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Tools for Self-Regulation and Healing Raul Almazar, RN, MA Senior Consultant SAMHSA National Center for Trauma Informed Care NASMHPD.

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Presentation on theme: "Tools for Self-Regulation and Healing Raul Almazar, RN, MA Senior Consultant SAMHSA National Center for Trauma Informed Care NASMHPD."— Presentation transcript:


2 Tools for Self-Regulation and Healing Raul Almazar, RN, MA Senior Consultant SAMHSA National Center for Trauma Informed Care NASMHPD

3 Stress/Trauma Lives in the Body A chronic overreaction to stress overloads the brain with powerful hormones that are intended only for short-term duty in emergency situations. Serum cortisol levels Chronic hyperarousal – nervous system does an amazing job of preparing the individual to deal with the stress but:

4  Growth, reproduction and immune system all go on hold  Leads to sexual dysfunction  Increases chances of getting sick  Often manifests as skin ailments  Increases permeability of the blood brain barrier  Dr. Robert Sapolsky: “Why Zebras Don’t Get Ulcers” – study on salmon

5 Serum Cortisol Bruce Perry Cortisol Response to a Cognitive Stress Challenge in PTSD Related to Childhood Abuse Finding: There were elevated levels of cortisol in both the time period in anticipation of challenge (from time 60 to 0) and during the cognitive challenge (time 0–20). PTSD patients and controls showed similar increases in cortisol relative to their own baseline in response to the cognitive challenge. (Bremner, Vythilingam, et al 2002)

6 Prevalence of Trauma in our Schools U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2012). Child Maltreatment 2011. Available from In 2011, child protective services in the United States received 3.4 million referrals, representing 6.2 million children. Of those cases referred, about 19% were substantiated and occurred in the following frequencies (1). more than 75 percent (78.5%) suffered neglect more than 15 percent (17.6%) suffered physical abuse Less than 10 percent (9.1%) suffered sexual abuse

7 Prevalence of Trauma in our Schools U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2012). Child Maltreatment 2011. Available from In older children there have been several national studies. The National Survey of Children's Exposure to Violence reports on 1 year and lifetime prevalence of childhood victimization in a nationally representative sample of 4549 children aged 0-17.2 More than half (60.6%) of the sample experienced or witnessed victimization in the past year. Specifically in the past year: almost half (46.3%) experienced physical assault 1 in 10 (10.2%) experienced child maltreatment fewer than 1 in 10 (6.1%) had experienced sexual victimization more than 1 in 4 (25.3%) had witnessed domestic or community

8 What Does It Look Like in our Schools? Many of the following characteristics apply to both males and females, but tend to be more extreme in males: The child often appears guarded, defensive, and angry. The child can be difficult to redirect, and dismisses support. The child manifests great reactivity. The reactivity is more frequent, more intense, and lasts longer than with unaffected children. Emotional outbursts often appear to be in response to seemingly unimportant events, and may have no immediately identifiable antecedent. When the child actually “loses it” and has a temper outburst or meltdown, behaviors may be extremely inappropriate and offensive, and include hurtful sexual comments, racial slurs, other personal comments, threats of harm, and actual physical aggression. (Hodas, 2006,

9 Self- Regulation The challenge is to not let the nervous system stay chronically aroused Have a plan to deal with triggers/arousal Symptoms as adaptations Socio-environmental strategies – Prevention Relational, Repetitive and rewarding experiences Practice, practice, practice

10 What Does It Look Like in our Schools? Internalized responses by females may involve social withdrawal and lack of response to adult efforts at engagement. More severe responses include depression, dissociative reactions, self-injurious behaviors, and suicidality. Males also withdraw and become depressed, but rarely will acknowledge depression. The child seems to make the same mistakes over and over, and does not appear to learn from experience. (Hodas, 2006,

11 What is a Crisis Prevention or Safety/Soothing Plan?  An individualized plan developed proactively by consumer and staff before a crisis occurs A therapeutic process A task that is trauma sensitive A partnership of safety planning A consumer-owned plan written in easy to understand language

12 Why Are They Used?  To help consumers during the earliest stages of escalation before a crisis erupts  To help consumers identify coping strategies before they are needed  To help staff plan ahead and know what to do with each person if a problem arises  To help staff use interventions that reduce risk and trauma to individuals

13 Essential Components  Triggers  Early Warning Signs  Strategies

14 TRIGGERS First, Identify Triggers

15 These Triggers A trigger is something that sets off an action, process, or series of events (such as fear, panic, upset, agitation) Also referred to as a “threat cue” such as: – bedtime – room checks – large men – yelling – people too close

16 More Triggers: What makes you feel scared or upset or angry and could cause you to go into crisis? Not being listened to Lack of privacy Feeling lonely Darkness Being teased or picked on Feeling pressured People yelling Arguments Being isolated Being touched Loud noises Not having control Being stared at Room checks Contact w/family

17 Do you have a student who has an especially difficult time with… Tasks that may be frustrating or anxiety provoking (writing, reading aloud, tests) Transitions (between classes, activities) Dismissals Holidays Before or After the Weekend A Certain Time of Day Being Touched Yelling Loud Noises Being Isolated Schedule Changes Participating in a Physical Activity Contact/ Lack of Contact with Family Male or Female Staff

18 More School-Specific Triggers Emergency/ Fire Drills Hungry/Thirsty (may be medication related) Competitive Situations Putting Personal Items into Lockers Being Stared At Undressing in Locker Rooms Sitting in the Front of the Room Witnessing a Restraint

19 What makes you feel upset? (Circle all that make you feel sad, mad, scared or other feelings) Being touched Too many people DarknessCertain time of year Certain time of Having my bedroom day/night door open Loud noisesYelling Thunderstorms MA DMH, Manual, Promoting Strength-Based Care, 2006

20 Second, Identify Early Warning Signs

21 Early Warning Signs A signal of distress that is a physical precursor and/or manifestation of upset. Some signals are not observable, but some are, such as: restlessness agitation pacing shortness of breath sensation of a tightness in the chest sweating

22 Early Warning Signs What might you or others notice or what you might feel just before losing control?  Clenching teeth  Wringing hands  Bouncing legs  Shaking  Crying  Giggling  Heart Pounding  Singing inappropriately  Pacing  Eating more  Breathing hard  Shortness of breath  Clenching fists  Loud voice  Rocking  Can’t sit still  Swearing  Restlessness  Other ___________

23 23 How do I know I am angry, scared or upset? (Circle all that apply) Cry Clench teeth Loud voice Red/hot face Laughing/giggling Being mean Swearing Racing BreathingWringing or rude heart hard hands Clenched TantrumsRocking Hyper Pacing fists MA DMH, Manual, Promoting Strength-Based Care, 2006

24 Third, Identify Strategies

25 Strategies: What are some things that help you calm down when you start to get upset?  Reading a book  Pacing/ Rocking  Coloring  Hugging a stuffed animal  Taking a hot shower  Deep breathing  Being left alone  Talking to peers  Therapeutic Touch, describe ______  Exercising  Eating  Writing in a journal  Taking a cold shower  Listening to music  Molding clay  Calling friends or family (who?)

26 Calming Strategies  Strategies are individually-specific calming mechanisms to manage and minimize stress, such as: time away from a stressful situation put head down on desk going for a walk talking to someone who will listen working out lying down listening to peaceful music

27 More Strategies  Blanket wraps  Using cold face cloth  Deep breathing exercises  Getting a hug  Running cold water on hands  Ripping paper  Using ice  Having your hand held  Snapping bubble wrap  Bouncing ball in quiet room  Using the gym

28 Even More Strategies  Male staff support  Female staff support  Jokes  Screaming into a pillow  Punching a pillow  Crying  Spiritual Practices: prayer, meditation, religious reflection  Touching preferences  Speaking with therapist  Being read a story  Using Sensory Room  Using Comfort Room  Other

29 HALT If a person is getting agitated, don’t forget to use HALT. ARE THEY… H ungry? A L T ngry? onely? ired? If it prevents one person from getting hurt or one person from relapse, It is worth it! If it prevents one person from getting hurt or one person from relapse, It is worth it! Noble Hospital, Westfield, Ma Screensaver – staff reminder T hirsty?

30 What Does Not Help When you are Upset?  Being alone  Not being listened to  Being told to stay in my room  Loud tone of voice  Peers teasing  Humor  Being ignored  Having many people around me  Having space invaded  Staff not taking me seriously “If I’m told in a mean way that I can’t do something … I lose it.” -- Natasha, 18 years old

31 Making the Plans Client- Centered Post on doors, bedrooms or bulletin boards Review in groups Create a “pocket” version for consumers – laminated card Develop a computer version to email

32 Crisis Plan Additional Guidelines for Use  Revise and re-tool after escalation using all de-briefing information  Help consumers “practice” strategies before they become upset  Teach about the impact of external and internal triggers and stressors & learn new skills to manage reaction  Support in “coping skills” group

33 What do consumers say they need in crisis planning?

34 What do Consumers Find Helpful?  MA DMH conducted a point in time survey: (MA DMH, 2003) 185 adolescents participated (average age = 16) 19 hospitals (acute & continuing care)  Response to the question: “What could staff do differently to avoid using restraint and seclusion?” Talk to me 80 Leave me alone 75 Distract me 54

35 Successful Crisis Planning- MAX A 9 year old boy with ADHD, a history of physical abuse, and multiple placements in foster homes. He carries around most of his belongings in his backpack and becomes highly distressed when he is asked to use a locker/cubby. He bolts or strikes out physically when he is frustrated. Effective Strategies:  Max is allowed to keep his belongings in his therapist office. When he is highly anxious, he is given an opportunity to check on his things.  Max has a SPACE PASS to use when he is feeling anxious or frustrated  Max is given an opportunity to play an Ipod game for 15-20 minutes

36 A 15 year old boy with a history of physical abuse, neglect, and aggressive behaviors. He has a strong need to control his environment. He is stimulated by negative peer attention and is easily agitated and distracted. Trae’s peers consider him a leader. Effective Strategies: – Trae has a study carrel that he calls his office. He has decorations, desk organizers, and office hours. This has allowed him to control his environment and avoid distractions. – Trae is a member of the school’s “Landscaping Crew”. When he is agitated, he is given time to rake, pull weeds, water, etc. Successful Crisis Safety Planning TRAE

37 How to Support Proactive Use of the Chosen Calming Strategies Review/Role-Play use in WRAP groups led or co- led by Peer Advocates/Consumers Take beyond basic ‘triggers’ to understanding each person’s physiological (biorhythm) needs (e.g., when most stressed; when most relaxed; need for and how often: exercise, stretching, outside time, naps, yoga, meditation, tai chi, etc.) Review and change after intervention

38 38  Understand sensory experience, modulation & integration Incorporate knowledge of sensory input and expertise of Occupational Therapy Assess the sensory diet of each person- served Identify sensory-seeking & sensory-avoiding behaviors  Adapt the physical environment & develop sensory rooms/spaces to respond to differing sensory needs. (Champagne, 2003)

39 Sensory-Based Approaches Calming Self-Soothing Activities – Hot Water – Wrapping in a heavy blanket – Decaf Tea – Rocking Chairs – Swings – Yoga – Drumming – Meditation – Creating (Legos, coloring, clay) – Crochet

40 Sensory-Based Approaches Grounding Physical Activities – Holding – Weighted Blankets & Vests – Arm & Hand Massage – Push-ups – “Tunnels”/ Body Socks – Wrist/Ankle Weights – Sour/Fireball Candies – Gum – Sandtrays

41 How do we care for OURSELVES and EACH OTHER?

42 Ten Strategies for Building Resilience 1.Make connections-- Family, friends, civic groups, faith-based organizations, other local groups 2. Avoid seeing crises as insurmountable problems. You can change how you interpret and respond to stressful events 3. Accept that change is a part of living. The only thing that is constant in life is change 4. Do something regularly, even if it seems small, which enables you to move toward your goals (Daniel, 2007)

43 Ten Strategies for Building Resilience 5. Take decisive actions rather than detaching completely and wishing problems and stresses would go away 6. Look for opportunities for self-discovery. People often grow in some respect as a result of their struggle with loss 7. Nurture a positive view of yourself. Develop confidence in your ability to solve problems; trust your instincts 8. Keep things in perspective. Keep a long-term perspective-- avoid blowing things out of proportion (Daniel, 2007)

44 Ten Strategies for Building Resilience 9.Maintain a hopeful outlook. Expect that good things will happen in your life; visualize what you want rather than worrying about what you fear 10. Take care of yourself. Pay attention to your own needs and feelings. Engage in activities you enjoy and find relaxing (Daniel, 2007)

45 Effective Stress Management Strategies

46 Do we ask our staff: What happened to you vs. what’s wrong with you?


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