1. The TAMAR Program David Washington, MSW Program Coordinator

2. How Maryland came to understand the need for Trauma Treatment

3. Phoenix Project SAMHSA Jail Diversion Site 1997 Served women with co-occurring disorders Pre and Post-booking diversion Mobile Crisis Unit Multi-Agency Partnership

4. Conclusions and Impacts (Phoenix Project Data) About 2/3 of women (68%) grew up in families in which one or both parents had active alcohol or substance abuse problems. About 24% grew up in families where one or both parents had a serious mental illness. Approximately 51% experienced childhood sexual abuse by a family member or someone outside the family prior to age 14.

5. Conclusions and Impacts (Continued) About 43% experienced physical abuse by a family member prior to age 14. By age 14, 59% reported using alcohol and 44% had begun using marijuana, By age 17, 57% had become pregnant. By age 18, 74% had experienced their first indications of serious mental illness & 34% had made at least 1 suicide attempt. By age 18, 27% had been arrested at least 1 time

6. TAMAR PROGRAM SAMHSA Women and Violence Site Maryland only site addressing the needs of incarcerated women Began in 3 local detention centers Currently serving 9 sites in Maryland Provides mental health, substance abuse, and trauma treatment for men & women in detention centers and State psychiatric hospitals

7. Tamar’s Story In the Old Testament, Tamar was a daughter of King David. Tamar’s half brother Amnon raped her. The author of II Samuel writes that afterwards she tore her clothes and retreated into her brother’s house. She is not mentioned in the Bible again.

8. TAMAR stands for: Trauma Addictions Mental health And Recovery

9. Question Criteria for JSAP/TAMAR Washington County Detention Center Question Criteria For JSAP/TAMAR Please circle Yes or No for each question 1.Do you have a chronic medical condition? 2.In your life, have you ever experienced any traumatic events? 1.Are you interested in treatment? 3.Do you have substance abuse issues? 4.If yes and female 1.Are you currently pregnant? 2.Have you had a baby within the last year? 3.Do you have custody of any children ages 12 or under? 4.Are you court ordered to any programs?

11. Preparing for Implementation Trauma training for community agencies Trauma training for staff Symptoms and behaviors are adaptations Everyone involved in contact with the survivor has the ability to be a helper The helper’s responses are essential tools and must be noticed and used constructively

12. TAMAR Program Components Administered by Master’s level, licensed mental health clinician Individual sessions Group sessions Linkage to case management and aftercare

13. How is TAMAR accessed? Screening administered at facility intake Trauma Specialist does in- depth assessment on those that screen “positive” for trauma Program is explained and offered to eligible individuals

14. TAMAR Groups Meet twice a week for 90 minute sessions Groups of 12-15 individuals Voluntary, no good time or credit earned for participation

15. TAMAR Treatment Manual The TAMAR Manual consists of 15 modules Modules incorporate psychodynamic therapy with expressive art therapy and psycho- educational techniques

16. Module 1 What is Trauma? Who Cares, Why Bother, What’s in it for Me ? Recognition of traumatic reactions makes management of survivors’ much easier A little bit of trauma awareness goes a long way Ongoing trauma treatment across a continuum of care is a major contributing factor to reducing recidivism in this population

17. CREATIVE RE-STRUCTURING IN TRAUMA TREATMENT Anita Rankin Recovery Above Nonsense I am becoming As I look for choices Reminded of the possibilities I will save my life Acknowledging the sweet and the bitter The World Begins to Radiate Lights

18. Module 2 What is Abuse? – Physical and Emotional Goal is to recognize behaviors/actions that constitute physical and emotional abuse Recognize the impact of physical and emotional abuse on their lives

19. Managing Traumatic Stress Through Art

20. Module 3 What is Abuse? – Sexual Abuse Goal is to recognize how sexual abuse has impacted their lives. Recognize self-defeating thoughts and behaviors and begin to develop their right to a healthy self-concept

21. Module 4 Trauma and Addiction – Goal is to recognize addictive/compulsive behaviors as coping mechanisms – Make the connection between addictive/compulsive behaviors and their trauma

22. Module 5 Facts on HIV/AIDS – Goal is to provide facts about HIV/AIDS as well as discuss myths and misconceptions – Demonstration of behavior skills to reduce the risk of HIV/AIDS transmission – This module may be triggering to many women and needs to be presented in a trauma context (i.e. presentation of overt sexual materials introduced with permission to feel and voice upset)

23. Module 6 Sexual Communication and Negotiation Skills – Discuss what constitutes sexual communication (both verbal and non-verbal) – Provides an opportunity to role-play negotiation skills (includes sexual assertiveness, safe sex, and refusal of unsafe sex)

24. Module 7 Containment – Why containment instead of disclosure? – Goal is to help members describe levels of consciousness and understand the different parts of memory. – Increases self-awareness

25. Module 8 Containment II - Grounding – Goal is to identify different grounding techniques. – Members will be able to practice grounding techniques daily, outside of group

26. Module 9 Tolerating Distress – Each member will begin to distinguish the negative aspects of being unable to tolerate distress – Each member will be able to recognize and verbalize benefits to learning how to tolerate distress

27. DISTRESS TOLERANCE Crisis Survival Strategies

28. Module 10 Self-Soothing – Members will identify existing methods of self- comfort – Each member will begin to distinguish healthy ways of coping from harmful/damaging ways

29. Module 11 Boundaries and Safety – Members begin to develop a sense of how much or how little control they have over what happens to their bodies – Begin to understand how to set interpersonal limits. – Boundary exercises (physical, verbal)

30. Physical Boundaries

31. Module 12 Trust and Intimacy – Members will be able to identify at least 1 barrier which inhibits their ability to trust other people – Members will be able to identify intimacy and see how it is separate from sex

32. Module 13 Parenting – Discuss how trauma, substance abuse, and mental health issues have affected their parenting choices and ability to parent – How trauma affects attachment

33. Module 14 Life Story – Group members are given the opportunity to share their life story with the group – Members will understand how trauma has impacted their entire life

34. Module 15 Closing Ritual – Members experience healthy closure – Members will learn to delineate leavings and their importance to the group – Helps members internalize messages from the group experience

35. While trauma may affect a person for the rest of his/her life, there are some criteria to assess recovery.

36. Recovery Criteria Physical symptoms of PTSD are within manageable limits Person is able to bear feelings associated with traumatic memories. Memories don’t limit what he/she chooses to do Memory of trauma is linked with feeling Damaged self-esteem is restored Important relationships have been reestablished Person has reconstructed a system of meaning & belief that encompasses the story of the trauma

37. TAMAR Outcome Measures AA= anxious arousal D=depression AI=anger/irritability ID=intrusive experiences DA=defensive avoidance DIS=dissociation SC=sexual concerns DSB=dysfunctional sexual behavior ISR=impaired self-reference TRB=tension reduction behaviors T=trauma SLF=self D=dysphoria Chart by:Anne Catapang

38. David Washington, MSW SAMHSA’s National Center for Trauma Informed Care Washington County Health Department 240-313-2161 davidwashington@dhmh.state.md.us Download your TAMAR Manual here: http://www.nasmhpd.org/TA/NCTIC.aspx Contact Information