2Tools for Self-Regulation and Healing Raul Almazar, RN, MASenior ConsultantSAMHSA National Center for Trauma Informed CareNASMHPD
3Stress/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 levelsChronic hyperarousal – nervous system does an amazing job of preparing the individual to deal with the stress but:
4Growth, reproduction and immune system all go on hold Leads to sexual dysfunctionIncreases chances of getting sickOften manifests as skin ailmentsIncreases permeability of the blood brain barrierDr. Robert Sapolsky: “Why Zebras Don’t Get Ulcers” – study on salmon
5Serum Cortisol Bruce Perry Cortisol Response to a Cognitive Stress Challenge in PTSD Related to Childhood AbuseFinding: 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)This finding may be the result of heightened anticipatory anxiety, or a different interpretation of the environment, among patients in the PTSD group. This would be consistent with prior studies of exaggerated startle response to the threat of the experimental context of a testing environment in PTSD (Morgan et al., 1995). It is also consistent with clinical observations that PTSD patients appear to have an inability to dampen responses to cues that do not represent true threat, an effect that may be related to dysfunctional neural circuitry involving medial prefrontal cortex, amygdala, or other brain regions (Bremner et al., 1999a,b).
6Prevalence of Trauma in our Schools 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 neglectmore than 15 percent (17.6%) suffered physical abuseLess than 10 percent (9.1%) suffered sexual abuseHow many kids at your school, sitting in your classrooms, have experienced OR are experiencing trauma as we speak? In 2011, 6.2 million represented in CPS referrals. Can you imagine the number of referrals that don’t get made?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 Available from
7Prevalence of Trauma in our Schools 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 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 assault1 in 10 (10.2%) experienced child maltreatmentfewer than 1 in 10 (6.1%) had experienced sexual victimizationmore than 1 in 4 (25.3%) had witnessed domestic or communityBullying is the buzzword in schools these days, and it is incredibly important that it is addressed. But, how many times are we asking ourselves WHY a student is bullying. We can’t fix a problem without understanding its source, and these statistics demonstrate that many of our students are affected by some type of trauma.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 Available from
8What 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.Keeping in mind, these may be some of the observable behaviors you see in your students. It does not necessarily mean that every student that exhibits these behaviors as experienced trauma. But how many of these behaviors do we classify as “manipulative”, “attention-seeking”, and “oppositional”.(Hodas, 2006,
9Self- RegulationThe challenge is to not let the nervous system stay chronically arousedHave a plan to deal with triggers/arousalSymptoms as adaptationsSocio-environmental strategies – PreventionRelational, Repetitive and rewarding experiencesPractice, practice, practice
10What 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,
11What is a Crisis Prevention or Safety/Soothing Plan? An individualized plan developed proactively by consumer and staff before a crisis occursA therapeutic processA task that is trauma sensitiveA partnership of safety planningA consumer-owned plan written in easy to understand language
12Why Are They Used?To help consumers during the earliest stages of escalation before a crisis eruptsTo help consumers identify coping strategies before they are neededTo help staff plan ahead and know what to do with each person if a problem arisesTo help staff use interventions that reduce risk and trauma to individuals
15These TriggersA 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:bedtimeroom checkslarge menyellingpeople too closeWhat are the triggers? They are activating events that set into motion a pattern of response to the stress.Triggers can be any number of things. Again, they are individual-specific. One person’s trigger is not going to be another person’s. Sometimes triggers are very clear; like loud noise & yelling.
16More Triggers: What makes you feel scared or upset or angry and could cause you to go into crisis? Not being listened toLack of privacyFeeling lonelyDarknessBeing teased or picked onFeeling pressuredPeople yellingArgumentsBeing isolatedBeing touchedLoud noisesNot having controlBeing stared atRoom checksContact w/family
17Do 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)DismissalsHolidaysBefore or After the WeekendA Certain Time of DayBeing TouchedYellingLoud NoisesBeing IsolatedSchedule ChangesParticipating in a Physical ActivityContact/ Lack of Contact with FamilyMale or Female StaffSometimes triggers are not clear at all. People yelling is very overt; we can all hear that. That’s very clear what’s leading to that activation. But some triggers are internal feeling states; feeling pressured, feeling lonely. You’re not going to see that.
18More School-Specific Triggers Emergency/ Fire DrillsHungry/Thirsty (may be medication related)Competitive SituationsPutting Personal Items into LockersBeing Stared AtUndressing in Locker RoomsSitting in the Front of the RoomWitnessing a RestraintThere are other triggers – some are more associational, particularly for people with a history of trauma. There are lots of associations to the terrible things that happen that remind and activate that anxiety. It can be a time of day; a season; a fragrance, a sound, an aroma; language, particular family member; a holiday.So it’s important to kind of ask those detailed questions and then listen to the information that you’re getting and if you’re not sure, clarify it. Sometimes there could be cultural nuances, so it’s really important to make sure you understand the information that you’re being given.
19What makes you feel upset? (Circle all that make you feel sad, mad, scared or other feelings)Being touched Too many peopleDarkness Certain time of year Certain time of Having my bedroom day/night door openLoud noises Yelling ThunderstormsMA DMH, Manual, Promoting Strength-Based Care, 2006
20Second, Identify Early Warning Signs Next, we move to the early warning signs and remember these are the behavioral cues that something is happening. A problem is brewing.
21Early Warning SignsA signal of distress that is a physical precursor and/or manifestation of upset. Some signals are not observable, but some are, such as:restlessnessagitationpacingshortness of breathsensation of a tightness in the chestsweatingTypically early warning signs are overt behaviors that we can see. But, these behaviors can be subtle and easily overlooked, especially if it a low-level of agitation, like pacing or foot tapping.Sometimes you cannot see the behavioral signs – like a “sensation of tightness” unless somebody’s got the understanding, language and capacity to express the problem.As we learned in the Neurobiology of Trauma presentation – the Broca’s area of the brain is impacted in times of crisis and people don’t always have access to language when they are in crisis. Language may not be readily available to the person we’re working with who is upset – so we may not hear them say they are having trouble.
22Early Warning Signs What might you or others notice or what you might feel just before losing control?Eating moreBreathing hardShortness of breathClenching fistsLoud voiceRockingCan’t sit stillSwearingRestlessnessOther ___________Clenching teethWringing handsBouncing legsShakingCryingGigglingHeart PoundingSinging inappropriatelyPacing
23How do I know I am angry, scared or upset? (Circle all that apply)Cry Clench teeth Loud voice Red/hot face Laughing/gigglingBeing mean Swearing Racing Breathing Wringing or rude heart hard handsHere is a tool that was developed for children in Massachusetts …Clenched Tantrums Rocking Hyper PacingfistsMA DMH, Manual, Promoting Strength-Based Care, 2006
25Strategies: What are some things that help you calm down when you start to get upset? Therapeutic Touch, describe ______ExercisingEatingWriting in a journalTaking a cold showerListening to musicMolding clayCalling friends orfamily (who?)Reading a bookPacing/ RockingColoringHugging a stuffed animalTaking a hot showerDeep breathingBeing left aloneTalking to peers
26Calming StrategiesStrategies are individually-specific calming mechanisms to manage and minimize stress, such as:time away from a stressful situation put head down on deskgoing for a walktalking to someone who will listenworking outlying downlistening to peaceful music
27More Strategies Blanket wraps Using cold face cloth Deep breathing exercisesGetting a hugRunning cold water on handsRipping paperUsing iceHaving your hand heldSnapping bubble wrapBouncing ball in quiet roomUsing the gym
28Even More Strategies Male staff support Touching preferences Female staff supportJokesScreaming into a pillowPunching a pillowCryingSpiritual Practices: prayer, meditation, religious reflectionTouching preferencesSpeaking with therapistBeing read a storyUsing Sensory RoomUsing Comfort RoomOther
29H A L T T If a person is getting agitated, don’t forget to use HALT. If it preventsone person fromgetting hurt or oneperson from relapse,It is worth it!ARE THEY…Hungry?Angry?Lonely?Tired?Noble Hospital, Westfield, MaScreensaver – staff reminderThirsty?
30What Does Not Help When you are Upset? Being aloneNot being listenedtoBeing told to stay in my roomLoud tone of voicePeers teasingHumorBeing ignoredHaving many people around meHaving space invadedStaff not taking me seriously“If I’m told in a mean way that I can’tdo something … I lose it.”-- Natasha, 18 years old
31Making the Plans Client-Centered Post on doors, bedrooms or bulletin boardsReview in groupsCreate a “pocket” version for consumers – laminated cardDevelop a computer version to
32Crisis Plan Additional Guidelines for Use Revise and re-tool after escalation using all de-briefing informationHelp consumers “practice” strategies before they become upsetTeach about the impact of external and internal triggers and stressors & learn new skills to manage reactionSupport in “coping skills” group
33What do consumers say they need in crisis planning?
34What 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 meLeave me aloneDistract me
35Successful 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 frustratedMax is given an opportunity to play an Ipod game for minutes
36Successful Crisis Safety Planning TRAEA 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.
37How to Support Proactive Use of the Chosen Calming Strategies Review/Role-Play use in WRAP groups led or co-led by Peer Advocates/ConsumersTake 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 interventionSo what are the common attributes of a plan?First of all, they’re incredibly creative. There’s great resourcefulness and creativity driven by staff ingenuity. Also - the plans and strategies are used, practiced, and everyone is fully on board.What’s more, each plan and strategy are linked to each person’s unique needs. They’re responsive to trauma histories. They incorporate people’s sensory experiences and the needs of the individual are allowed to supercede the rules of the institution.
38Sensing A ChangeUnderstand sensory experience, modulation & integrationIncorporate knowledge of sensory input and expertise of Occupational TherapyAssess the sensory diet of each person-servedIdentify sensory-seeking & sensory-avoiding behaviorsAdapt the physical environment & develop sensory rooms/spaces to respond to differing sensory needs (Champagne, 2003)Sensory experience is something all human beings share.We all have ‘sensory diets’ – this concept comes from Jean Ayres, a well-known Occupational Therapist, who identified that each person has their own sensory needs or ‘diets’ – primarily we are either looking for stimulation or looking to avoid stimulation. Sensory needs and experiences directly impact our feeling state.These sensory needs change over time – they are not static. If you become ill or have a migraine headache – your sensory needs change.We can take this concept of sensory need and apply it to our treatment interventions and our environments.
39Sensory-Based Approaches Calming Self-Soothing ActivitiesHot WaterWrapping in a heavy blanketDecaf TeaRocking ChairsSwingsYogaDrummingMeditationCreating (Legos, coloring, clay)CrochetCalming activities are particularly helpful for people with tension and anxiety who have difficulty unwinding and feeling physically relaxed.
40Sensory-Based Approaches Grounding Physical ActivitiesHoldingWeighted Blankets & VestsArm & Hand MassagePush-ups“Tunnels”/ Body SocksWrist/Ankle WeightsSour/Fireball CandiesGumSandtraysHere are simple sensory activities that can help ground and orient people – and impact how they feel.These strategies are helpful for people who have difficulty maintaining focus, like children with ADHD, people who hallucinate, people who dissociate or those who cannot focus for long periods of time.
41How do we care for OURSELVES and EACH OTHER? There is a Spanish proverb that says, “If we are not good for ourselves, how can we be good for others”?
42Ten Strategies for Building Resilience Make connections-- Family, friends, civic groups, faith-based organizations, other local groups2. Avoid seeing crises as insurmountable problems. You can change how you interpret and respond to stressful events3. Accept that change is a part of living. The only thing that is constant in life is change4. Do something regularly, even if it seems small, which enables you to move toward your goals(Daniel, 2007)
43Ten Strategies for Building Resilience 5. Take decisive actions rather than detaching completely and wishing problems and stresses would go away6. Look for opportunities for self-discovery. People often grow in some respect as a result of their struggle with loss7. Nurture a positive view of yourself. Develop confidence in your ability to solve problems; trust your instincts8. Keep things in perspective. Keep a long-term perspective--avoid blowing things out of proportion(Daniel, 2007)
44Ten 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)
45Effective Stress Management Strategies Must help you FEEL betterMust help you FUNCTION betterTake action. Don’t just wish your problems would goaway or try to ignore them.Instead, figure out what needs to be done,make a plan to do it,and then take action
46Do we ask our staff: What happened to you vs. what’s wrong with you?