Presentation on theme: "Trauma Informed Care: Positive Alternatives to Seclusion & Restraint"— Presentation transcript:
1 Trauma Informed Care: Positive Alternatives to Seclusion & Restraint Presented by:New York State Office of Mental HealthExecutive Director’s MeetingOctober 17, 2012How to Work Effectively, Collectively and Kindly Towards Improving Outcomes for the Persons We Serve
2 What is Trauma?Trauma is extreme stress that overwhelms a person’s ability to cope or disrupts one’s sense of safety.Psychological trauma occurs as a result of a traumatic event where a person experiences or witnesses injury or threats to self or others.Prevalence of trauma for psychiatric inpatients is 80-90%.There are a wide range of potentially traumatic events that either happen to the youth or are witnessed by them.Can you give some examples of events that would have a negative impact on a child?
3 Trauma Includes:Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic lossA severe one time, or repeated eventThose that are perpetrated by someone knownActs that betray trustCommunity or school violenceSeparation from parentsPhysical illnessThis slide identifies the types of trauma that are typically considered to most severely leads to serious mental health problems in youth we treat.Generally speaking the most harmful trauma experiences tend to be those that were perpetrated by someone close – someone well known to the victim and/or were:IntentionalRepeatedProlongedAnd the earlier this happened, age wise, the more profound the impact on brain developmentCan a youth be traumatized if the incident only happened once? Yes. For example, a child that has witnessed the violent death of a parent can be traumatized.One time events can be equally traumatic – we do not want to minimize single occurrences like a rape, a serious automobile accident, or being involved in a natural disaster, like Hurricane Katrina. Obviously these types of events can be devastating.
4 Typical Trauma-related Symptoms DissociationFlashbacksNightmaresHyper-vigilanceTerrorAnxietyPejorative auditory hallucinationsDifficulty w/problem solvingNumbnessDepressionSubstance abuseSelf-injuryEating problemsPoor judgment and continued cycle of victimizationAggressionWhat we want you to understand is that these “symptoms” are not signs of pathology – rather they are survival strategies that have helped them cope with terrible pain and challenges.The key is learn how the behavior developed and teach new coping strategies.
5 Some Common Reactions to Trauma Mary S. Gilbert, Ph.D. Physical ReactionsMentalReactionsEmotional ReactionsBehavioralNervous energy, jitter,muscle tensionUpset stomachRapid Heart RateDizzinessLack of energy, fatigueTeeth grindingChanges in the way you think about yourselfChanges in way you think about the worldChanges in the way you think about other peopleHeightened awareness of your surrounding (hypervigilance)Lessened awareness, disconnection from yourself (dissociation)Difficulty concentratingPoor attention or memory problemsDifficulty making decisionIntrusive imagesFear, inability to feel safeSadness, grief, depressionGuiltAnger, irritabilityNumbness, lack of feelingsInability to enjoy anythingLoss of trustLoss of self-esteemFeeling helplessEmotional distance from othersIntense or extreme feelingsFeeling chronically emptyBlunted, then extreme feelingsBecoming withdrawn or isolated from othersEasily startledAvoiding places or situationBecoming confrontational and aggressiveChange in eating habitsLoss or gain in weightRestlessnessIncrease or decrease in sexual activitySelf-injuryLearned helplessnessAddictive behaviors5
6 Attachment & Relational Deficits Appear guarded & anxiousDifficult to re-direct, reject supportHighly emotionally reactiveHold on to grievancesDo not take responsibility for behaviorMake the same mistakes over and overRepetition compulsion / traumatic re-enactment(Hodas, 2004)
7 Response to Trauma is a Learned Response Trauma causes a change in brain chemistry and brain developmentThere is an immediate “fight or flight” response when triggeredCauses a heightened sense of fear/dangerScientists have studied the brains of people who have experienced trauma and have noted that the ability to regulate response is drastically effected. They seem to always to be in a state of high alert, ready to “fight or flight”-to protect themselves from remembered harmful experiences. This is their automatic, learned response.Our task is to help the child learn new ways of responding.Another example of how the brain of a traumatized youth might respond:Have you ever heard the term “speechless terror,” when people are unable to speak in times of great stress?That happens when traumatic memories shut down the part of the brain that instigates response.So, when we ask people in the midst of crisis and/or traumatic re-enactment, to “tell us about it,” they really are not able to.
9 State Change Aggression Fear Calm/ Continuous/ Engaged Here is an example of this transition. This is a slide that depicts what happened with a young man named Robert. Robert was severely physically abused by his stepfather on a regular basis. He was on a psychiatric unit and he was actually having a good day; everything was going great for Robert. Then he perceived that a male staff member said something demeaning to him. What happened? He immediately went from a calm, continuous state to a state of aggression. He lunged at the staff member. What happens when you lunge at a staff member? You get restrained. Robert was restrained and then he started to re-experience the physical abuse he suffered as a child. He began to dissociate and lose all sense of reality.What was discovered afterwards, through meticulous debriefing, was that when he overheard the staff person say something, he heard it in his stepfather’s tone of voice. Robert perceived it as demeaning. So, he went from a calm, continuous state to three extreme states of emergency. The transition between calm and continuous states and discrete states of emergency are fundamental for understanding trauma and how the brain responds to perceived threat and stress.Calm/Continuous/EngagedDissociation
10 Parameters that change between states AffectThoughtBehaviorSense-of-selfConsciousness
11 Triggers and Flashbacks Triggers are sights, sounds, smells, touches, that remind person of the trauma.Flashbacks are recurring memories, feelings, thoughts.Traumatic stress brings the past to the present.The memory of the traumatizing event can trigger a response of intense fear, horror and helplessness in which extreme stress overwhelms their capacity to cope.We must be aware of the negative impact exposure to those people/places – or people, places or things that can result in have in triggering or re-traumatizing. For example, a dark room may trigger a memory of abuse in a dark room. Just hearing a voice similar to the abuser may create a crisis situation for the child.
12 Post Traumatic Stress Disorder (PTSD) The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons’ experience of:Actual or threatened deathActual or threatened serious injuryThreat to physical integrityPost-Traumatic Stress Disorder is a trauma diagnosis.Many of you have heard of PSTD associated with soldiers returning from combat. These folk have personally experienced and/or witnessed dreadful things.The children we work with often have a diagnosis of PSTD.PTSD is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened.Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat.Family, other children and staff who witness or participate in restraints and seclusions can suffer from PTSD.Effects of a traumatic event may occur a few hours, several days, or a month after exposure to traumatic events, including after Restraint or Seclusion. Trauma symptoms (physical, Intrusive and avoidant symptoms such as in slides 6 and 9) would be present. PTSD may develop if symptoms continue (acute PTSD is less than three months and chronic PTSD duration greater than three months) and if left untreated. Our work in TIC will help alleviate the symptoms and potential of developing PTSD.
13 Longitudinal Course of PTSD Symptoms in Children with Burns 5045403530PTSD-RI Score252015105Acute Assessment Month AssessmentTime Period
15 Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control(De Bellis et al, 1999)34
16 Emotional Brain (Restak, 1988) To further highlight this point, let’s consider two important structures in the brain.This part is called the amygdala. It is responsible for fight or flight. We all have an amygdala.Another part of the brain is the hippocampus, which is above the amygdala.The hippocampus applies context to the situation and helps to regulate the amygdala and other functions in the brain.(Restak, 1988)
17 Between Stimulus and Response CerebralCortexHippocampusSlowerSensory ThalamusAmygdalaSo what happens is that we have an IMMEDIATE response.This is what happens to people with traumatic stress.Their amygdala is activated, their capacity to wait for the “context” is diminished, and they respond rapidly to a perceived threat or emergency and shift into an ‘emergency state of behavior’.Very FastStimulusResponse(LeDoux, 1996)
18 Between Stimulus and Response CortexHippocampusMuch SlowerMuch SlowerSensory ThalamusAmygdalaVery FastResponseStimulus(LeDoux, 1996)
19 Goal of Treatment Maintain Calm/Continuous/ Engaged State Prevent Discontinuous StatesBuild Cognitive Structuresthat allow Choices
20 Between Stimulus and Response SocialEnvironmentalInterventionCortexNeuroregulatoryInterventionPsychotherapyHippocampusSlowerPsychopharmacologySensory ThalamusAmygdalaVery FastResponseStimulus(LeDoux, 1996)
21 Between Stimulus and Response COGNITION!!!Traumatic ReminderResponseTraumatic StateWe need to help staff view themselves as craftspersons, not factory workers - so that they can skillfully create or shape the environments for the people we serve.When we work in an outpatient world, we do this.We actually ask people what is triggering for them and we try to build what we call a “wedge of cognition” - the ability to think when they’re feeling distressed.So what happens - if Talia is at school and hears someone say something demeaning about her breasts, she thinks…“Wait a minute; he says that to all the girls; nothing happens to them; nothing’s going to happen to me;I’m okay, he’s a jerk and my clinician told me to just take a deep breath and ignore it.”So, she is building a wedge of cognition and that is what we want to do for the people we serve. We want them to know that they have alternatives besides those discrete states of emergency.Social-environmentalInterventionNeuro-regulatoryInterventionIntervention
22 Trauma Informed CareRecognize prevalence of trauma- take “universal precautions”Commitment to acceptance, dignity and social inclusionAssess and treat for traumaUniversal precautions apply to all
23 Trauma Assessments Identifies past or current trauma Looks at current behaviors and the effects of trauma on daily lifeHelps develop clinical approaches to recovery/diagnosisAssessments are formal interviews done by the clinical staff, but that information must be available to all team members.They reveal information that gives an insight into past trauma, current behaviors and possible diagnosis.Assessments help the clinical staff to work with the individual to plot recovery plans.Courtesy of Caldwell Management Associates
24 Trauma Assessments- Focuses on what “happened to you” not “what is wrong with you”- Conducted upon admission or shortly afterward- For children, assessment through play and behavioral observationOur focus need to change from what is wrong with the person to what happened to them.It needs to start immediately upon admission with everyone on board.For young or nonverbal children, staff may use art or play therapy to gain important trauma information.Courtesy of Caldwell Management Associates
25 Trauma-Informed Treatment The focus is on:Safety,StabilizationSelf-managementHealthcare staff need:- training in this kind of treatment- access to experts for consultation and recommendations for treatmentBeginning trauma treatment focuses on ‘safety and stabilization’ – helping the person regain equilibrium to be able to function better, to be able to self-regulate.Insight, meaning making and adjustment and adaptation will come with time, treatment, support and new coping skills.Our focus is to try to help people stay engaged in treatment, learning and healing which are all needed in order to recover and lead a better life.
26 Trauma Informed CareEnsures that the recipient is center of their own treatmentEmpowers recipient & their familiesPromotes safety and trustfulnessHas goals of education and wellness self managementIs transparent and open to outside partiesTIC respects and empowers the individual as the center of their own wellness.
27 Trauma Informed Language Is always…….person centeredrespectfulconscious of tone of voice, cadence and volumeaware of body languagehelpful and hopefulobjective, neutralcollaborativeAsk: Why is it important to be mindful of our tone of voice and body language?
28 Trauma Informed Environment Interaction is always respectfulIs pleasant, tidy, cleanProvides opportunities for individual “space” and activitiesContains welcoming settings & attitudesSignage is always person centered and worded positivelyIn TIC, each child is appreciated and respected. Individuality and acknowledgement of individual needs is a priority.Open communication is signaled by an atmosphere where staff are approachable.Example: The use of “do not” signs and rules is transformed into helpful and encouraging verbiage.
29 thing over and over again expecting a different result.” “The definition of insanity is continuing to do the samething over and over again expecting a different result.”- Albert Einstein
30 When staff are upset and act on emotion, Control“Authority or power to regulate, direct or dominate. A means of restraint. To exercise restraining or directing influence over…”News FlashWhen staff are upset and act on emotion,they lose 30 points of IQ.
31 Problems Associated with a Controlling Culture Focus is often on staff not the recipient.Addressing problems is built around staff and program operations.Compliance and containment are mistaken as actual learning of new skills by the recipient and/or real improvement.Rules become more important as staff knowledge of their origin erodes.
32 “Every restraint I’ve reviewed, started with a staff member enforcing a rule.”Ross Greene, Ph.D.RRI Grand Rounds ~ Cambridge HospitalJanuary 20, 2004
33 Problems Associated with a Controlling Culture Minor violations often lead to control struggles.Fosters a belief that privileges (rights?) must be earned.Reinforces a need to control the recipient.Poorly trained/regulated staff who coerce recipients into compliance are not identified or required to change.
34 Moving from Control to Collaboration Moms rock small children over and over to help them go from an emotional to a calm state. (Grounding Activity)With traumatized individuals rocking (or similar grounding activities) help them to self regulate, essentially to go from an emotional to a calm state.It’s not about consequences, it’s about shaping behaviors.
35 ShapingOver time consistently working with the recipient to understand what needs to be learned.Giving frequent positive feedback as to how the recipient is doing.Praising the recipient for successes.
37 Collaboration “To work jointly with others” The underlying philosophy of collaboration is premised on treating everybody with dignityand respect.
38 Collaboration (How to Do It) Observe warning signsRecognize a driving needEmploy a practicable strategyEmpower the personTap into an interest or strengthAsk for optionsAppreciate where the recipient iscoming fromPraise the recipient for who they are
39 Moving from Control to Collaboration There is a need to teach the recipient how to self regulate and how to shift cognitive sets.
40 The Importance of Interaction Day to day routineEstablishing rapportOn-going assessmentsPersonal greetings/farewellsMaking ourselves availableUsing activities as a forumIt is so very important that staff see their role as crafts persons and not gatekeepers or person-sitters or jailers.The day-to-day routine needs to be person-centered. Every day we should all go home exhausted, not because we have physically exerted ourselves, but rather that we have continually engaged with the persons we serve, interacting, intervening when necessary, providing services, meeting needs, assisting, teaching, helping with coping strategy practice sessions...It’s not that people just stand around, but sometimes there are many opportunities that we miss each day to interact.We can’t forget basic Psych 101: in order to help anyone, we’ll need to establish rapport, a trusting relationship, a partnership in hope and recovery.If we’re really service-minded, we’ll make the effort to greet every person served when we arrive on-duty and notify them that w are leaving for the day. It really is beneficial to do this in a manner that asks if there is anything we can do for them before we leave. Just think if we all were doing this. Wow!Our words, so many times, need to be: “what can I do to help?” Make ourselves visible and available for support.Our paraprofessional staff need to use activities as a forum for interaction, assessment and discussion.
41 “If I could say anything to all the staff in the world it would be this: forget everything you were taught in school and be prepared to listen…don’t criticize and think it’s a lie. Just listen and ask questions and be kind. Just take the time to listen…”(Interview with a adult trauma survivor (CD), 2005)
42 Creating Therapeutic Treatment Environments Understand sensory experience, modulation and integrationDetermine sensory-seeking & sensory-avoiding states and behaviors.Develop sensory rooms & use the physical environment to respond to differing sensory needs(Champagne, 2003)(ask people what they look for if stressed? - more stimulation, less stimulation? Our inpatient units)
43 Simple Sensory Enhancements Keep the environment well-maintained; adding calming, attractive features like:art workplantsfish tanksmusiccomfortable seatingrocking chairs or gliding rockersbedrooms with new bedspreadsplace to exercisecurtains
44 Sensory Modulation Approaches Sensory modulation and integration activities can be particularly beneficial for those with sensory sensitivity/acuity such as symptoms of ADHD, impulse control and trauma.People are drawn to certain sensory experiences
45 Sensory Modulation Approaches Activity examples include:Grounding physical activities:Holding, weighted blankets, arm massages, “tunnels,” body socks, walk with joint compression, wrist/ankle weights, aerobic exercise, sour/fireball candiesCalming self-soothing activities:Hot shower/bath, drumming, decaf tea, rocking in a rocking chair, beanbag tapping, yoga, wrapping in a heavy quilt, meditation
46 Sensory Room: Definition An appealing physical space painted with soft colors & filled with furnishings and objects that promote relaxation and/or stimulation.
47 Sensory Room Equipment Calming MusicPeach colored wallsLava LampGliding Rocking ChairsMats with weighted blanketsProjected Light (moving/changing)Large balls - bouncingSmall balls - pressureAromatherapyFish tanksLarge Tupperware container with raw rice
48 Sensory Room: Guidelines for Use Select fire resistant items, latex free, generally safe and washablePlace selected items in locked cabinetCreate policies and procedures for use and maintenance of room and equipmentTrain staff and supervise for appropriate useSchedule access anytime during operationsInclude use of sensory room items on the Individual Crisis Prevention Plan (Safety Tool)(Champagne, 2003)
49 Providing for Comfort - Comfort Rooms - Historically, Quiet or Time-Out Rooms often provided minimal comfort. When used for comfort, a sensory/comfort room needs to provide sanctuary from stress, contain items that help provide comfort, promote relaxation and should be a place for persons to experience feelings within acceptable boundaries.
50 Comfort Room Environment The set up is to be physically comfortable and pleasing to the eye, including a recliner chair, walls with soft colors, murals (images to be the choice of persons served on each unit), and colorful curtains.It is a preventative tool that may help to reduce the need for restraint.
51 Comfort Room ContentsComfort items such as stuffed animals, soft blanket, headphones, audio tapes, reading materials, etc., can be made available to persons wishing to use the room.
52 The ChallengeCan we change our inpatient cultures and become collaborative, responsive, and nourishing?Can we offer places of sanctuary that remembers the person we are serving and facilitates healing and recovery?How must we change if we want these changes to occur?