Trauma-Informed Care: Positive Alternatives to Seclusion & Restraint - PowerPoint Presentation

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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

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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).

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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.

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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

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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

.

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Typical Trauma-related Symptoms

DissociationFlashbacksNightmares Hyper-vigilanceTerrorAnxietyPejorative auditory hallucinationsDifficulty with problem solving

NumbnessDepressionSubstance abuseSelf-injuryEating problemsPoor judgment and continued cycle of victimizationAggression

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

.

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Some Common Reactions to TraumaMary S. Gilbert, Ph.D.

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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

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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

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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

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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.

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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

).

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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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Parameters that change between states

Affect

Thought

Behavior

Sense-of-self

Consciousness

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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.

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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.

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Posttraumatic Stress Disorder (PTSD) is a trauma diagnosis

Criterion A (one required): A stressorCriterion B (one required): Intrusion symptomsCriterion C (one required): AvoidanceCriterion D (two required): Negative alterations in cognitions and moodCriterion E (two required): Alterations is arousal and reactivityCriterion F: Duration (B, C, D, and E for more than one month)Criterion G: Functional significanceCriterion H: Exclusion (not due to meds, substance use, or other illnessIndividuals may also experience dissociative symptoms and/or delayed expression.

http://

www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

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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

.

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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.

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Longitudinal Course of PTSD Symptoms in Children with Burns

Everyone’s reaction is unique.

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Scott Rauch

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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

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Emotional brain

Restak

,

1988

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Goal of Treatment

Maintain

Calm/Continuous/Engaged

State

Prevent Discontinuous States

Build Cognitive Structures

that

allow Choices

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Trauma-Informed Care

Recognize prevalence of

trauma -

take “universal precautions”

Commitment to acceptance, dignity and social inclusion

Assess and treat for trauma

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Trauma Assessments

Identifies past or current traumaLooks at current behaviors and the effects of trauma on daily lifeHelps develop clinical approaches to recovery/diagnosis

Courtesy of Caldwell Management Associates

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Trauma Assessments

Focuses on what “happened to you” not “what is wrong with you” Conducted upon admission or shortly afterwardFor children, assessment through play and behavioral observation

Courtesy of Caldwell Management Associates

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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

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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

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Trauma-Informed Language

Is always…….

Person-centered

R

espectful

Conscious

of tone of voice, cadence and volume

Aware

of body language

Helpful

and hopeful

Objective

, neutral

C

ollaborative

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Trauma-Informed Environment

Interaction is always respectfulIs pleasant, tidy, cleanProvides opportunities for individual “space” and activitiesContains welcoming settings and attitudesSignage 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

.

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

- Albert Einstein

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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.

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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.

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“Every restraint I’ve reviewed, started with a staff memberenforcing a rule.”

Ross Greene, Ph.D.

RRI Grand Rounds ~ Cambridge Hospital

January 20, 2004

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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.

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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.

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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.

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The Three S’s of Praise

Short

Specific

Sincere

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Collaboration

“To work jointly with others”

The underlying philosophy of collaboration

is premised

on treating everybody with dignity

and respect.

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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

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Moving from Control to Collaboration

There

is a need to teach the recipient how to

self-regulate

and how to shift cognitive sets.

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The Importance of Interaction

Day-to-day

routine

Establishing rapport

On-going assessments

Personal greetings/farewells

Making ourselves available

Using activities as a forum

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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.

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“

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

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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

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Simple Sensory Enhancements

Keep the environment well-maintained; adding calming, attractive features like:

artwork plantsfish tanksmusiccomfortable seating

rocking chairs or gliding rockers

bedrooms with new bedspreads

place to exercise

curtains

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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.

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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

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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

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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

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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.

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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.

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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?