1. 1 New York State Office of Mental Health Lessons Learned Conference May 24-25, 2011 Triggers, Warning Signs and Coping Strategies: Beyond the ICPP

2. 2 What is Trauma?  The personal experience of interpersonal violence including sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence, terrorism, and disasters. (NASMHPD, 2004)  It is extreme stress that overwhelms a person’s ability to cope or disrupts one’s sense of safety

3. State Change

4. Parameters that change between states AffectAffect ThoughtThought BehaviorBehavior Sense-of-selfSense-of-self ConsciousnessConsciousness

5. 5 Learned Response ► Brain chemistry/development affected by trauma ► Immediate “fight or flight” response ► Heightened sense of fear/danger

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

7. 7 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distance from others Intense or extreme feelings Feeling chronically empty Blunted, then extreme feelings Becoming withdrawn or isolated from others Easily startled Avoiding places or situation Becoming confrontational and aggressive Change in eating habits Loss or gain in weight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

8. 8 Traumatic stress, when triggered, brings the past to the present. Traumatic stress, when triggered, brings the past to the present.

9. 9 Triggers ► A trigger is something that sets off an action, process, or series of events (such as fear, panic, anger, anxiety or agitation). Examples include:  bedtime  room checks  presence of large men  yelling  people being too close  guilt, criticism or put downs

10. 10 Identifying Triggers ► Trauma Assessment ► Risk Assessment ► Individual Calming Plan ► Clinical Interviews ► Informal discussions ► On-going process

11. 11 Triggers are not always obvious: ► Particular time of day/night ► Particular time of year ► Anniversary of a loss ► Internal triggers ► Someone who looks/sounds familiar ► Staff issues/difficulty ► Other idiosyncratic issues related to trauma. Consumers have unique histories with uniquely specific triggers – it is essential to ask & incorporate

12. 12 Warning Signs A signal of distress or a physical precursor to crisis. This may be a manifestation of a developing crisis. Some signals are not observable, but some are, such as: A signal of distress or a physical precursor to crisis. This may be a manifestation of a developing crisis. Some signals are not observable, but some are, such as: ► Restlessness ► Agitation ► Being argumentative ► Pacing ► Shortness of breath ► Sensation of a tightness in the chest ► Sweating

13. 13 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

14. 14 Warning Signs Atypical Behaviors Not always disruptive Could be an improvement in behavior Something highly idiosyncratic Can be extremely subtle Not always displayed just prior to crisis

15. 15 The Importance of Interaction ► Day to day routine ► Establishing rapport ► On-going assessments ► Personal greetings/farewells ► Making ourselves available ► Using activities as a forum

16. 16 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)

17. 17 Strategies Strategies are individual-specific calming mechanisms to manage and minimize stress, those things that help to self-regulate such as: Strategies are individual-specific calming mechanisms to manage and minimize stress, those things that help to self-regulate such as:  time away from a stressful situation  going for a walk  talking to someone who will listen  working out  lying down  listening to peaceful music

18. 18 Developing Strategies ► Highly specific to the individual ► Must be practicable ► Must be attainable ► Need to be practiced ► May need additional strategies before/after ► Sensory modulation ► Reward versus coping ► Not always what we expect ► Building new cognitive pathways

19. 19 Coping Strategies (Activities that can be self initiated) ► Reaching out to others for support ► Eating comfort foods ► Focusing Exercises ► Stress Reduction and Relaxation Techniques ► Doing things that divert your attention ► Doing things you enjoy ► Getting sunlight/fresh air There is a need to identify those things that the recipient has done when they begin to Feel “Triggered” or set off by a life event that helps them self-regulate.

20. 20 What May Not Help…... ► Being alone ► Not being listened to ► Being told to stay in my room ► Loud tone of voice ► Peers teasing ► Humor ► Being ignored ► Having many people around me ► Having space invaded ► Staff not taking me seriously “If I’m told in a mean way that I can’t do something … I lose it.” -- Natasha, 18 years old

21. 21 "We are continually faced with great opportunities which are brilliantly disguised as unsolvable problems." Margaret Mead Margaret Mead

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