayA little bit of trauma awareness goes a long way 

 Ongoing trauma treatment across a continuum Ongoing trauma treatment across a continuum of care is a major contributing factor to reducing of care is a major contributing factor to reducing of care is a major contributing factor to reducing of care is a major contributing factor to reducing recidivism in this population

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Module 2

Module 2

What is Abuse? What is Abuse? Ph i l d E ti l Ph i l d E ti l 

Physical and EmotionalPhysical and Emotional

Goal is to recognize behaviors/actions Goal is to recognize behaviors/actions

that constitute physical and emotional that constitute physical and emotional abuse

abuse

Recognize the impact of physical and Recognize the impact of physical and

ti l b th i li

ti l b th i li

emotional abuse on their lives emotional abuse on their lives

Module 3

Module 3

What is Abuse? What is Abuse? S l Ab S l Ab 

Sexual AbuseSexual Abuse

Goal is to recognize how sexual abuse Goal is to recognize how sexual abuse

has impacted their lives. has impacted their lives.

Recognize selfRecognize self--defeating thoughts and defeating thoughts and

behaviors and begin to develop their behaviors and begin to develop their

i ht t h lth lf

i ht t h lth lf tt

right to a healthy self

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Module 4

Module 4

Trauma and Addiction Trauma and Addiction

G l i t i ddi ti / l i

G l i t i ddi ti / l i

 Goal is to recognize addictive/compulsive Goal is to recognize addictive/compulsive behaviors as coping mechanisms

behaviors as coping mechanisms

 Make the connection between Make the connection between

addictive/compulsive behaviors and their addictive/compulsive behaviors and their trauma trauma

Module 5

Module 5

Facts on HIV/AIDS Facts on HIV/AIDS G l i t id f t b t HIV/AIDS G l i t id f t b t HIV/AIDS 

 Goal is to provide facts about HIV/AIDS as Goal is to provide facts about HIV/AIDS as well as discuss myths and misconceptions well as discuss myths and misconceptions

 Demonstration of behavior skills to reduce the Demonstration of behavior skills to reduce the risk of HIV/AIDS transmission

risk of HIV/AIDS transmission

 This module may be triggering to many This module may be triggering to many

women and needs to be presented in a trauma women and needs to be presented in a trauma women and needs to be presented in a trauma women and needs to be presented in a trauma context (i.e. presentation of overt sexual

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Module 6

Module 6

Sexual Communication and Sexual Communication and N ti ti Skill

N ti ti Skill Negotiation Skills Negotiation Skills

 Discuss what constitutes sexual Discuss what constitutes sexual communication (both verbal and non

communication (both verbal and non--verbal)verbal)

 Provides an opportunity to roleProvides an opportunity to role--play play negotiation skills (includes sexual negotiation skills (includes sexual

assertiveness safe sex and refusal of unsafe assertiveness safe sex and refusal of unsafe assertiveness, safe sex, and refusal of unsafe assertiveness, safe sex, and refusal of unsafe sex) sex)

Module 7

Module 7

Containment Containment

Why containment instead of disclosure?Why containment instead of disclosure?

 Goal is to help members describe levels of Goal is to help members describe levels of consciousness and understand the different consciousness and understand the different parts of memory

parts of memory

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Module 8

Module 8

Containment II

Containment II -- GroundingGrounding

G l i t id tif diff t di G l i t id tif diff t di

 Goal is to identify different grounding Goal is to identify different grounding techniques

techniques

 Members will be able to practice grounding Members will be able to practice grounding techniques daily, outside of group

techniques daily, outside of group

Module 9

Module 9

Tolerating Distress Tolerating Distress

 Each member will begin to distinguish the Each member will begin to distinguish the negative aspects of being unable to tolerate negative aspects of being unable to tolerate distress

distress

 Each member will be able to recognize and Each member will be able to recognize and verbalize benefits to learning how to tolerate verbalize benefits to learning how to tolerate distress

distress distress distress

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Module 10

Module 10

Self

Self--SoothingSoothing

 Members will identify existing methods of selfMembers will identify existing methods of self--comfort

comfort

 Each member will begin to distinguish healthy Each member will begin to distinguish healthy ways of coping from harmful/damaging ways ways of coping from harmful/damaging ways

Module 11

Module 11

Boundaries and Safety Boundaries and Safety

M b b i t d l f h

M b b i t d l f h

 Members begin to develop a sense of how Members begin to develop a sense of how much or how little control they have over what much or how little control they have over what happens to their bodies

happens to their bodies

 Begin to understand how to set interpersonal Begin to understand how to set interpersonal limits

limits

 Boundary exercises (physical verbal)Boundary exercises (physical verbal)

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Module 12

Module 12

Trust and Intimacy Trust and Intimacy

 Members will be able to identify at least 1 Members will be able to identify at least 1 barrier which inhibits their ability to trust other barrier which inhibits their ability to trust other people

people

 Members will be able to identify intimacy and Members will be able to identify intimacy and see how it is separate from sex

see how it is separate from sex

Module 13

Module 13

Parenting Parenting Di h t b t b Di h t b t b 

Discuss how trauma, substance abuse, Discuss how trauma, substance abuse, and mental health issues have affected and mental health issues have affected their parenting choices and ability to parent their parenting choices and ability to parent

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Module 14

Module 14

Life Story Life Story G b i th t it G b i th t it 

Group members are given the opportunity Group members are given the opportunity to share their life story with the group to share their life story with the group

Members will understand how trauma has Members will understand how trauma has impacted their entire life

impacted their entire life

Module 15

Module 15

Closing Ritual Closing Ritual

Members experience healthy closureMembers experience healthy closure

Members will learn to delineate leavings and Members will learn to delineate leavings and their importance to the group

their importance to the group

Helps members internalize messages from Helps members internalize messages from the group experience

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While trauma may affect a

person for the rest of his/her

life, there are some criteria to

assess recovery

assess recovery

.

Source: Harvey, 1996 Source: Harvey, 1996

Recovery Criteria

 Physical symptoms of PTSD are within manageable Physical symptoms of PTSD are within manageable limits

limits limits limits

 Person is able to bear feelings associated with traumatic Person is able to bear feelings associated with traumatic memories.

memories.

 Memories don’t limit what he/she chooses to doMemories don’t limit what he/she chooses to do  Memory of trauma is linked with feelingMemory of trauma is linked with feeling

 Damaged selfDamaged self--esteem is restoredDamaged selfDamaged self esteem is restoredesteem is restoredesteem is restored

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Trauma _______________

Trauma

Breaking the Cycle

Depression Anxiety Trauma Re-triggered Arrested And Sentenced Jail Time Addictions Illegal Activity To Maintain And Compulsions

Thank You

Alisha F. Saulsbury, LCSW - C 410-476-4441 (3) tamars98@gmail.com

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