Alisha Saulsbury, Trauma, Addiction, Mental Health and Recovery (TAMAR)
What is TAMAR 1?
TAMAR (Trauma, Addiction, Mental Health and Recovery) is a trauma-focused program for women that has been implemented in select Maryland detention centers. The TAMAR program aims to provide appropriate services to trauma victims and break the cycle of substance abuse, arrest, and incarceration. Participating women have been identified or self-identified as having a history of physical and/or sexual abuse and a recent treatment history for a mental health condition as well as a drug use/abuse disorder. Individuals eligible to participate are encouraged to voluntarily join the program with the knowledge that participation does not in itself reduce jail time. Program services are delivered by a licensed, Master’s level clinician who is responsible for providing bio-psycho-educational treatment in accordance with the TAMAR program manual. TAMAR staff managers provide coordination of services while the woman is incarcerated, develop an aftercare plan with her, make community referrals, advocate for “mainstream” services, and establish communication for monitoring the receipt of treatment upon her reentry to the community. The program provides for the education of jail staff, community mental health providers, and appropriate stakeholders with regard to the needs of trauma survivors. TAMAR is a 15-week program that delivers 30 trauma related topics or exercises to incarcerated women.
Why Was TAMAR Created?
TAMAR, a joint effort of the Maryland Department of Health and Mental Hygiene, the Maryland Correctional Administrators Association, local detection centers, and a group of core services agencies, began in three detention centers across the state of Maryland. The program was developed in light of the recognition that many women in the criminal justice system have histories of extensive trauma, and that such trauma continues to impact these women in negative ways 2 . TAMAR began in an effort to develop a custody environment for women that would lessen the likelihood of re-traumatization and assist individuals in finding the capacity to self-regulate. TAMAR is designed to help both the women and correctional officers to understand the significant impact of trauma and violence, and seeks to encourage interactions between staff and inmates that are respectful and non-harmful. Although only a recent emerging intervention in corrections, several states (including Massachusetts, Rhode Island, and Hawaii) have experienced positive results upon implementation of trauma-based principles and interventions.
“Traumatic past experiences are not seen as an excuse, but an explanation, in understanding a woman’s behavior.”
How Are Participants Selected?
At intake, women are provided with a brief assessment and brochure about the program. Participation in TAMAR is voluntary and no good time is accrued for participation. Upon intake, the following questions are asked:
- Are you haunted by terrible things that happened in your past (distressing dreams or flashbacks)?
- Have you experienced, witnessed or been confronted with events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others?
- Do you have periods of time in your life that you cannot remember that are not because of substance abuse?
The program has also significantly reduced disciplinary action, reduced recidivism, reduced the use of seclusion and restraints, and promoted connection and trusting relationships between inmates and staff.
The form is confidential and placed in a sealed envelope and forwarded to the trauma specialist, who in turn meets with the individual, conducts a free assessment, explains the TAMAR program, and if eligible, the woman is invited to participate.
What are the Components of the Program?
The TAMAR program provides a series of group sessions that meet for 90 minutes (typically on a twice-weekly basis) and is designed to provide participants with necessary techniques to self-soothe and self-regulate. Facilities that are implementing TAMAR have received training on trauma for all staff, and employ a trauma specialist at each facility. Up to 15 TAMAR modules may be used in the program. These modules incorporate psychodynamic therapy with expressive art therapy and psycho-educational techniques and include:
- What is trauma? This module is designed to help participants become aware of how trauma has impacted their lives.
- What is physical abuse? Many individuals served through TAMAR did not understand that what happened to them was not normal. Frequently, group members reported that they just thought the abuse was normal.
- What is sexual abuse? This session is dedicated to recognizing how sexual abuse has impacted their lives.
- Trauma and addiction. The goal of this module is to start to connect the dots between addictive/compulsive behaviors and coping mechanisms to deal with trauma. The realization that using (or abusing) drugs and alcohol could be self-medicating explains a great deal and begins the process of gaining insight.
- Facts on HIV/AIDS. Risky sexual behaviors and experiencing common assaults and rapes pose a public health concern. Many group members are misinformed or just uninformed about HIV transmission.
- Sexual communication and negotiation skills. This module includes discussion about what constitutes sexual communication, both verbal and nonverbal, as well as role-playing negotiation skills such as practicing how to refuse unsafe sex.
- Containment. This session helps members understand memory and increase self-awareness.
- Containment II – Grounding. A critical part of self-regulation is the ability to calm oneself when triggers occur. Grounding techniques are practiced.
- Tolerating distress. All of the problems that occur when one is unable to tolerate distress are discussed. Members are encouraged to use grounding techniques when they experience stress.
- Self-soothing. Each group member will be able to identify a healthy replacement for previous self-destructive methods of self-comfort.
- Boundaries and safety. The group discusses how much control they have over what happens to their bodies. Boundary exercises (physical and verbal) are practiced.
- Trust and intimacy. Trauma and inability to trust frequently go hand-in-hand. Barriers that inhibit ability to trust are explored.
- Parenting discussion. How trauma affects attachment as well as how trauma, substance abuse and mental health issues have affected their parenting choices and ability to parent are explored.
- Life story. If desired, members are given the opportunity to share their life story with the group. This session allows members to understand how trauma has impacted so many aspects of their lives.
- Closing ritual. This final session provides members with a sense of completion and healthy closure.
Trauma survivors are frequently hyper vigilant and in a state of hyper arousal. Officers who have received training on how to identify trauma symptoms and how to avoid re-traumatizing women are more successful at reducing the likelihood of injury. Telling an individual what is going to happen during the pat-down, for example, and warning where hands will be placed greatly reduces the anxiety and sometimes aggressive response from inmates.
What are the Benefits to Participants and Staff?
TAMAR was intended to benefit not only the women who participate, but also the staff who work with them on a daily basis.
The benefits experienced by the participants of TAMAR have been numerous and include:
- Physical symptoms of post-traumatic stress disorder are within manageable limits;
- Offenders are able to bear feelings associated with traumatic memories;
- Memories of trauma are linked with feelings;
- Damaged self-esteem is restored; and
- Important relationships have been re-established.
Considerable benefits to officers in facilities where TAMAR has been implemented have also been reported, including:
- A calmer work environment;
- A significant reduction in incidents; and
- A feeling of making a difference in peoples’ lives.
Interview with Alisha Saulsbury
Alisha Saulsbury, LCSW, is the Trauma Specialist for the Maryland Mid-Shore area. Ms. Saulsbury administers the TAMAR program in the Mid-Shore area, and provides training around the country about how to implement and the benefits of the TAMAR program.
Q When did the TAMAR program start? How and why was it created?
A The program began in the late 1990s. We originally received a three year grant from SAMHSA (Substance Abuse and Mental Health Services Administration) after a study we conducted with the Maryland Mental Health Hygiene Association, Division of Special Populations, and the University of Maryland Department of Psychiatry. The study revealed that recidivism rates with women in our criminal justice system were quite high, and we wanted to know why – and what could be done about it. We hired staff to conduct clinical interviews in criminal justice facilities. What we found were a lot of co-occurring disorders and self-medicating due to trauma.
Q How many programs serving women are in operation in Maryland today?
There are about ten TAMAR programs in Maryland, and most serve women. There are twelve TAMAR groups going on in facilities around the state, and TAMAR is used around the country. We offer training at no cost to facilities nationwide that are interesting in starting TAMAR for women.
Q What are the main components of the program?
A We offer modules in the detention centers (see complete list in TAMAR program description above) and at times have been able to provide support when women return to the community. The TAMAR program has been adapted in different ways around the country, but for our purposes we started the program for, and work only with women. We offer a ninety-minute psycho-educational and psychodynamic group on a twice weekly basis. Right now, we are running a ten-week program. Essentially we are working with women to help them to figure out how – when they become anxious and flooded – to help themselves to cope in a healthy way.
Q How are participants referred to the program? How many women participate at any given time?
A The TAMAR staff are subcontractors who come in and out of the jails. Representatives from medical, mental health, substance abuse, the drug court, and classification meet weekly for a multidisciplinary team meeting. During these meetings, staff share information about any new inmates with substance abuse histories or who are experiencing or have experienced trauma. Each year, every officer in the facility receives training on trauma, so staff are more easily able to identify women who could benefit from the resources offered through TAMAR. Referrals are also made by word of mouth, and by women hearing about the program from other inmates. Women who participate in TAMAR are generally post-sentence, but we do also serve women who are pretrial. Ideally, between six and eight women participate in the group at any given time.
Q Are there any reasons women could be excluded from participating?
A For safety reasons, we cannot accept women who are psychotic or unstable for the safety of the group. Sometimes women meet the criteria for co-occurring disorders, but either are not yet stable or are in the process of detoxing. When warranted, I will see women on a one on one basis until they are stabilized.
Q Besides Maryland, are there other states using the TAMAR program with women?
A Some facilities in Hawaii, Massachusetts (Framingham) and Rhode Island are using TAMAR or parts of it with women offenders. We send trainers around the country to conduct training sessions on TAMAR free of charge. Trainers provide training for everyone in the facility – officers, clinical staff, kitchen workers – everyone needs to be trauma-informed in order to interact and work more effectively with women in the facilities.
Q What has been surprising to you as you have undertaken this work?
A In my own experience, I would say that 90% of the women I come face to face with know they should not engage in the problem behaviors that have led to their criminal justice involvement. But for many of these women, acting out in these ways (e.g., violence, drug abuse) made them feel better, and was the best way they knew to cope. Many could not connect their trauma to their subsequent behaviors. Many could not even recognize that they had been traumatized and had just normalized their traumatic experiences. As a result we have moved away from asking while we are taking a woman’s history – “what’s wrong with you?” and have started asking “what happened to you?” I have also been moved by how important our “closing exercise” is to women who participate in our program. It is very meaningful for them. For some women, it is the first thing they have ever completed in their lives. If we have any reason to think someone might be leaving the group before the closing ceremony, we make sure to tell them what they mean to the group before they go.
Q What has inspired you the most in your work?
A What I find most incredible is the women’s resilience. Seeing and hearing stories about how the women have been able to achieve different outcomes when they start to take care of and love themselves, and have the awareness and desire to change. Women can’t do this unless someone helps them to believe that there is hope. Sometimes we see women who are so broken, who recount horrible stories of trauma but who still have hope. It may simply be for some women that no one has ever asked them “the” question they need: i.e., “what’s happened to you?” To see their lives change, is what inspires me to go to work every day. I believe that these women are making real changes in their lives and that is so incredibly inspiring. To see that someone can go through all of these experiences, be locked up, be using, have had a terrible time in life – but we can still see that change happen. It is amazing to see women take pride in things like getting their own place, smiling, and just being drug free and lucid.
Q What do you see happening in criminal justice as it relates to women or gender-informed practices in the next few years? What progress still needs to be made?
A We need to be continually raising awareness about trauma and must continue to provide training for all those who work with women in the justice system. Many practitioners still need training on how to talk to women in a way that does not degrade them. Sometimes we assume people know how to take in this information and implement it, but that is not always the case. A lot has been done to this end, but much more remains to be done. In addition to a need for more training, funding for these kinds of programs continues to be a challenge.
Q What advice do you have for professionals who want to achieve better outcomes with the justice-involved women with whom they work?
A We need to make sure that those who are working in criminal justice get better background information about women’s trauma histories. This might be accomplished just by asking them “Has there been anything in your life that has significantly impacted or changed or gotten you off course?” “Has anything in particular derailed you in your journey?”, or “How do you understand that you got to the point where you are in your life today?” “Who do you wish could have been there for you that hasn’t been?” We find that it is quite rare that nothing traumatic has happened to these women; usually there is something considerably traumatic in their histories that warrants our attention.
Q What are some of the most compelling lessons you have learned that you can offer to others?
A I am constantly impressed by the resiliency of the human spirit, and motivated by remembering that we need to always be learning and that we don’t know it all. I think the most important thing I could share about this work is that when you treat the trauma, you can treat the problem behavior. Women who have been traumatized are engaged in self-defeating behavior to mask the pain. When trauma is treated, their behavior can get better…when women feel better, their behavior can change. In the last few years, it has become clear that the field is embracing this approach more. The increase in the number of requests for our training has shown us that; but we need to keep raising awareness and sharing with others how they can become more trauma-informed.
For a more detailed description of the work of TAMAR, click here.