CorrectCare

The TARGET Approach
Taking the Fear Out of Trauma Services

By John F. Chapman, PsyD, CCHP, Julian Ford, PhD, David Albert, PhD, Josephine Hawke, PhD, and Marisol Cruz St. Juste, MA

In a recent Standards Q&A column, a reader asked for NCCHC’s position on critical incident debriefing in light of recent research that questions the efficacy of this process (Fall 2005 CorrectCare). Questions like this reflect a thoughtful revisiting of sensitive areas in health care in light of newer research.

That particular question focused on how best to address the aftermath of psychological traumas that correctional personnel often face. We believe it is important to revisit the larger question of how correctional health care professionals can best understand, prevent, manage and treat post-traumatic stress as they care for incarcerated individuals and assist other personnel.

In 2005, Connecticut began to introduce the concept of trauma-sensitive screening and treatment to its detention centers. Similar initiatives have followed in the state’s forensic hospital for children, the juvenile training school and other state-run out-of-home placements. The goal was for staff and children in the juvenile justice and mental health care systems to have a common language about traumatic stress and post-traumatic stress disorder and useful skills for preventing or recovering from PTSD.

Traumatic Stress and Incarceration
Anyone who has practiced in the correctional health care field understands the relationship between incarceration and traumatic stress. However, many systems fail to address the stressors that occurred either before or after incarceration.

A survey published by the National Children’s Traumatic Stress Network found that only one-half of children with known trauma histories in child welfare, mental health or foster care received trauma screening. Emerging studies among juvenile justice populations clarify and describe the frequency of psychiatric disorders including PTSD. These studies lead us to conclude that PTSD and traumatic stress reactions are a significant health problem in both adult and juvenile correctional systems.

Not surprisingly, when traumatic stress reactions and PTSD are left untreated, utilization of both physical and mental health care increases, according to correctional health expert Jacqueline Moore, PhD, RN, CCHP-A. (Moore’s forthcoming book, Administration and Management of Correctional Health Care, Vol. 2, is one of few texts that deal with traumatic stress as a management as well as a clinical issue; it also examines the implications for health services.)

TARGET Aims at Traumatic Stress
The issue of traumatic stress has been studied for several years at the University of Connecticut Health Center Department of Psychiatry. There, a new approach for screening and intervening to manage traumatic stress was developed. This approach is called the Trauma Adaptive Recovery Group Education and Therapy, or TARGET.

A review by key administrators and program specialists in Connecticut’s Court Support Services Division determined that the model potentially was a good fit for the juvenile detention system. This led to collaboration between the state detention centers and UCHC, and detention’s transition to a trauma-sensitive system.

TARGET is a strength-based, biopsychosocial approach to teaching self-regulation skills to survivors of trauma and extreme stress. It teaches practical skills to enable trauma survivors to process current stressful experiences. The model acknowledges the role of the body’s emergency alarm system in keeping the individual safe, but seeks to allow communication between body and mind to “turn off” this activation when it is not needed.

The TARGET approach follows seven steps that are recalled in the acronym FREEDOM:
• Focus (Slow down, Observe and Self-check, or SOS)
• Recognize triggers
• Emotion self-check
• Evaluate thoughts
• Define personal needs/goals
• Open new options for achieving goals
• Make a contribution (e.g., helping others)

The acronyms help children to remember their steps and allow a quick reference point for staff dealing with children whose behaviors may be escalating.

Objections to Trauma Screening
Before starting the TARGET model in the detention centers, much preparatory work had to be done. The idea of screening the juvenile detainees for traumatic stress was met with great concern among staff, including those in mental health services, who raised three major arguments.

The first was that asking about traumatic experiences would open the wounds of the past trauma in a setting where support was less available than in a hospital or community treatment program. This concern was resolved by pointing out that the questions in the trauma screening instrument were very similar to questions on standard risk assessments.

In fact, the screening tool selected, the Traumatic Events Screening Instrument for Children
(TESI-C), is a series of questions, either self-administered or interview-based, that allow the child to respond with “yes,” “no” or “pass.” This gives the child security through control over the information he or she wishes to divulge. (For information about the TESI-C, see www.ncptsd.org.)

The second concern was that dealing with trauma issues might open a “can of worms” and create unnecessary work for staff by destabilizing youths and leading to acting-out behaviors. However, the TESI-C was designed to ask about traumas in a down-to-earth manner that shows youths that screeners are interested in understanding how life experiences have affected them in order to help them. The TARGET model also provides a brief education module that screeners use to reassure youths that they will be learning useful skills for managing the stress that trauma can cause.

As a result, asking questions about trauma has not led to problems with aggressive or acting-out behavior (or self-harming behavior). Instead, use of the screening and TARGET education module has empowered staff to prevent these behaviors more effectively without resorting to use of force or punitive interactions.

Finally, a small minority of detention line staff resisted the transition from a primarily punitive approach. This was countered by helping them to understand that when youths are given the tools to gain control over their emotional states, they have greater responsibility for their actions. TARGET proved to be acceptable to many of these more-traditional personnel because it provides practical skills for staff and youths to use together to responsibly and effectively help youths to deescalate.

Implementing the Model
The TARGET model began in practice in the New Haven Juvenile Detention Center in January 2005 with the introduction of trauma screening and TARGET groups. However, laying the groundwork began more than a year earlier.

The first step was to train detention staff and administrators in biopsychosocial principles of traumatic stress and stress reduction. This was a major component of implementation that took the support of the facility and state administrators to pull together stakeholders from various departments (health care, education, etc.) and obtain buy-in.

After the principles were taught, the second step began. The UCHC team trained, coached and supervised detention staff members as they administered screenings and implemented the TARGET intake and group interventions.

State detention superintendent Karl Alston insisted that all staff become familiar with the model and fluent in its terms. He also identified crisis managers for each shift who were trained in group administration to act as real-time facilitators through crisis response and intervention.

“TARGET groups create options for the child,” says Jody Ortiz, a 15-year staff worker at the New Haven facility. “Staff facilitators trained as crisis managers specialize in recognizing stress triggers and then encourage the child to complete the SOS and the TARGET process. This resolves the situation in a more effective manner.”

Positive Response
New Haven Detention staff tell the story of a youth who was remanded for two weeks by the judge at his detention hearing because of aggressive acting out. This youth began to attend a TARGET group that started right after the hearing. At the next detention hearing two weeks later, the judge asked the young man how he had managed to stay out of trouble. The judge was pleased by his change in behavior but perplexed by the response: “I did an SOS.”

The moral of this story is that TARGET quickly proved helpful for both youths and staff, and the next step is to inform judges and other key personnel in the justice system (such as probation officers, prosecutors and public defenders) about trauma screening and TARGET. (For example, see the Winter 2006 Juvenile and Family Court Journal.)

Overall, the response to trauma screening and TARGET has been very positive. The New Haven facility is filled with posters reminding staff and detainees of the seven steps of FREEDOM, and the staff have begun to encourage an SOS for youngsters at the first signs of potential acting out instead of immediately opting for force or room confinement.

Problems have occurred, as well. Children sometimes request an SOS to avoid certain tasks, so it is important for staff to set limits around the SOS to avoid unnecessary interference with school or activities. Failure to utilize the model can create problems and requires great administrative effort to ensure consistency.

“What will make the SOS approach work is all staff members being consistent, allowing children to take an SOS as needed,” observes Sandra Levay, a detention staff member and facilitator. “It can be problematic if staff members ignore a child’s request. The child’s anxiety level may rise and behaviors can easily escalate.”

The model is designed to help staff and youths to be more aware of their own stress levels and to be proactive and empowered rather than reactive and punitive so that stress is managed instead of leading to behavior problems or disciplinary actions. TARGET is hard work for staff as well as youths, but it actually is much easier than the alternative extremes of having stress run rampant or attempting to maintain control by force and intimidation.

Outcome data are not yet available, but efforts are underway to measure changes in restraints, disciplinary problems and other outcomes of concern to staff and administrators, initially at the New Haven Detention Center and ultimately at all of the state detention centers. Studies have been completed with TARGET for adults in substance abuse treatment, and are underway with young mothers and girls who are in or are at risk for involvement in the criminal justice system.

A Promising Solution
Data analyzed from the TESI-C and PTSD screening instruments are consistent with national data suggesting that almost all youths in detention have experienced at least one (and typically several) traumas of a variety of types in their lives, and that full and partial PTSD affect more than one in four.

The TARGET model and TESI screening system provide a simple, straightforward means of dealing with high-risk youngsters in juvenile justice settings who struggle with behavioral and emotional dyscontrol. TARGET also is being used with adults in prison and reentering the community, with favorable responses from staff and recipients.

The model provides a common language for the correctional system, and for systems beyond the facility walls. It allows for staff empowerment through education and skill building. Correction and detention staff are often skeptical of new approaches, but the responses we have seen are promising.

Most importantly, TESI screening and TARGET begin to address a significant correctional public health problem that affects tens of thousands of incarcerated youths and adults and the correctional staff whose safety and well-being depend upon being able to manage volatile environments in safe and effective ways.

— About the authors: John F. Chapman, PsyD, CCHP, is clinical services coordinator for the State of Connecticut Judicial Branch, Court Support Services Division. The other authors are with the University of Connecticut Health Center: Julian Ford, PhD, is associate professor of psychiatry; David Albert, PhD, and Josephine Hawke, PhD, are assistant professors of psychiatry; and Marisol Cruz St. Juste, MA, is a research clinician. Contact the authors at john.chapman@jud.ct.gov.

[This article first appeared in the Spring 2006 issue of CorrectCare.]