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%.
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 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
This 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:
Intentional
Repeated
Prolonged
And the earlier this happened, age wise, the more profound the impact on brain development
Can 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
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
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.

5. Some Common Reactions to Trauma Mary S. Gilbert, Ph.D.
Physical Reactions
Mental
Reactions
Emotional Reactions
Behavioral
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 5

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
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 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.

8. Play and Fear
(Panksepp, 1998)

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/
Engaged
Dissociation

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.
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 death
Actual or threatened serious injury
Threat to physical integrity
Post-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 Burns50 45 40 35 30
PTSD-RI Score 25 20 15 10 5
Acute Assessment Month Assessment
Time Period

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) 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
Cerebral
Cortex
Hippocampus
Slower
Sensory Thalamus
Amygdala
So 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 Fast
Stimulus
Response
(LeDoux, 1996)

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

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

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

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

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

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
Assessments 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 observation
Our 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,
Stabilization
Self-management
Healthcare staff need:
- training in this kind of treatment
- access to experts for consultation and recommendations for treatment
Beginning 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 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
TIC respects and empowers the individual as the center of their own wellness.

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
Ask: Why is it important to be mindful of our tone of voice and body language?

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
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.

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

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

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

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
It 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 integration
Determine 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 work
plants
fish tanks
music
comfortable seating
rocking chairs or gliding rockers
bedrooms with new bedspreads
place to exercise
curtains

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 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

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 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)

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 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 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?