1. Trauma-Informed Care: Positive Alternatives to Seclusion & Restraint How to Work Effectively, Collectively and Kindly Towards Improving Outcomes for the Persons We Serve Executive Director’s Meeting October 17, 2012

2. 2 Note: This presentation has been slightly modified and updated since its original presentation in 2012, to reflect current events and the most current understanding of trauma and PTSD in the DSM-5 (APA 2013).

3. 3 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 youth, or are witnessed by them. Think of some events that would have a negative impact on a child.

4. 4 Traumas that can lead to serious mental health problems: Sexual and 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

5. 5 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: Intentional Repeated Prolonged And the earlier in life this happened, the more profound the impact on brain development Can a youth be traumatized if the incident only happened once? Yes. For example, a child who 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, Hurricane Irene, or Superstorm Sandy. Obviously these types of events can be devastating.

6. 6 Typical Trauma-related Symptoms Dissociation Flashbacks Nightmares Hyper-vigilance Terror Anxiety Pejorative auditory hallucinations Difficulty with problem solving Numbness Depression Substance abuse Self-injury Eating problems Poor judgment and continued cycle of victimization Aggression What 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.

7. 7 Some Common Reactions to Trauma Mary S. Gilbert, Ph.D.

8. 8 Attachment and Relational Deficits Appear guarded and anxious Difficult to redirect, 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

9. 9 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

10. 10 Scientists 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 person learn new ways of responding. Another example of how the brain of a traumatized person 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. It’s Science

11. 11 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.

12. 12 Play Panksepp, 1998 Neuroscientist Jaak Panksepp studied play. It illustrates everything we’ve been talking about. Specifically, about how important it is for us to set up nurturing environments in our treatment programs. Play is what children do. If a child is not playing, we know there is something wrong. Dr. Panksepp studied young rats at play. This slide illustrates the two primary methods of rats at play. They have dorsal contacts and pins (a wrestling move).

13. 13 Play and Fear Panksepp, 1998 Panksepp’s rats lived in a laboratory. They had never been out of the laboratory. Dr. Panksepp kept track of how often they played. Basically, they played all the time. They’re born; they have this wonderful life; they live in a cage in a laboratory and they play, play, play. So what he did was put a “minimal fear stimulus,” a single cat hair in their cage. Just one cat hair. Mind you, these rats have never seen a cat. He put one cat hair inside their cage and what do you think happened? They stopped playing completely. The cat hair was in the cage for 24 hours…and they did not play for 24 hours.

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15. 15 Parameters that change between states Affect Thought Behavior Sense-of-self Consciousness

16. 16 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.

17. 17 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 things that can result 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 person.

18. 18 Posttraumatic Stress Disorder (PTSD) is a trauma diagnosis Criterion A (one required): A stressor Criterion B (one required): Intrusion symptoms Criterion C (one required): Avoidance Criterion D (two required): Negative alterations in cognitions and mood Criterion E (two required): Alterations is arousal and reactivity Criterion F: Duration (B, C, D, and E for more than one month) Criterion G: Functional significance Criterion H: Exclusion (not due to meds, substance use, or other illness Individuals may also experience dissociative symptoms and/or delayed expression. http://www.ptsd.va.gov/professional/PTSD- overview/dsm5_criteria_ptsd.asp

19. 19 You’ve heard of PSTD associated with soldiers returning from combat. Soldiers have personally experienced and/or witnessed dreadful things. The people we work with often have a diagnosis of PSTD. PTSD 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.

20. 20 Family, other children and staff who witness or participate in restraint and seclusion 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 would be present. PTSD may develop if symptoms continue and if left untreated. Our work in TIC will help alleviate the symptoms and potential of developing PTSD.

21. 21 Longitudinal Course of PTSD Symptoms in Children with Burns Everyone’s reaction is unique.

22. 22 Scott Rauch

23. 23 Lateral Ventricles Measures in an 11-year-old maltreated boy with chronic PTSD, compared with a healthy, non-maltreated matched control De Bellis et al, 1999

24. 24 Emotional brain Restak, 1988

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27. 27 Goal of Treatment Maintain Calm/Continuous/Engaged State Prevent Discontinuous States Build Cognitive Structures that allow Choices

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30. 30 Trauma-Informed Care Recognize prevalence of trauma - take “universal precautions” Commitment to acceptance, dignity and social inclusion Assess and treat for trauma

31. 31 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

32. 32 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

33. 33 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

34. 34 Trauma-Informed Care Ensures that the recipient is center of their own treatment Empowers recipient and their family Promotes safety and trustfulness Has goals of education and wellness self management Is transparent and open to outside parties

35. 35 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

36. 36 Trauma-Informed Environment Interaction is always respectful Is pleasant, tidy, clean Provides opportunities for individual “space” and activities Contains welcoming settings and attitudes Signage is always person centered and worded positively In 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.

37. 37 “The definition of insanity is continuing to do the same thing over and over again expecting a different result.” - Albert Einstein

38. 38 Control “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.

39. 39 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.

40. 40 “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

41. 41 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.

42. 42 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.

43. 43 Shaping 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.

44. 44 The Three S’s of Praise Short Specific Sincere

45. 45 Collaboration “To work jointly with others” The underlying philosophy of collaboration is premised on treating everybody with dignity and respect.

46. 46 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 Praise the recipient for who they are

47. 47 Moving from Control to Collaboration There is a need to teach the recipient how to self-regulate and how to shift cognitive sets.

48. 48 The Importance of Interaction Day-to-day routine Establishing rapport On-going assessments Personal greetings/farewells Making ourselves available Using activities as a forum

49. 49 It is so very important that staff see their role as craftspersons, 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.

50. 50 “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 an adult trauma survivor (CD), 2005

51. 51 Creating Therapeutic Treatment Environments Understand sensory experience, modulation and integration. Determine sensory-seeking and sensory-avoiding states and behaviors. Develop sensory rooms and use the physical environment to respond to differing sensory needs. Champagne, 2003

52. 52 Simple Sensory Enhancements Keep the environment well-maintained; adding calming, attractive features like: artwork plants fish tanks music comfortable seating rocking chairs or gliding rockers bedrooms with new bedspreads place to exercise curtains

53. 53 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.

54. 54 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 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

55. 55 Sensory Room Definition: An appealing physical space painted with soft colors and filled with furnishings and objects that promote relaxation and/or stimulation. Equipment Ideas: 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

56. 56 Sensory Room: Guidelines for Use Select fire-resistant, latex-free, generally safe and washable items 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

57. 57 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, and promote relaxation. It should be a place to experience feelings within acceptable boundaries.

58. 58 Comfort Rooms Environment: The setup 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 use of restraint. 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.

59. 59 The Challenge Can we change our inpatient cultures and become collaborative, responsive, and nourishing? Can we offer places of sanctuary that remember the person we are serving and facilitates healing and recovery? How must we change if we want these changes to occur?