Trauma’s Impact in the CourtsChildren in the Courts

Administrative Office of the Courts

Therese Skinner, LCSW-JLAP Clinical Therapist

Why am I presenting a CLE? Education

Bachelors of Arts Psychology, University of Wyoming

Master of Social Work, University of Arkansas-Little Rock

Trauma Training-

Trauma Focused Cognitive Behavior Therapy (TF-CBT)

UALR course “Trauma treatment for Adolescents and Children” preliminary national training and online exam

4 days UAMS year 1

1 year monthly phone calls, supervision, 3 case presentations

2 days UAMS year 2-listed on website

Appropriate treatment ages 4-18

Dialectical Behavior Therapy (DBT)

Skills training, foundational training, intensive training, team training, mindfulness training, Substance Use Disorder training, Intensive Prolonged Exposure (PTSD treatment) 4th year, final certification process

Court Experience

State program (ArkSTART dual diagnosis ID/MH program assessment-community mental health/911 systems work)

Residential therapist Youth Home-Foster system adolescents, SMI adolescents throughout the State’s courts working with AALs, guardians, courts, FINS, and lawyers

Day Treatment Therapist-Highschool age LRSD, NLR, Pulaski Special Schools-FINS, juvenile court system, AAL, Foster system

School Based Clinician/Outpatient clinician Pinnacle Pointe-England School District, North Little Rock Alternative Middle School and High School-Rose City, Little Rock Central High School, school systems with trauma clients within clinic-DHS system, FINS system, administration, juvenile courts, adult criminal courts

Ethically why you should care about Trauma…

Preamble

[2] As a representative of clients, a lawyer performs various functions. As advisor, a lawyer provides a client with an informed understanding of the client's legal rights and obligations and explains their practical implications. As advocate, a lawyer zealously asserts the client's position under the rules of the adversary system. As negotiator, a lawyer seeks a result advantageous to the client but consistent with requirements of honest dealing with others. As an evaluator, a lawyer acts by examining a client's legal affairs and reporting about them to the client or to others.

[4] In all professional functions a lawyer should be competent, prompt and diligent. A lawyer should maintain communication with a client concerning the representation. A lawyer should keep in confidence information relating to representation of a client except so far as disclosure is required or permitted by the Rules of Professional Conduct or other law.

(Arkansas Courts | [Current] Arkansas Rules of Professional Conduct, n.d.)

Ethically???? What if you have trauma??

Rule 1.3. Diligence.

A lawyer shall act with reasonable diligence and promptness in representing a client

Comments

[1] A lawyer should pursue a matter on behalf of a client despite opposition, obstruction or personal inconvenience to the lawyer, and take whatever lawful and ethical measures are required to vindicate a client's cause or endeavor. A lawyer must also act with commitment and dedication to the interests of the client and with zeal in advocacy upon the client's behalf.

[2] A lawyer's work load must be controlled so that each matter can be handled competently.

[3] Perhaps no professional shortcoming is more widely resented than procrastination. A client's interests often can be adversely affected by the passage of time or the change of conditions; in extreme instances, as when a lawyer overlooks a statute of limitations, the client's legal position may be destroyed. Even when the client's interests are not affected in substance, however, unreasonable delay can cause a client needless anxiety and undermine confidence in the lawyer's trustworthiness. A lawyer's duty to act with reasonable promptness, however, does not preclude the lawyer from agreeing to a reasonable request for a postponement that will not prejudice the lawyer's client.

(Arkansas Courts | [Current] Arkansas Rules of Professional Conduct, n.d.)

Ethically what if your client has trauma?

Rule 1.14. Client with Diminished Capacity

(a) When a client's ability to make adequately considered decisions in connection with the representation is diminished, whether because of minority, mental disability or for some other reason, the lawyer shall, as far as reasonably possible, maintain a normal client-lawyer relationship with the client.

(b) When the lawyer reasonably believes that the client has diminished capacity, is at risk of substantial physical, financial or other harm unless action is taken and cannot adequately act in the client's own interest, the lawyer may take reasonably necessary protective action, including consulting with individuals or entities that have the ability to take actions to protect the client, and in appropriate cases, seeking the appointment of a guardian ad litem, conservator or guardian. Extreme caution must be exercised by a lawyer before nominating the lawyer, a member or employee of the lawyer's firm, or a relative within the third degree or relationship to serve as guardian ad litem, conservator or guardian.

(c) Information relating to the representation of a client with diminished capacity is protected by Rule 1.6. When taking protective action pursuant to paragraph (b), the lawyer is impliedly authorized under Rule 1.6(a) to reveal information about the client, but only to the extent reasonably necessary to protect the client's interests.

(Arkansas Courts | [Current] Arkansas Rules of Professional Conduct, n.d.)

What is “Trauma”???

(Arkansas Building Effective Services for Trauma, n.d.)

Traumatic Stress

(Arkansas Building Effective Services for Trauma, n.d.)

Wait! Not so simple…How do we

diagnose trauma???

DSM V the new era from DSM IV-TR

The criteria for posttraumatic stress disorder PTSD have changed considerably with the newest edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders(DSM-5). Changes to the diagnostic criteria from the DSM-IV to DSM-5 include: the relocation of PTSD from the anxiety disorders category to a new diagnostic category named “Trauma and Stressor-related Disorders”, the elimination of the subjective component to the definition of trauma, the explication and tightening of the definitions of trauma and exposure to it, the increase and rearrangement of the symptoms criteria, and changes in additional criteria and specifiers.

(Pai et al., 2017)

Trauma and Stressor-Related Disorders

DSM 5

PTSD-Posttraumatic Stress Disorder

ASD-Acute Stress Disorder

Adjustment disorder

Reactive attachment disorder (RAD) (diagnosed only in children)

Disinhibited social engagement disorder (DSED) (diagnosed only in children)

Other specified trauma- and stressor-related disorder

Unspecified trauma- and stressor-related disorder

(Collection of Evidence-based Practices for Children and Adolescents with Mental Health Treatment Needs Virginia

Commission on Youth TRAUMA-AND STRESSOR-RELATED DISORDERS, 2017)

Pull up your big girl panties…Why some experience trauma and others do not

DBT Biosocial Theory

(Linehan, 2015)

Why PTSD? (PE, Dr. Foa, VA theory…)

(Harned, 2019)

Trauma exists…now what??? Treatments.

Trauma Focused Cognitive Behavior Therapy TFCBT

EMDR

Brainspotting

Prolonged Exposure

DBTPE

Evidenced Based!!!

Children/Adolescents (under 18)

(Arkansas Building Effective Services for Trauma, n.d.)

Trauma Focused Cognitive Behavior Therapy-TF-CBT

(TF-CBT Training Package, 2013)

How can I find a TF-CBT Therapist?

(UAMS can help)

(Arkansas Building Effective Services for Trauma, n.d.)

Eye Movement Desensitization and Reprocessing

EMDR EMDR (Eye Movement Desensitization and Reprocessing) is a psychotherapy that enables people to heal from the symptoms and emotional

distress that are the result of disturbing life experiences. Repeated studies show that by using EMDR therapy people can experience the benefits of psychotherapy that once took years to make a difference. It is widely assumed that severe emotional pain requires a long time to heal. EMDR therapy shows that the mind can in fact heal from psychological trauma much as the body recovers from physical trauma. When you cut your hand, your body works to close the wound. If a foreign object or repeated injury irritates the wound, it festers and causes pain. Once the block is removed, healing resumes. EMDR therapy demonstrates that a similar sequence of events occurs with mental processes. The brain’s information processing system naturally moves toward mental health. If the system is blocked or imbalanced by the impact of a disturbing event, the emotional wound festers and can cause intense suffering. Once the block is removed, healing resumes. Using the detailed protocols and procedures learned in EMDR therapy training sessions, clinicians help clients activate their natural healing processes.

More than 30 positive controlled outcome studies have been done on EMDR therapy. Some of the studies show that 84%-90% of single-trauma victims no longer have post-traumatic stress disorder after only three 90-minute sessions. Another study, funded by the HMO Kaiser Permanente, found that 100% of the single-trauma victims and 77% of multiple trauma victims no longer were diagnosed with PTSD after only six 50-minute sessions. In another study, 77% of combat veterans were free of PTSD in 12 sessions. There has been so much research on EMDR therapy that it is now recognized as an effective form of treatment for trauma and other disturbing experiences by organizations such as the American Psychiatric Association, the World Health Organization and the Department of Defense. Given the worldwide recognition as an effective treatment of trauma, you can easily see how EMDR therapy would be effective in treating the “everyday” memories that are the reason people have low self-esteem, feelings of powerlessness, and all the myriad problems that bring them in for therapy. Over 100,000 clinicians throughout the world use the therapy. Millions of people have been treated successfully over the past 25 years.

EMDR therapy is an eight-phase treatment. Eye movements (or other bilateral stimulation) are used during one part of the session. After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist’s hand as it moves back and forth across the client’s field of vision. As this happens, for reasons believed by a Harvard researcher to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level. For instance, a rape victim shifts from feeling horror and self-disgust to holding the firm belief that, “I survived it and I am strong.” Unlike talk therapy, the insights clients gain in EMDR therapy result not so much from clinician interpretation, but from the client’s own accelerated intellectual and emotional processes. The net effect is that clients conclude EMDR therapy feeling empowered by the very experiences that once debased them. Their wounds have not just closed, they have transformed. As a natural outcome of the EMDR therapeutic process, the clients’ thoughts, feelings and behavior are all robust indicators of emotional health and resolution—all without speaking in detail or doing homework used in other therapies.

(What is EMDR? | EMDR Institute – EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY, 2019)

Where do I find EMDR “certified”

therapist?

(EMDR Institute – EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY, 2019)

Brainspotting (EMDR lite)

Brainspotting is a powerful, focused treatment method that works by identifying, processing and releasing core neurophysiological sources of emotional/body pain, trauma, dissociation and a variety of other challenging symptoms. Brainspotting is a simultaneous form of diagnosis and treatment, enhanced with Biolateral sound, which is deep, direct, and powerful yet focused and containing.

Brainspotting functions as a neurobiological tool to support the clinical healing relationship. There is no replacement for a mature, nurturing therapeutic presence and the ability to engage another suffering human in a safe and trusting relationship where they feel heard, accepted, and understood.

Brainspotting gives us a tool, within this clinical relationship, to neurobiologically locate, focus, process, and release experiences and symptoms that are typically out of reach of the conscious mind and its cognitive and language capacity.

Brainspotting works with the deep brain and the body through its direct access to the autonomic and limbic systems within the body’s central nervous system. Brainspotting is accordingly a physiological tool/treatment which has profound psychological, emotional, and physical consequences.

(Brainspotting – Where you look affects how you feel, n.d.)

Where do I find a certified Brainspotting

therapist?

Good Question.

Prolonged Exposure-PE

Prolonged exposure teaches individuals to gradually approach their trauma-related memories, feelings and situations. They presumably learn that trauma-related memories and cues are not dangerous and do not need to be avoided.

Introduction to PE

Exposure is an intervention strategy commonly used in cognitive behavioral therapy to help individuals confront fears. Prolonged exposure is a specific type of cognitive behavioral therapy that teaches individuals to gradually approach trauma-related memories, feelings and situations.

Most people want to avoid anything that reminds them of the trauma they experienced, but doing so reinforces their fear. By facing what has been avoided, a person can decrease symptoms of PTSD by actively learning that the trauma-related memories and cues are not dangerous and do not need to be avoided.

This treatment is strongly recommended for the treatment of PTSD.

(“Prolonged Exposure (PE),” n.d.)

Dialectical Behavior Therapy-Prolonged

Exposure (PE’s better half)

The Dialectical Behavior Therapy Prolonged Exposure (DBT PE) protocol is designed to treat PTSD among suicidal, self-injuring, and multi-diagnostic adolescents and adults receiving Dialectical Behavior Therapy (DBT). The DBT PE protocol is based on Prolonged Exposure (PE) therapy, a highly effective treatment for PTSD that utilizes in vivo and imaginal exposure followed by processing as the core treatment strategies. The integrated DBT and DBT PE protocol treatment uses a stage-based approach to comprehensively address the full range of problems experienced by high-risk, severe, and complex clients with PTSD.

(Treating PTSD, n.d.)

Where do I find a DBT-PE therapist?

(Treating PTSD, n.d.)

Trauma goes to court…clients

Recognizing trauma

Letting Judge Judy go home for the

day

Seeking mental health support

I have poor clients!

I have minority clients

I have non-compliant clients

“They need a good “whoopin’”

Trauma goes to court…lawyers, judges, court

”I don’t need help”

Our friend and colleague-VICARIOUS TRAUMA

Vicarious trauma is an occupational challenge for people working and volunteering in the

fields of victim services, law enforcement, emergency medical services, fire services, and

other allied professions, due to their continuous exposure to victims of trauma and

violence. This work-related trauma exposure can occur from such experiences as listening

to individual clients recount their victimization; looking at videos of exploited children;

reviewing case files; hearing about or responding to the aftermath of violence and other

traumatic events day after day; and responding to mass violence incidents that have

resulted in numerous injuries and death (Vicarious Trauma Toolkit | What is Vicarious

Trauma?, n.d.)

We have a way we do things here

Compassion fatigue

I don’t feel anything anymore

I don’t care about anything anymore

Toll on relationships

Substances

Where to get help for trauma if you’re a

lawyer or a judge or anyone???

JLAP

Hotlines

Insurance companies

Internet (PLEASE BE CAREFUL)

Websites listed

Psychology Today

Awareness, support, addressing our

friend trauma…

Education

Resources

Support

Ethically-how can I address trauma in

the court???

Address it.

Seek support of JLAP

Seek support of OPC

Gratitude to all of

you…

(Contemplation of Justice, n.d.)

Questions?

References.

Arkansas Building Effective Services for Trauma. (n.d.). Https://Arbest.Uams.Edu/. Retrieved April 30, 2020, from https://arbest.uams.edu

Arkansas Courts | [Current] Arkansas Rules of Professional Conduct. (n.d.). Rules.Arcourts.Gov. Retrieved April 30, 2020, from https://rules.arcourts.gov/w/ark/current-arkansas-rules-of-professional-conduct#

Brainspotting – Where you look affects how you feel. (n.d.). Retrieved April 30, 2020, from https://brainspotting.com

Collection of Evidence-based Practices for Children and Adolescents with Mental Health Treatment Needs Virginia Commission on Youth TRAUMA-AND STRESSOR-RELATED DISORDERS. (2017). http://vcoy.virginia.gov/documents/collection/018%20Trauma2.pdf

Contemplation of Justice. (n.d.). Www.Supremecourt.Gov. Retrieved April 30, 2020, from https://www.supremecourt.gov/about/infosheets/ContemplationOfJustice.html?rwndrnd=0.4481974656227976

Harned, M. (2019) DBT Prolonged Exposure Protocol Treatment Forms and Handouts. Mharned@dbtpe.org

Linehan, M. M. (2015). DBT® skills training handouts and worksheets (2nd ed.). Guilford Press

Pai, A., Suris, A., & North, C. (2017). Posttraumatic Stress Disorder in the DSM-5: Controversy, Change, and Conceptual Considerations. Behavioral Sciences, 7(4), 7. https://doi.org/10.3390/bs7010007

Prolonged Exposure (PE). (n.d.). Https://Www.Apa.Org. https://www.apa.org/ptsd-guideline/treatments/prolonged-exposure

TF-CBT Training Package. (2013). Trauma-Focused Cognitive Behavioral Therapy. https://tfcbt.org/about-tfcbt/

Treating PTSD. (n.d.). Treating PTSD. Retrieved April 30, 2020, from https://dbtpe.org

Vicarious Trauma Toolkit | What is Vicarious Trauma? (n.d.). Vtt.Ovc.Ojp.Gov. https://vtt.ovc.ojp.gov/what-is-vicarious-trauma

What is EMDR? | EMDR Institute – EYE MOVEMENT DESENSITIZATION AND REPROCESSING THERAPY. (2019). Emdr.Com. https://www.emdr.com/what-is-emdr/