Trauma Informed Care: Positive Alternatives to Seclusion & Restraint Presented by: New York State Office of Mental Health Executive Director’s Meeting.

Trauma Informed Care: Trauma Informed Care: Positive Alternatives to Positive Alternatives to Seclusion & RestraintSeclusion & Restraint

Trauma Informed Care: Trauma Informed Care: Positive Alternatives to Positive Alternatives to Seclusion & RestraintSeclusion & Restraint

Presented by:Presented by:New York State Office of Mental HealthNew York State Office of Mental Health

Executive Director’s MeetingExecutive Director’s MeetingOctober 17, 2012October 17, 2012

How to Work Effectively, Collectively and Kindly How to Work Effectively, Collectively and Kindly Towards Improving Outcomes for the Persons We Towards Improving Outcomes for the Persons We

ServeServe

What is Trauma?What is Trauma?

TraumaTrauma is extreme stress that overwhelms a is extreme stress that overwhelms a person’s ability to cope orperson’s ability to cope or disrupts one’s sense of disrupts one’s sense of safety.safety.

Psychological traumaPsychological trauma occurs as a result of a occurs as a result of a traumatic event where a person experiences or traumatic event where a person experiences or witnesses injury or threats to self or others.witnesses injury or threats to self or others.

Prevalence of traumaPrevalence of trauma for psychiatric inpatients is for psychiatric inpatients is 80-90%.80-90%.

Trauma Includes:Trauma Includes:

Sexual & physical abuse, neglect, emotional abuse, Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss abandonment, poverty, sudden and traumatic loss

A severe one time, or repeated eventA severe one time, or repeated event

Those that are perpetrated by someone knownThose that are perpetrated by someone known

Acts that betray trustActs that betray trust

Community or school violenceCommunity or school violence

Separation from parentsSeparation from parents

Physical illnessPhysical illness

Typical Trauma-related Typical Trauma-related SymptomsSymptoms

DissociationDissociation FlashbacksFlashbacks Nightmares Nightmares Hyper-vigilanceHyper-vigilance TerrorTerror AnxietyAnxiety Pejorative auditory Pejorative auditory

hallucinationshallucinations Difficulty w/problem Difficulty w/problem

solvingsolving

NumbnessNumbness DepressionDepression Substance abuseSubstance abuse Self-injurySelf-injury Eating problemsEating problems Poor judgment and Poor judgment and

continued cycle of continued cycle of victimizationvictimization

Aggression

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

Physical Physical ReactionReaction

ss

Mental Mental

ReactionsReactions Emotional Emotional ReactionsReactions

Behavioral Behavioral

ReactionsReactions

Nervous Nervous energy, jitter, energy, jitter,

muscle muscle tensiontension

Upset Upset stomachstomach

Rapid Heart Rapid Heart RateRate

DizzinessDizziness

Lack of Lack of energy, energy, fatiguefatigue

Teeth Teeth grindinggrinding

Changes in the way you Changes in the way you think about yourselfthink about yourself

Changes in way you think Changes in way you think about the worldabout the world

Changes in the way you Changes in the way you think about other peoplethink about other people

Heightened awareness of Heightened awareness of your surrounding your surrounding (hypervigilance)(hypervigilance)

Lessened awareness, Lessened awareness, disconnection from disconnection from yourself (dissociation)yourself (dissociation)

Difficulty concentratingDifficulty concentrating

Poor attention or memory Poor attention or memory problemsproblems

Difficulty making decisionDifficulty making decision

Intrusive imagesIntrusive images

Fear, inability to feel Fear, inability to feel safesafe

Sadness, grief, Sadness, grief, depressiondepression

GuiltGuilt

Anger, irritabilityAnger, irritability

Numbness, lack of Numbness, lack of feelingsfeelings

Inability to enjoy Inability to enjoy anythinganything

Loss of trustLoss of trust

Loss of self-esteemLoss of self-esteem

Feeling helplessFeeling helpless

Emotional distance from Emotional distance from othersothers

Intense or extreme Intense or extreme feelingsfeelings

Feeling chronically Feeling chronically emptyemptyBlunted, then extreme Blunted, then extreme feelings feelings

Becoming withdrawn Becoming withdrawn or isolated from or isolated from othersothers

Easily startledEasily startled

Avoiding places or Avoiding places or situationsituation

Becoming Becoming confrontational and confrontational and aggressiveaggressive

Change in eating Change in eating habitshabits

Loss or gain in weightLoss or gain in weight

RestlessnessRestlessness

Increase or decrease Increase or decrease in sexual activityin sexual activity

Self-injurySelf-injury

Learned helplessnessLearned helplessness

Addictive behaviorsAddictive behaviors

Attachment & Relational DeficitsAttachment & 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)(Hodas, 2004)

Response to Trauma is a Response to Trauma is a Learned ResponseLearned Response

Trauma causes a change in brain Trauma causes a change in brain chemistry and brain developmentchemistry and brain development

There is an immediate “fight or flight” There is an immediate “fight or flight” response when triggeredresponse when triggered

Causes a heightened sense of Causes a heightened sense of fear/dangerfear/danger

Play and FearPlay and Fear

(Panksepp, 1998)(Panksepp, 1998)

State ChangeState Change

Parameters that change Parameters that change between statesbetween states

AffectAffect ThoughtThought BehaviorBehavior Sense-of-selfSense-of-self ConsciousnessConsciousness

Triggers and FlashbacksTriggers and Flashbacks

TriggersTriggers are sights, sounds, smells, are sights, sounds, smells, touches, that remind person of the touches, that remind person of the trauma. trauma.

FlashbacksFlashbacks are recurring memories, are recurring memories, feelings, thoughts.feelings, thoughts.

Traumatic stress Traumatic stress brings the past to the brings the past to the present.present.

Post Traumatic Stress Post Traumatic Stress Disorder (PTSD)Disorder (PTSD)

Post Traumatic Stress Post Traumatic Stress Disorder (PTSD)Disorder (PTSD)

The development of characteristic The development of characteristic symptoms, following exposure to a symptoms, following exposure to a traumatic stressor involving direct traumatic stressor involving direct personal experience or witnessing personal experience or witnessing another persons’ experience of: another persons’ experience of:

Actual or threatened deathActual or threatened death Actual or threatened serious injuryActual or threatened serious injury Threat to physical integrityThreat to physical integrity

Time Period

PT

SD

-RI

Sco

re

Acute Assessment 3 Month Assessment 0

Longitudinal Course of PTSD Symptoms Longitudinal Course of PTSD Symptoms in Children with Burnsin Children with Burns

5

10

15

20

25

30

35

40

45

50

Rauch Brain scansRauch Brain scans

Scott Rauch

Lateral Ventricles Measures in an 11 Year Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Compared with a Healthy, Non-Maltreated

Matched ControlMatched Control

(De Bellis et al, 1999)

Emotional BrainEmotional Brain

(Restak, 1988)(Restak, 1988)

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus Amygdala

CerebralCortex

Very Fast

SlowerHippocampus

ResponseResponse

(LeDoux, 1996)(LeDoux, 1996)


StimulusStimulus


Very Fast

Much Slower

ResponseResponse

Cortex

Hippocampus


Much Slower

Goal of TreatmentGoal of Treatment

• Maintain Calm/Continuous/Maintain Calm/Continuous/ Engaged StateEngaged State

• Prevent Discontinuous StatesPrevent Discontinuous States

• Build Cognitive Structures Build Cognitive Structures that allow Choicesthat allow Choices


StimulusStimulus


Very Fast

Slower

ResponseResponse

Cortex

Hippocampus

Neuroregulatory InterventionPsychotherapy

Psychopharmacology

Social Environmental Intervention



ResponseResponse

StimulusStimulus

Traumatic Reminder

Traumatic State

InterventionIntervention

Social-environmental Intervention

Neuro-regulatory

Intervention

COGNITION!!!COGNITION!!!

Trauma Informed CareTrauma Informed Care

Recognize prevalence of trauma- take Recognize prevalence of trauma- take “universal precautions”“universal precautions”

Commitment to acceptance, dignity and Commitment to acceptance, dignity and social inclusionsocial inclusion

Assess and treat for traumaAssess and treat for trauma

Trauma AssessmentsTrauma Assessments

Identifies past or current traumaIdentifies past or current trauma

Looks at current behaviors and the Looks at current behaviors and the effects of trauma on daily lifeeffects of trauma on daily life

Helps develop clinical approaches to Helps develop clinical approaches to recovery/diagnosisrecovery/diagnosis

Courtesy of Caldwell Management Associates

Trauma AssessmentsTrauma Assessments

- Focuses on what - Focuses on what ““happened to you”happened to you” not not ““what is wrong with you”what is wrong with you”

- Conducted upon admission or shortly - Conducted upon admission or shortly afterwardafterward

- For children, assessment through play - For children, assessment through play and behavioral observationand behavioral observation

Courtesy of Caldwell Management Associates

Trauma-Informed Trauma-Informed TreatmentTreatment

The focus is on:The focus is on:SSafety, afety, SStabilization tabilization SSelf-managementelf-management

Healthcare staff need:Healthcare staff need:- training in this kind of treatment- training in this kind of treatment- access to experts for consultation - access to experts for consultation and recommendations for treatment and recommendations for treatment

Trauma Informed CareTrauma Informed Care

Ensures that the recipient is center of their own Ensures that the recipient is center of their own treatmenttreatment

Empowers recipient & their familiesEmpowers recipient & their families

Promotes safety and trustfulnessPromotes safety and trustfulness

Has goals of education and wellness self Has goals of education and wellness self management management

Is transparent and open to outside partiesIs transparent and open to outside parties

Trauma InformedTrauma Informed Language Language

Is always…….Is always…….

person centeredperson centered respectful respectful conscious of tone of voice, cadence and conscious of tone of voice, cadence and

volumevolume aware of body languageaware of body language helpful and hopefulhelpful and hopeful objective, neutralobjective, neutral collaborativecollaborative

Trauma Informed Trauma Informed Environment Environment

Interaction is always respectfulInteraction is always respectful

Is pleasant, tidy, cleanIs pleasant, tidy, clean

Provides opportunities for individual Provides opportunities for individual “space” and activities“space” and activities

Contains welcoming settings & attitudesContains welcoming settings & attitudes

Signage is always person centered and Signage is always person centered and worded positivelyworded positively

““The definition of insanity is The definition of insanity is continuing to do the same continuing to do the same

thing over and over again thing over and over again expecting a different result.”expecting a different result.”

- Albert Einstein

ControlControlControlControl

““Authority or power to regulate, direct or dominate. A Authority or power to regulate, direct or dominate. A means of restraint. To exercise restraining or directing means of restraint. To exercise restraining or directing

influence over…” influence over…”

News FlashNews FlashWhen staff are upset and act on emotion,When staff are upset and act on emotion,

they lose 30 points of IQ.they lose 30 points of IQ.

Problems Associated withProblems Associated witha Controlling Culturea Controlling Culture


Focus is often on staff not the recipient.Focus is often on staff not the recipient.

Addressing problems is built around staff and Addressing problems is built around staff and program operations.program operations.

Compliance and containment are mistaken as Compliance and containment are mistaken as actual learning of new skills by the recipient actual learning of new skills by the recipient and/or real improvement.and/or real improvement.

Rules become more important as staff Rules become more important as staff knowledge of their origin erodes. knowledge of their origin erodes.

““Every restraint I’ve reviewed, Every restraint I’ve reviewed,

started with a staff memberstarted with a staff member

enforcing a rule.” enforcing a rule.”

Ross Greene, Ph.D.Ross Greene, Ph.D.

RRI Grand Rounds ~ Cambridge HospitalRRI Grand Rounds ~ Cambridge Hospital

January 20, 2004January 20, 2004


Minor violations often lead to control struggles.Minor violations often lead to control struggles.

Fosters a belief that privileges (rights?) must be Fosters a belief that privileges (rights?) must be earned. earned.

Reinforces a need to control the recipient.Reinforces a need to control the recipient.

Poorly trained/regulated staff who coerce Poorly trained/regulated staff who coerce recipients into compliance are not identified or recipients into compliance are not identified or required to change.required to change.

Moving from Control to Moving from Control to CollaborationCollaboration


Moms rock small children over and over to help them go Moms rock small children over and over to help them go from an emotional to a calm state. (Grounding Activity)from an emotional to a calm state. (Grounding Activity)

With traumatized individuals rocking (or similar With traumatized individuals rocking (or similar grounding activities) help them to self regulate, grounding activities) help them to self regulate, essentially to go from an emotional to a calm state.essentially to go from an emotional to a calm state.

It’s not about consequences, it’s about shaping It’s not about consequences, it’s about shaping behaviors.behaviors.

ShapingShapingShapingShaping

Over time consistently working with the Over time consistently working with the recipient to understand what needs to be recipient to understand what needs to be learned.learned.

Giving frequent positive feedback as to Giving frequent positive feedback as to how the recipient is doing.how the recipient is doing.

Praising the recipient for successes.Praising the recipient for successes.

The Three S’s of PraiseThe Three S’s of PraiseThe Three S’s of PraiseThe Three S’s of Praise

ShortShort

SpecificSpecific

SincereSincere

CollaborationCollaborationCollaborationCollaboration

““To work jointly with others”To work jointly with others”

The underlying philosophy of collaboration is The underlying philosophy of collaboration is premised on treating everybody with dignity premised on treating everybody with dignity

and respect.and respect.

CollaborationCollaboration(How to Do It)(How to Do It)

CollaborationCollaboration(How to Do It)(How to Do It)

Observe warning signsObserve warning signs Recognize a driving needRecognize a driving need Employ a practicable strategyEmploy a practicable strategy Empower the personEmpower the person Tap into an interest or strengthTap into an interest or strength Ask for optionsAsk for options Appreciate where the recipient is Appreciate where the recipient is

coming fromcoming from Praise the recipient for who they arePraise the recipient for who they are



There is a need to teach the recipient how There is a need to teach the recipient how to self regulate and how to shift cognitive to self regulate and how to shift cognitive sets.sets.

The Importance of InteractionThe Importance of Interaction

Day to day routineDay to day routine Establishing rapportEstablishing rapport On-going assessmentsOn-going assessments Personal greetings/farewellsPersonal greetings/farewells Making ourselves availableMaking ourselves available Using activities as a forum Using activities as a forum

“ “If I could say anything to all the staff in If I could say anything to all the staff in the world it would be this: forget the world it would be this: forget everything you were taught in school everything you were taught in school and be prepared to listen…don’t and be prepared to listen…don’t criticize and think it’s a lie. Just listen criticize and think it’s a lie. Just listen and ask questions and be kind. Just and ask questions and be kind. Just take the time to listen…”take the time to listen…”

(Interview with a adult trauma survivor (CD), 2005)(Interview with a adult trauma survivor (CD), 2005)

Creating Therapeutic Creating Therapeutic Treatment EnvironmentsTreatment Environments

Understand sensory experience, Understand sensory experience, modulation and integrationmodulation and integration

Determine sensory-seeking & sensory-Determine sensory-seeking & sensory-avoiding states and behaviors.avoiding states and behaviors.

Develop sensory rooms & use the physical Develop sensory rooms & use the physical environment to respond to differing sensory environment to respond to differing sensory needsneeds

((Champagne, Champagne, 2003) 2003)

Simple Sensory EnhancementsSimple Sensory Enhancements

art workart work plantsplants fish tanksfish tanks musicmusic comfortable comfortable

seatingseating

rocking chairs or rocking chairs or gliding rockersgliding rockers

bedrooms with bedrooms with new bedspreads new bedspreads

place to exerciseplace to exercise curtainscurtains

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

Sensory Modulation Sensory Modulation ApproachesApproaches

Sensory modulation and integration activities Sensory modulation and integration activities can be particularly beneficial for those with can be particularly beneficial for those with sensory sensitivity/acuity such as symptoms sensory sensitivity/acuity such as symptoms of ADHD, impulse control and trauma.of ADHD, impulse control and trauma.

People are drawn to certain sensory People are drawn to certain sensory experiencesexperiences

Sensory Modulation Sensory Modulation ApproachesApproaches

Grounding physical activitiesGrounding physical activities:: Holding, weighted blankets, arm massages, Holding, weighted blankets, arm massages,

“tunnels,” body socks, walk with joint “tunnels,” body socks, walk with joint compression, wrist/ankle weights, aerobic compression, wrist/ankle weights, aerobic exercise, sour/fireball candiesexercise, sour/fireball candies

Calming self-soothing activities:Calming self-soothing activities: Hot shower/bath, drumming, decaf tea, rocking in Hot shower/bath, drumming, decaf tea, rocking in

a rocking chair, beanbag tapping, yoga, wrapping a rocking chair, beanbag tapping, yoga, wrapping in a heavy quilt, meditationin a heavy quilt, meditation

Activity examples include:

Sensory Room: DefinitionSensory Room: Definition

An appealing physical space An appealing physical space painted with soft colors & filled with painted with soft colors & filled with furnishings and objects that promote furnishings and objects that promote relaxation and/or stimulation.relaxation and/or stimulation.

Sensory Room EquipmentSensory Room Equipment Calming MusicCalming Music Peach colored wallsPeach colored walls Lava LampLava Lamp Gliding Rocking ChairsGliding Rocking Chairs Mats with weighted blanketsMats with weighted blankets Projected Light (moving/changing)Projected Light (moving/changing) Large balls - bouncingLarge balls - bouncing Small balls - pressureSmall balls - pressure AromatherapyAromatherapy Fish tanksFish tanks Large Tupperware container with raw riceLarge Tupperware container with raw rice

Sensory Room:Sensory Room:Guidelines for UseGuidelines for Use

Select fire resistant items, latex free, generally safe and Select fire resistant items, latex free, generally safe and washablewashable

Place selected items in locked cabinetPlace selected items in locked cabinet

Create policies and procedures for use and maintenance Create policies and procedures for use and maintenance of room and equipmentof room and equipment

Train staff and supervise for appropriate useTrain staff and supervise for appropriate use

Schedule access anytime during operationsSchedule access anytime during operations

Include use of sensory room items on the Individual Include use of sensory room items on the Individual Crisis Prevention Plan (Safety Tool)Crisis Prevention Plan (Safety Tool)

((ChampagneChampagne, 2003), 2003)

Providing for ComfortProviding for Comfort- Comfort Rooms -- Comfort Rooms -

Historically, Quiet or Time-Out Rooms often Historically, Quiet or Time-Out Rooms often provided minimal comfort. When used for provided minimal comfort. When used for comfort, a sensory/comfort room needs to comfort, a sensory/comfort room needs to provide sanctuary from stress, contain items provide sanctuary from stress, contain items that help provide comfort, promote that help provide comfort, promote relaxation and should be a place for relaxation and should be a place for persons to experience feelings within persons to experience feelings within acceptable boundaries.acceptable boundaries.

Comfort Room Comfort Room EnvironmentEnvironment

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.

Comfort Room Comfort Room ContentsContents

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.

The ChallengeThe Challenge

Can we change our inpatient culturesCan we change our inpatient culturesand become collaborative, responsive, and and become collaborative, responsive, and nourishing? nourishing?

Can we offer places of sanctuary that Can we offer places of sanctuary that remembers the person we are serving and remembers the person we are serving and facilitates healing and recovery?facilitates healing and recovery?

How must we change if we want these How must we change if we want these changes to occur?changes to occur?

Trauma Informed Care: Positive Alternatives to Seclusion & Restraint Presented by: New York State Office of Mental Health Executive Director’s Meeting.

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