Triggers, Warning Signs and Coping Strategies: Beyond the ICPP - PowerPoint Presentation

Slide1

Triggers, Warning Signs and Coping Strategies: Beyond the ICPP

Originally presented at the PARS Project’s Lessons

Learned Conference

May 24-25, 2011

Slide2

The Essential Components

Most of

us have probably heard about the three essential components of an Individual Calming Plan, or Crisis Prevention

Plan,

or Soothing Plan.

They are:

triggers

,

warning signs,

and

coping

strategies

.

Slide3

NASMHPD (2006):The experience of violence and victimization including sexual

abuse, physical abuse, severe neglect, loss,

domestic

violence and/or the witnessing of violence, terrorism

or disasterDSM-5 (APA 2013):The previous edition, DSM-IV, had addressed PTSD as an anxiety disorder.The DSM-5 includes a new chapter on Trauma- and Stressor-Related Disorders. Trauma includes:direct experience of the traumatic event;witnessing the traumatic event in person; learning that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

What is Trauma?

Slide4

If we think about this, trauma is a significant experience in one’s life that is going to have an effect on that person throughout their lifetime. There is a wide range of potentially traumatic events that either happen to a person or are witnessed by them.

Everyone of us are

different,

and what affects us is

different, and how it affects us is different.

Slide5

An

E

xample of State Change

Robert, a 22-year-old

man with a history of severe childhood physical abuse, displayed aggressive behavior on

the psychiatric

unit and was physically restrained.

Calm/

Continuous/

Engaged

Aggression

Fear

Dissociation

Slide6

Robert had been severely physically abused by his stepfather on a regular basis. He was actually having a good day on the psychiatric unit; everything was going great for Robert. Then he perceived that a male staff member said something demeaning to him. (He said he heard his father’s voice as staff talked behind 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.

Slide7

Parameters that change between states

Affect

Thought

Behavior

Sense-of-selfConsciousness

All of this is built on principles

of

normal development.

Slide8

We must recognize that when triggered, the response of an individual involves changes in a number of parameters.How we feel

can immediately change from calm and content to anything from a sense of uneasiness, to anxiety, to fear, or panic.

As a result this affects

what we think - the need to be safe, to protect oneself, to surviveThe resulting behavior is being driven by how we feel and we think. May or may not be rational. Our sense of self is begins to unravel, become less definitive. Often, there is a loss of control.Consciousness is no longer clear. There is much difficulty in differentiating between past and present, previous trauma and the here and now. Dissociation is common and often used as a coping mechanism.

Slide9

Brain chemistry and development is affected

by trauma

Immediate

“fight or flight” response

Heightened sense of fear/dangerLearned ResponseWith persons who have experienced trauma,

there

is a learned response, essentially a survival

mechanism

in place.

Scientists have studied the brains of these people

and

have noted that the ability to regulate response is drastically affected.

They seem to always to be in a state of high alert, ready for “fight or flight” to

protect themselves from remembered harmful

experiences.This is their automatic, learned response.

There is this heightened sense of fear or danger that is pervasive.

Their response

to this is often unexpected and can be violent.

Slide10

Between stimulus and response

Stimulus

LeDoux

,

1996

Very Fast

Hippocampus

Slower

Sensory Thalamus

Cortex

Amygdala

Slide11

The amygdala is essentially our survival mechanism; its response is immediate.

The

hippocampus

is the part of our brain that

is responsible to put the triggering event into context, present the variables.The cerebral cortex is the decision maker, deciding if I am really in danger here.This all occurs in a fraction of a second.With persons who have experienced trauma, there are changes to the brain.The hippocampus and cerebral cortex both have shrunk and are not working effectively.That leaves only the response activated by the amygdala:Fight, Flight

or Freeze.

Fight, Flight or

Freeze

Slide12

Some Common Reactions to TraumaMary S. Gilbert, Ph.D., Grand Rapids, Michigan

Physical Reactions

Mental Reactions

Emotional Reactions

Behavioral Reactions

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

Slide13

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

Triggers may be sights, sounds, smells, touches, anything that reminds the person of the trauma and causes them to feel unsafe, anxious or fearful.

Persons with histories of traumatic stress often experience flashbacks which are recurring memories, feelings or thoughts that cause the person to re-experience the trauma and all the associated feelings.

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.

Because of their traumatic stress the past comes to the present, dissociation often occurs and the person is again experiencing the traumatic event.

We must be aware of the negative impact exposure to 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

.

Slide14

A trigger is something that sets off an action, process, or series of events such as fear, panic, anger, anxiety or

agitation. Can you think of any examples?

Triggers

People being too close

Room checks

Presence of large men

Yelling!

Bedtime

Guilt, criticism, put-downs

Slide15

A trigger is something sets off an action or causes a person to behave in a certain way in response to fear, panic, or anxiety.

Thinks about the examples given on the previous slide.

Bedtime: A

time when many past abuses occurred Room checks: Reminders of the abuser coming into their room Large men: Think about it. Who often does the restraining?These examples really need to be in the forefront of our thinking when we look at how our treatment environments are, including the way staff speak to consumers, the words, the cadence, the tone, the attitude that is displayed. We need to ask if the environment is conducive to self-soothing and self-regulation.

Triggers

Slide16

Trauma AssessmentRisk Assessment

Individual Calming Plan

Clinical

interviews

Informal discussionsOngoing processIdentifying Triggers

Slide17

Most of us do a Trauma or Risk Assessment on admission. Some may do a more comprehensive assessment

than

others, but

it’s

usually done on admission.Often, the next step is to develop a calming plan, or crisis management plan. This is where we take the information obtained through the assessment process and make a plan for what to do and not do if a crisis emerges.Most facilities also conduct discipline specific interviews or assessments. The information is transferred to the clinical record and used to develop treatment strategies.But is that enough?Identifying Triggers

Slide18

Let’s look at some drawbacks to this process. Studies have shown that when persons are revisiting their trauma history, the Broca area of the brain, the part responsible for speech shuts down.

We count a lot on our assessments but we need to understand that what we get during these formal assessments may not be all that there is. The person may not be able to verbalize the information we are asking them to divulge.

The process must continue on and one that involves everyone on the treatment team and I do mean everyone, from the psychiatrist to the housekeeper, yes and even the food service worker.

Identifying Triggers

Slide19

We all know that at the right time and place there are situations that arise that cause the person served to show us or tell us a little more about themselves. It is at those times that we need to listen, we need to ask questions and we need to share this new information with the team.

Then there are other times where we are just observing and we either notice something or we get the feeling something is just not right.

We

need to act in those situations by either interacting, and setting the calming plan in motion or communicating the information to someone who can.

Identifying Triggers

Slide20

Particular time of day/night

Particular time of year

Anniversary of a loss

Internal triggers

Someone who looks/sounds familiarStaff issues/difficulty Other idiosyncratic issues related to traumaTriggers are not always obviousIt could be…

Slide21

So many times we don’t realize that a person has been triggered.We only see the behavioral response.

We need to look for possible triggers which could be:

- A particular time of day, night or of the year.

-

Internal triggers, those set off by the person’s disorder or thinking. - Someone who looks or sounds like someone in their past. - Let’s not forget about staff, their attitudes, the words they use, how they say them, staff conflicts - And we can’t ignore the fact that many times the triggers are very difficult to identify and may be highly idiosyncratic to that person’s trauma history.We have to ask, we have to be observant, and we have to ask again.Hidden Triggers

People have unique histories with uniquely specific triggers.It is

essential to ask

and incorporate.

Slide22

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 tightness in the chest Sweating

Warning Signs

Slide23

DissociationFlashbacks

Nightmares

Hyper-vigilance

Terror

AnxietyPejorative auditory hallucinationsDifficulty w/problem solvingTypical Trauma-related SymptomsNumbnessDepression

Substance abuse

Self-injury

Eating problems

Poor judgment and continued cycle of victimization

Aggression

Remember earlier we

saw the work that Mary Gilbert did on reactions to trauma. Some

of those reactions could be considered warning signs, but we want to be very careful here.What you need to understand is that ……

These

“symptoms” are not signs of pathology ...rather, they are survival strategies

that have helped to

cope with terrible pain and challenges

.

Slide24

The key is learn how the behavior developed and teach new coping strategies.

We

can’t demand that the person stop doing certain things until we can teach them new more desirable and practicable coping strategies and they are at a point where the new strategy is as effective as the old.

Slide25

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

Slide26

The key here is to identify behaviors/actions that are warning signs and start intervening immediately.

What we need to notice

(and it requires

us to be observant all the time) is any behavior that seems

atypical or unusual for this person in the context of where or when it is happening. Some get the wrong sense that this is always disruptive or aggressive or self injurious. Nothing can be farther from the truth.Some times it’s

an improvement in behavior;

the person appears to be making progress and is no longer displaying behaviors that are targeted for

treatment. Maybe - and

maybe not

- is

what I say. The bottom line is that we need to check it out.There are times where it is so difficult to recognize the warning sign because it is so idiosyncratic to the individual or so subtle it goes unnoticed. Other times, it’s

not displayed in close proximity to the crisis. Here is where debriefing is so

important. In order to identify these we’ll need to backtrack and look at what behaviors were being displayed just prior to the crisis, and again just prior to

that, and so on.

Sometimes it’s necessary to get everyone in a room together and ask them to

voice whatever they know about this person’s behaviors.

Likes

,

dislikes,

etc.

Slide27

The Importance of Interaction

Day to day routine

Establishing rapport

Ongoing

assessmentsPersonal greetings and farewells

Making ourselves available

Using activities as a forum

It is so very important that staff see their role as

craftspeople

and not gate keepers 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…

well,

you get the

point

.

Slide28

I am not saying 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 when we leave

for the day. It

really is beneficial to do this in a manner that asks if there is anything we can do for the before we leave. Just think if we all were doing this.

Wow!

Our words need so many times to be “what can I do to help?” and make ourselves visible and available for support.

Our paraprofessional staff need to use activities as a forum for interaction, assessment and discussion.

Slide29

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,

2005)

Slide30

Strategies

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 musicStrategies

need to be practicable - meaning doable in times of crisis

-

and

need to work as well as the maladaptive coping mechanisms

the person has been

using

.

Slide31

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

Sometimes it’s trial and error.

Slide32

Remember, strategies

must be

doable

in the time of crisis.

And if we’re teaching a skill that replaces the less desirable one, it must be able to be used once the person leaves the facility.

It can’t be something that we put out of reach.

Too

many

times,

the strategy that will work is seen by staff as a motivator for improved or non-aggressive behavior. An example is if the person can calm themselves by listening to their

iPod and the rules say that in order to use the iPod the person needs to be calm and non-aggressive for two days, it’s not going to work. The strategy that is the tool to help the person is out of reach.

We can’t wait till

a crisis develops to have the person practice the strategy.

It needs to be practiced at neutral

times - and remember, non-successes are mistakes not

failures. Partial successes need to be

embraced,

and staff use

these

to further shape the person

.

Slide33

Sometimes there is a need to employ steps in the process.

Sometimes

what has been identified as a strategy will only work if

it’s

part of a process with steps before and after.With what we’ve learned about sensory modulation, staff need to be thinking in the area of all seven senses.One major area of concern

is that staff

often see

the strategy as a reward for negative behavior.

Our

thinking must change here.

Sometimes what we get is not what we expect or want to accept. We need to be careful here and recognize that the behavior being displayed may be a better choice than what could have been displayed.

Slide34

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

Too many

times,

we feel we need to be involved. But once discharged, the person needs to be able to

self-initiate

their coping strategies and know who they can count on for assistance.

Slide35

Being

alone

Not being listened

to

Being told to stay in my room

Loud tone of

voice

Peers teasing

What May Not Help…...

“If I’m told in a mean way that I can’t

do something … I lose it.”

Natasha

, 18

years old

Slide36

"We are continually faced with

great

opportunities

which are brilliantly

disguised as unsolvable problems.“ Margaret Mead

No one ever said the job would be

easy, or

that

it would not

seem

impossible

at

times. But for those thoughtful people who have embraced the Six Core Strategies, it is working across the country, and it’s

working because they refuse to give up.

I know, I know. Many of us think of our jobs as scary, really difficult to do day in and day out, not so safe, really dangerous, emotionally draining. Well………….

Slide37

…Really?!