“Trauma-informed” was a term I was first introduced to when I was working as a substance abuse counselor at Valley State Prison for Women in Chowchilla, California, about five to six years ago. At the time, I remember all the substance abuse staff wondering how would we were going to incorporate this new treatment in our programs at the time. The answer was easy; we would receive training on how to be trauma-informed so that we would be able to be on board with the new changes.
When working in a criminal justice setting you have consider that many of the women prisoners being treated come into the prison terrified, scared, traumatized, beaten, and have mental health illness as well as addiction issues. The female inmates (clients) who now sit before you have been through a long journey before even getting to your office. Imagine being strip-searched when you first enter the prison and having to take off all your clothes in front of male and female correction officers to make sure you do not have any weapons in or on you. In addition, the correction officers also check to make sure that prisoners are not smuggling any kind of drugs and, just as seen on television, they have them squat and cough. For most of the world, that situation can be traumatizing, especially if you have never been to jail or prison. Having someone you don’t know see you naked and exposed creates trauma in itself. The clients sitting in front of you might have tears in their eyes; low self-esteem; might have been beaten the night before in their prison cell; and might have posttraumatic stress disorder (PTSD).
These are some of the things to consider when sitting in the room with angry female inmates: they are not angry with you. They could be angry, hurt, upset, abused or traumatized for reasons that have nothing to do with you. Do not take it personally if they lash out. These women have simply come to your office for help and for you to be a helper and healer in their world.
Trauma-Informed vs. Trauma-Specific
When looking at trauma-informed versus trauma-specific treatment, it is important to know the difference. According to Finkelstein and colleagues,
Addressing trauma in substance abuse treatment involves both “trauma-informed” and “trauma-specific” approaches. Trauma-informed systems and services take into account knowledge about trauma—its impact, interpersonal dynamics, and paths to recovery—and incorporate this knowledge thoroughly in all aspects of service delivery. The primary goals of trauma-specific services are more focused: to address directly the impact of trauma on people’s lives and to facilitate trauma recovery and healing. Ideally, substance abuse treatment programs will create trauma-informed environments, provide services that are sensitive and responsive to the unique needs of trauma survivors, and offer trauma-specific interventions (Finkelstein et al., 2004).
When we think about trauma that women have faced, many different images might come to mind. There might be a picture in our head of a hurricane that swept the town and claimed many lives of family members; or there might be a picture in your head of a person in the emergency room who had been hit by a car or truck. In any case, trauma is generally something that some individuals live with for a lifetime and cope with on an everyday basis. The American Psychiatric Association (APA) states that
Trauma is an emotional response to a terrible event like an accident, rape, or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships, and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives (APA, 2015).
SAMHSA’s TIP 57
When working with women it is important to have trauma awareness. In the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Treatment Improvement Protocol (TIP) 57, trauma-informed counselor competencies are outlined to help counselors with understanding the difference between trauma-informed and trauma-specific concepts. A review of these points will help counselors familiarize themselves with trauma awareness (SAMHSA, 2014):
- Understand the differences among various kinds of abuse and trauma, including: physical, emotional, and sexual abuse; domestic violence; experiences of war for both combat veterans and survivors of war; natural disaster; and community violence
- Understand the different effects that various kinds of trauma have on human development and the development of psychological and substance use issue
- Understand how protective factors, such as strong emotional connections to safe and nonjudgmental people and individual resilience, can prevent and ameliorate the negative impact trauma has on both human development and the development of psychological and substance abuse issues
- Understand the importance of ensuring the physical and emotional safety of clients
- Understand the importance of not engaging in behaviors, such as confrontation of substance use, or other seemingly unhealthy client behaviors, which might activate trauma symptoms or acute stress reactions
- Demonstrate knowledge of how trauma affects diverse people throughout their lifespans and with different mental health problems, cognitive and physical disabilities, and substance use issues
- Demonstrate knowledge of the impact of trauma on diverse cultures with regard to the meanings various cultures attach to trauma and the attitudes they have regarding behavioral health treatment
- Demonstrates knowledge of the variety of ways clients express stress reactions both behaviorally (e.g., avoidance, aggression, passivity) and psychologically/emotionally (e.g., hyperarousal, avoidance, intrusive memories)
TIP 57 also outlines trauma-informed counselor skills that will help counselors identify the skills that can make them the most effective when working with traumatized clients (SAMHSA, 2014):
- Expedites client-directed choice and demonstrates a willingness to work within a mutually empowering (as opposed to a hierarchical) power structure in the therapeutic relationship
- Maintains clarity of roles and boundaries in the therapeutic relationship
- Shows competence in screening and assessment of trauma history (within the bounds of his or her licensing and scope of practice), including knowledge of and practice with specific screening tools
- Demonstrates an ability to identify clients’ strengths, coping resources, and resilience
- Facilitates collaborative treatment and recovery planning with an emphasis on personal choice and a focus on clients’ goals and knowledge of what has previously worked for them
- Respects clients’ ways of managing stress reactions while supporting and facilitation taking risk to acquire different coping skills that are consistent with clients’ values and preferred identity and way of being in the world
- Demonstrates knowledge and skill in general trauma-informed counseling strategies, including, but not limiting to: grounding techniques that manage dissociative experience; cognitive behavioral tools that focus on both anxiety reduction and distress tolerance; and stress management and relaxation tools that reduce hyperarousal
- Identifies signs of STS reaction and takes steps to engage in appropriate self-care activities that lessen the impact of these reactions on clinical work with clients
- Recognizes when the needs of clients are beyond his or her scope of practice and/or when clients’ trauma material activates persistent secondary trauma or countertransference reactions that cannot be resolved in clinical supervision; makes appropriate referrals to other behavioral health professionals
Books, Curricula, and Helpful Tools
The following is a list of books, curricula, and other tools that can be used to help treat women in correctional facilities:
Helping Women Recover
Helping Women Recover (2008) by Stephanie Covington, PhD, is an integrated curriculum addressing trauma and addiction based on relational and cognitive behavioral theories and integrating expressive arts. This curriculum features seventeen sessions at ninety minutes each and is great for use in a criminal justice setting.
In Seeking Safety (2001), Lisa Najavits, PhD, provides present-focused therapy promoting safety and recovery and integrates cognitive-behavioral theory with interpersonal and case management domains. This curriculum features twenty-five sessions that range from fifty to ninety minutes each. This is great for use in a criminal justice setting.
TIP 57: Trauma-Informed Care in Behavioral Health Services
SAMHSA’s TIP 57 is a great book to have as a reference for best practices.
Women’s Treatment Specialist Endorsement
The Women’s Treatment Specialist Endorsement (WTS-E) is for counselors who are currently certified and who wish to add credentials signifying their competence in women’s treatment. Titles of courses include (CCBADC, 2009):
- Women’s health
- Gender-specific risk factors: domestic violence and sexual abuse
- Trauma-specific treatment
- Systems coordination: Resources and partnerships across the lifespan
- Parenting issues and developmental milestones throughout the lifespan
The applicant must provide documentation of a minimum of one years’ (two thousand hours) work experience and fill out an application. The definition of women’s specialty experience means
working in a women-specific alcohol/drug treatment or prevention setting that offers women’s specific treatment, intervention or prevention for women. Specialty service offered may include, but are not limited to: Parenting, recovery and the family, trauma, referrals and consultation to and with women’s specific services, domestic violence and alcohol/drug use, abuse or dependence (CCBADC, 2009).
The Offender Mentor Certification Program
I had the honor of being the director of the Offender Mentor Certification Program (OMCP), an innovative program that certifies inmates to become substance abuse counselors while being incarcerated. For the past eight years I worked inside the prison walls training, counseling, supervising, and directing inmates who volunteered to participate in this exciting new approach to certification. Three years of the eight years, I worked under the direction of the California Association of Alcohol and Drug Abuse Counselors (CAADAC) which has since consolidated with the California Association of Addiction Recovery Resources (CAARR) to become the California Consortium of Addiction Programs and Professionals (CCAPP).
There were over twelve prison locations that offered the OMCP which I directed and managed. The program was an absolute success in not only achieving certification status for the participants involved, but in increasing the availability of treatment in the prison environment in which these inmates are located. The true success will be in the progression toward recovery the inmates demonstrate after receiving treatment from these long-term incarcerated counselors.
A California Department of Corrections and Rehabilitation (CDCR) OMCP fact sheet from last year outlined the goals of the program:
The OMCP is a voluntary program for long-term and life-term inmates, which provides offenders with the training and certification needed to allow them to become certified mentors for alcohol and drug counseling. Once participants graduate from this program, they are assigned as inmate mentors at the Substance Abuse Treatment (SAT) programs within Reentry Hub facilities. The primary goal of the OMCP is to provide a sustainable workforce of certified inmate mentor alcohol and drug counselors who, along with certified contracted drug and alcohol counselors, provide enhanced treatment services to inmates assigned to the SAT programs. This program is also intended to reduce the incidence of substance abuse relapse and recidivism among SAT program participants. OMCP candidates, at the completion of training, can obtain a substance abuse counseling certification from a certifying organization recognized by the Department of Health Care Services (DHCS). OMCP mentors currently earn their certification through the California Association of Alcoholism and Drug Abuse Counselors (CAADAC) and have used the certification to obtain employment upon release (CDCR, 2014).
The OMCP is geared toward success and carefully reviews each applicant and participant. Many candidates were not selected for various reasons and were removed from the program for various causes. For instance, inmates can be removed or not selected for the program if they had received a serious disciplinary action or could not meet the qualifications or requirements outlined in the application. The coursework and training required a high degree of commitment, as it was an expedited academic program that moved rapidly from course to course. Therefore an intense interview process took place to ensure that only the most highly qualified candidates were selected. I remember, as though it was just yesterday, holding interviews with a long list of male and female inmates in order to qualify a mere fifty candidates for the OMCP. For weeks I went through pages and pages of resumes, essays, and interviews. Once selected, the twenty-five male and twenty-five female inmates were brought into rooms, in each separate prison, and informed that they made it into the program. The inmates selected clapped, cried, and cheered for being given the opportunity to participate in the program.
As it became to be known as “education boot camp” for inmates serving long-term or life sentences, each looked forward to the challenge and the opportunity that lie ahead. Similar to counselors on the “outside,” these individuals wanted to make a change in not only their life, but in other’s lives, while being incarcerated. The inmates deserve to be celebrated as the “cream of the crop” and were held to high standards as role models and leaders in the prison environment.
Throughout my tenure of working in the twelve different prisons, side by side with inmates, I garnered a unique respect for them. The mentors were full of hope and determination, and displayed a high level of intelligence and integrity. Their willingness to learn something new became second nature quickly for some, while others struggled in the beginning. Overall the long-term and lifer population definitely impressed me with their academic skills and the ability to go above and beyond to help clients. This group definitely excelled in challenging situations when presented with them. The hard work and the “don’t give up” attitudes displayed by OMCP mentors going through the program were priceless.
There was a two-week segment of the OMCP that the CDCR would carve out specifically to facilitate a trauma-informed training for the inmates studying to become substance abuse counselors. I found that to be the most rewarding segment for the inmates because it taught the female inmates how to become trauma-informed while still incarcerated. I must admit those two weeks were packed with information and the prison did a great job incorporating the content in an easily understood format.
The OMCP women mentors worked in a trauma-informed substance abuse program and did a great job making clients feel safe. The OMCP mentors would cofacilitate staff classes such as Seeking Safety and Helping Women Recover. There was a handout titled “Safe Coping Skills” in the Seeking Safety curriculum that they would go over that would supply tools for the clients to use when in need. Some of the skills included: “List your options,” “Create meaning,” “Set boundaries,” “Cry,” “Pace yourself,” “Stay safe,” “Set an action plan,” “Learn from experience,” “Detach from emotional pain,” Self-nurture,” and “Create a new story,” just to name a few. (Najavits, 2002).
Core Concepts of Treatment incorporates curriculum that teaches clients to “Stay safe,” “Respect yourself,” “Use coping not substances to escape the pain,” “Make the present and future better than the past,” “Learn to trust,” and “Take good care of your body,” among others. The skills and lessons presented by these important guides were tremendously informative and needed. After being trained, the OMCP mentors would think about trauma as a factor of treatment when working with the women. They would pay attention to tone, delivery, and most importantly, make it a safe environment for women to share their feelings. Many clients also appreciated the all-women groups, as some of the clients had been through treatment in coed groups when they were not incarcerated.
I cannot express how important it is to educate yourself on how to become well versed in trauma-informed and trauma-specific treatment methods, especially if you are working with female trauma survivors. Make sure when you are doing an assessment with all female inmates that you screen for past and present trauma. Many times clients can be misdiagnosed by receiving an inaccurate assessment when a counselor or clinician misses something that was a key factor in diagnosing or helping her in the long run. I cannot tell you enough how very important it is to take your time on the assessment, as I have seen time and time again where a professional has rushed through a session and missed key items. It is so important to slow down, to take the necessary time, and not to rush the process. Another important point to consider is to make sure that you have incorporated trauma treatment for yourself by reaching out for services if you have had trauma in your life. Trauma may likely manifest itself unexpectedly during a session with your client, causing you to encounter some countertransference issues if not properly addressed by a professional beforehand. Lastly, make sure that your practice or facility is trauma-informed when working with incarcerated women.
I received a phone call in the afternoon while I was writing this article. The phone call I received was about a young man that lost his life in a motorcycle accident. The gentleman’s voice on the phone was quiet and soft spoken when telling me the sad news. I was shocked to learn that the fatally injured man was an OMCP mentor that I helped coach to become a substance abuse counselor. The thought of him losing his life crushed my heart thinking about all the hard work and determination he put in to become a certified alcohol and drug abuse counselor. He was on a mission and wanted to help counsel clients that were suffering from addiction and be of service. I suddenly began to feel lightheaded, and sadness fell over me by the end of the phone call.
Today we have lost a phenomenal substance abuse counselor, son, and father. I would like to dedicate this article to Clay White, a former OMCP graduate who lost his life on April 26, 2015.
Mr. White, you’ve helped inspire future OMCP mentors inside and outside the prison walls and have helped many clients on your journey. You will always be remembered in our minds as a strong individual that loved to counsel and help clients with their struggles and addictions. Rest in peace.
American Psychological Association (APA). (2015). Trauma. Retrieved from http://www.apa.org/topics/trauma/
California Certification Board of Alcohol and Drug Counselors (CCBADC). (2009). Women’s treatment specialist endorsement (WTS-E) education and experiential requirements. Retrieved from https://www.caadac.org/site_media/media/attachments/flatpages_flatpage/101/wts_endorsement_0309_final-version2.pdf
California Department of Corrections and Rehabilitation (CDCR). (2014). Offender mentor certification program (OMCP). Retrieved from http://www.cdcr.ca.gov/rehabilitation/offender-mentor-certification-program.html
Covington, S. (2008). Helping women recover: A program for treating addiction (rev. ed.). San Francisco, CA: Jossey-Bass.
Finkelstein, N., VandeMark, N., Fallot, R., Brown, V. B., Cadiz, S., & Heckman, J. (2004). Enhancing substance abuse recovery through integrated trauma treatment. Retrieved from http://aia.berkeley.edu/strengthening_connections/handouts/4b/Enhancing%20Substance%20Abuse%20Recovery%20through%20Integrated%20Trauma%20Treatment%20%282004%29.pdf
Najavits, L. M. (2001). Seeking safety: A treatment manual for PTSD and substance abuse. New York, NY: Guilford Press.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2014) A treatment improvement protocol: Trauma-informed care in behavioral health services: TIP 57. Retrieved from http://store.samhsa.gov/shin/content/SMA14-4816/SMA14-4816.pdf