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Trauma Informed Care: Positive Alternatives to Seclusion & Restraint Presented by: New York State Office of Mental Health Executive Director’s Meeting.

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Presentation on theme: "Trauma Informed Care: Positive Alternatives to Seclusion & Restraint Presented by: New York State Office of Mental Health Executive Director’s Meeting."— Presentation transcript:

1 Trauma Informed Care: Positive Alternatives to Seclusion & Restraint Presented by: New York State Office of Mental Health Executive Director’s Meeting October 17, 2012 How 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%.

3 Trauma Includes:  Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss  A severe one time, or repeated event  Those that are perpetrated by someone known  Acts that betray trust  Community or school violence  Separation from parents  Physical illness

4 Typical Trauma-related Symptoms  Dissociation  Flashbacks  Nightmares  Hyper-vigilance  Terror  Anxiety  Pejorative auditory hallucinations  Difficulty w/problem solving  Numbness  Depression  Substance abuse  Self-injury  Eating problems  Poor judgment and continued cycle of victimization   Aggression

5 Some Common Reactions to Trauma Mary S. Gilbert, Ph.D. Physical Reactions MentalReactions Emotional Reactions BehavioralReactions Nervous energy, jitter, muscle tension Upset stomach Rapid Heart Rate Dizziness Lack of energy, fatigue Teeth grinding Changes in the way you think about yourself Changes in way you think about the world Changes in the way you think about other people Heightened awareness of your surrounding (hypervigilance) Lessened awareness, disconnection from yourself (dissociation) Difficulty concentrating Poor attention or memory problems Difficulty making decision Intrusive images Fear, inability to feel safe Sadness, grief, depression Guilt Anger, irritability Numbness, lack of feelings Inability to enjoy anything Loss of trust Loss of self-esteem Feeling helpless Emotional distance from others Intense or extreme feelings Feeling chronically empty Blunted, then extreme feelings Becoming withdrawn or isolated from others Easily startled Avoiding places or situation Becoming confrontational and aggressive Change in eating habits Loss or gain in weight Restlessness Increase or decrease in sexual activity Self-injury Learned helplessness Addictive behaviors

6 Attachment & Relational Deficits   Appear guarded & anxious   Difficult to re-direct, reject support   Highly emotionally reactive   Hold on to grievances   Do not take responsibility for behavior   Make the same mistakes over and over   Repetition compulsion / traumatic re-enactment (Hodas, 2004)

7 Response to Trauma is a Learned Response  Trauma causes a change in brain chemistry and brain development  There is an immediate “fight or flight” response when triggered  Causes a heightened sense of fear/danger

8 Play and Fear (Panksepp, 1998)

9 State Change

10 Parameters that change between states  Affect  Thought  Behavior  Sense-of-self  Consciousness

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.

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: The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons’ experience of:  Actual or threatened death  Actual or threatened serious injury  Threat to physical integrity

13 Time Period PTSD-RI Score Acute Assessment 3 Month Assessment 0 Longitudinal Course of PTSD Symptoms in Children with Burns

14 Rauch Brain scans Scott Rauch

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)

16 Emotional Brain (Restak, 1988)

17 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Cerebral Cortex Very Fast Slower Hippocampus Response (LeDoux, 1996)

18 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Very Fast Much Slower Response Cortex Hippocampus (LeDoux, 1996) Much Slower

19 Goal of Treatment Maintain Calm/Continuous/ Maintain Calm/Continuous/ Engaged State Engaged State Prevent Discontinuous States Prevent Discontinuous States Build Cognitive Structures Build Cognitive Structures that allow Choices that allow Choices

20 Between Stimulus and Response Stimulus Sensory Thalamus Amygdala Very Fast Slower Response Cortex Hippocampus Neuroregulatory Intervention Psychotherapy Psychopharmacology Social Environmental Intervention (LeDoux, 1996)

21 Between Stimulus and Response Response Stimulus Traumatic Reminder Traumatic State Intervention Social- environmental Intervention Neuro- regulatory Intervention COGNITION!!!

22 Trauma Informed Care  Recognize prevalence of trauma- take “universal precautions”  Commitment to acceptance, dignity and social inclusion  Assess and treat for trauma

23 Trauma Assessments  Identifies past or current trauma  Looks at current behaviors and the effects of trauma on daily life  Helps develop clinical approaches to recovery/diagnosis 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 observation Courtesy of Caldwell Management Associates

25 Trauma-Informed Treatment  The focus is on: Safety, Stabilization Self-management  Healthcare staff need: - training in this kind of treatment - access to experts for consultation and recommendations for treatment

26 Trauma Informed Care  Ensures that the recipient is center of their own treatment  Empowers recipient & their families  Promotes safety and trustfulness  Has goals of education and wellness self management  Is transparent and open to outside parties

27 Trauma Informed Language Is always…….  person centered  respectful  conscious of tone of voice, cadence and volume  aware of body language  helpful and hopeful  objective, neutral  collaborative

28 Trauma Informed Environment  Interaction is always respectful  Is pleasant, tidy, clean  Provides opportunities for individual “space” and activities  Contains welcoming settings & attitudes  Signage is always person centered and worded positively

29 “ The definition of insanity is continuing to do the same thing over and over again expecting a different result.” - Albert Einstein

30 ControlControl “Authority or power to regulate, direct or dominate. A means of restraint. To exercise restraining or directing influence over…” “Authority or power to regulate, direct or dominate. A means of restraint. To exercise restraining or directing influence over…” News Flash When 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 Hospital January 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 ShapingShaping  Over 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.

36 The Three S’s of Praise ShortSpecificSincere

37 CollaborationCollaboration “To work jointly with others” “To work jointly with others” The underlying philosophy of collaboration is premised on treating everybody with dignity The underlying philosophy of collaboration is premised on treating everybody with dignity and respect. and respect.

38 Collaboration (How to Do It)  Observe warning signs  Recognize a driving need  Employ a practicable strategy  Empower the person  Tap into an interest or strength  Ask for options  Appreciate where the recipient is coming from coming from  Praise 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. 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 routine  Establishing rapport  On-going assessments  Personal greetings/farewells  Making ourselves available  Using activities as a forum

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…” “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) (Interview with a adult trauma survivor (CD), 2005)

42 Creating Therapeutic Treatment Environments  Understand sensory experience, modulation and integration  Determine sensory-seeking & sensory- avoiding states and behaviors.  Develop sensory rooms & use the physical environment to respond to differing sensory needs (Champagne, 2003) (Champagne, 2003)

43 Simple Sensory Enhancements  art work  plants  fish tanks  music  comfortable seating  rocking chairs or gliding rockers  bedrooms with new bedspreads  place to exercise  curtains Keep the environment well-maintained; adding calming, attractive features like:

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 Grounding physical activities: Grounding physical activities: Holding, weighted blankets, arm massages, “tunnels,” body socks, walk with joint compression, wrist/ankle weights, aerobic exercise, sour/fireball candies Holding, weighted blankets, arm massages, “tunnels,” body socks, walk with joint compression, wrist/ankle weights, aerobic exercise, sour/fireball candies Calming self-soothing activities: Hot shower/bath, drumming, decaf tea, rocking in a rocking chair, beanbag tapping, yoga, wrapping in a heavy quilt, meditation Hot shower/bath, drumming, decaf tea, rocking in a rocking chair, beanbag tapping, yoga, wrapping in a heavy quilt, meditation Activity examples include:

46 Sensory Room: Definition An appealing physical space painted with soft colors & filled with furnishings and objects that promote relaxation and/or stimulation. An appealing physical space painted with soft colors & filled with furnishings and objects that promote relaxation and/or stimulation.

47 Sensory Room Equipment  Calming Music  Peach colored walls  Lava Lamp  Gliding Rocking Chairs  Mats with weighted blankets  Projected Light (moving/changing)  Large balls - bouncing  Small balls - pressure  Aromatherapy  Fish tanks  Large Tupperware container with raw rice

48 Sensory Room: Guidelines for Use  Select fire resistant items, latex free, generally safe and washable  Place selected items in locked cabinet  Create policies and procedures for use and maintenance of room and equipment  Train staff and supervise for appropriate use  Schedule access anytime during operations  Include use of sensory room items on the Individual Crisis Prevention Plan (Safety Tool) (Champagne, 2003) (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. 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 Contents Comfort 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 Challenge Can we change our inpatient cultures and become collaborative, responsive, and nourishing? Can 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?


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