Creating Trauma Informed Systems of Care for Human Service Settings

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Creating Trauma Informed Systems of Care for
Human Service Settings

• Trauma Sensitive Tools
• Part I

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Trauma Sensitive ToolsPart One

• Outline
• Identifying and Assessing Traumatic Experiences
  in Service Users
• Developing Individualized Crisis Prevention Plans
  

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• Trauma Assessment

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Trauma Assessment

• Purpose
• Used to identify past or current trauma,
  violence, abuse, and assess related effects
• Provides context for current symptoms and guides
  clinical approaches and recovery progress
• Informs the treatment culture to minimize
  potential for re-traumatization
• (Cook et al., 2002 Fallot Harris, 2002 Maine
  BDS, 2000)

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Trauma Assessment

• Start with a trained and knowledgeable staff
• Continued follow-up, preferably with same staff
  is suggested, due to sensitivity of issue.
• Can be done with de-escalation preference survey.
• Most important point is concept of Universal
  Precautions
• (Ibid)

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Trauma Assessment

• Should minimally include
• Type sexual, physical, emotional abuse or
  neglect, exposure to disaster
• Age when the abuse occurred
• Who perpetrated the abuse
• Assessment of such symptoms as dissociation,
  flashbacks, hyper-vigilance, numbness,
  self-injury, anxiety, depression, poor school
  performance, conduct problems, eating problems,
  etc. (Ibid)

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Trauma Assessment

• Results and positive responses must be
  addressed in treatment planning or assessment is
  useless.
• Interview is conducted upon intake or shortly
  after
• Importance of therapeutic engagement during
  interview cannot be over emphasized
• For children, assessment through play and
  behavior observations (Ibid)

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Trauma Assessment

• Other MH factors to assess
• History of S/R involuntary IM medication
  experiences
• Individual experiences in inpatient/residential
  settings fear, dissociation, anger,
  powerlessness
• Homelessness, addiction, domestic violence
• What happened when disclosed? More loss?
  Validation and protection?
• Interest in working on a safety plan (see
  prevention tools module)

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Immediate Concerns that Require Intervention

• Continued trauma experiences including partner
  violence
• Lack of safety in home, community or treatment
  setting
• Need to collaborate with/report to other agencies
  (child welfare, mental health, schools)

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• Individual Crisis Planning

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Individual Crisis Prevention Plans

• What are they?
• Why are they used?
• What elements make up a plan?

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What is a Crisis Prevention Plan?

• A Crisis Prevention Plan is more than just a
  plan.
• Fundamentally it is an individualized plan
  developed in advance to prevent a crisis and
  avoid the use of secure observation or
  disciplinary confinement.

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What is a Crisis Prevention Plan?

• It is also
• A therapeutic process
• A task that is trauma sensitive
• A plan that is tailored to the needs of each
  individual
• A partnership of safety planning
• A collaboration between consumers and staff to
  create a crisis strategy together
• A consumer-owned plan written in easy to
  understand language

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Other Names for Crisis Prevention Plans

• Safety Tool
• De-escalation Preference Tool
• Advance Crisis Plan
• Individual Crisis Plan
• Personal Safety Plan
• Personal Safety Form
• Safety Zone Tool

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Why Are Safety Tools Used?

• Purpose
• To help consumers during the earliest stages of
  escalation before a crisis erupts
• To help consumers identify coping strategies
  before they are needed
• To help staff plan ahead and know what to do with
  each person if a problem arises
• To help staff use interventions that reduce risk
  and trauma to individuals

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Essential Components

• 1. Triggers
• 2. Early Warning Signs
• 3. Strategies

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• First, Identify Triggers

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Triggers

• A trigger is something that sets off an action,
  process, or series of events (such as fear,
  panic, upset, agitation)
• bedtime
• room checks
• large men
• yelling
• people too close

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More Triggers What makes you feel scared or
upset or angry and could cause you to go into
crisis?

• Not being listened to
• Lack of privacy
• Feeling lonely
• Darkness
• Being teased or picked on
• Feeling pressured
• People yelling
• Room checks

• Arguments
• Being isolated
• Being touched
• Loud noises
• Not having control
• Being stared at
• Other (describe)
• ________________

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More Triggers

• Particular time of day/night___________
• Particular time of year_______________
• Contact with family _________________
• Other __________________________
• Youth have unique histories with uniquely
  specific triggers - essential to ask
  incorporate

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• Second, Identify Early Warning Signs

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Early Warning Signs

• A signal of distress is a physical precursor and
• manifestation of upset or possible crisis. Some
  signals are not observable, but some are, such
  as
• restlessness
• agitation
• pacing
• shortness of breath
• sensation of a tightness in the chest
• sweating

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Early Warning SignsWhat might you or others
notice or what you might feel just before losing
control?

• Eating more
• Breathing hard
• Shortness of breath
• Clenching fists
• Loud voice
• Rocking
• Cant sit still
• Swearing
• Restlessness
• Other ___________

• Clenching teeth
• Wringing hands
• Bouncing legs
• Shaking
• Crying
• Giggling
• Heart pounding
• Singing inappropriately
• Pacing

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• Third, Identify Strategies

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Strategies

• Strategies are individual-specific calming
  mechanisms to manage and minimize stress, 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

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StrategiesWhat are some things that help you
calm down when you start to get upset?

• Time alone
• Reading a book
• Pacing
• Coloring
• Hugging a stuffed animal
• Taking a hot shower
• Deep breathing
• Being left alone
• Talking to peers

• Therapeutic Touch, describe ______
• Exercising
• Eating
• Writing in a journal
• Taking a cold shower
• Listening to music
• Talking with staff
• Molding clay
• Calling friends or
• family (who?) ______

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More Strategies

• Blanket wraps
• Lying down
• Using cold face cloth
• Deep breathing exercises
• Getting a hug
• Running cold water on hands

• Ripping paper
• Using ice
• Having your hand held
• Going for a walk
• Snapping bubble wrap
• Bouncing ball in quiet room
• Using the gym

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Even More Strategies

• Male staff support
• Female staff support
• Humor
• Screaming into a pillow
• Punching a pillow
• Crying
• Spiritual Practices prayer, meditation,
  religious reflection

• Touching preferences
• Speaking with therapist
• Being read a story
• Using Sensory Room
• Using Comfort Room
• Identified interventions_____

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What Does Not Help When you are Upset?

• 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

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Preferences in Extreme Emergencies(to minimize
trauma re-traumatization)

• Preference list for emergencies
• Time Out
• Medication
• by mouth
• by injection
• Preferred medication ______________
• Prefer women/men
• Hold my hands, do not restrain my body
• Consider racial, cultural, and religious factors

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Preferences in Extreme Emergencies(to minimize
trauma re-traumatization)

• Pre-existing medical conditions that place you at
  risk
• Physical disabilities/limitations that place you
  at risk
• Are you able to communicate with staff when you
  are having a hard time?
• If not, what can staff do at these moments to
  help?

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De-escalation Preference SurveyEssential
Elements for Success

• How the discussion is initiated
• Authentic interest, development of relationship,
  time spent
• Where discussion is initiated
• Calm, quiet space
• Continuously addressing tool throughout stay with
  client, and in treatment team
• Practice, revise, use

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Example of Successful Prevention Planning Talia

• Talia
• Is a 16 year old adolescent female with a
  history of sexual abuse and aggressive behaviors.
  When made to follow the unit routine, she often
  becomes aggressive which often leads to a
  restraint.
• Warning Signs
• Talia gets up from what she is doing and starts
  to pace.

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Example of Successful Prevention Planning Talia
(continued)

• Effective Strategies
• Pacing inside is often disruptive to the rest of
  the adolescents. Staff ask Talia if she would
  like to be able to go out and swing on the swing
  set whenever she feels frustrated (a swing
  PRN).
• Institutional Obstacles
• Rules had been more important than individual
  support

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Example of Successful Prevention Planning Rasheed

• Rasheed
• Is a 10 year old boy with ADHD, a history of
  physical abuse, and multiple failed placements in
  foster homes. He often strikes out at staff
  physically when he gets frustrated.
• Effective Strategies
• Rasheed was given a fanny pack to wear, with a
  stress ball, sugarless lollipops and a small soft
  stuffed animal to rub. When he feels frustrated,
  he takes something out of his pack to calm
  himself.

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Example of Successful Prevention Planning
Rasheed (continued)

• Effective Strategies
• Rasheed goes to the calming room on his own if
  he feels very frustrated.
• Benefits
• Rasheed learns to recognize when he is getting
  frustrated and chooses to self-soothe. Staff,
  who used to be exasperated with Rasheed, now feel
  that they can support him and work together with
  him to stay calm.

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Example of Successful Prevention Planning Lois

• Lois
• Has a diagnosis of PTSD and Dissociative
  Identity Disorder. Dissociative states and voices
  tell her she is bad and leads to cutting behavior
  and running around and screaming.
• Warning Signs
• Inability to focus in school, in group and with
• staff. Moving her legs all around.

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Example of Successful Prevention Planning Lois
(continued)

• Effective Strategies
• A weighted blanket, initially suggested by
  staff, did not work all of the time. Staff asked
  her if she would like a tailored sleeping bag to
  help her legs stay calm. She liked this idea.
  I feel like a mummy. I feel safe.
• Historical Myth
• Required restraint for uncontrollable self-
  injury. Considered impossible to manage,
  manipulative and difficult.

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Example of Successful Prevention Planning Raymond
Raymond is a 15 year old male adolescent with a
history of gang involvement, arrests, and
aggression. He watched his father beat up his
mother. He has a violent temper when he does not
get his way. Most restraints occur after meals.
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Example of Successful Prevention Planning
Raymond (continued)
Effective Strategies Raymond wants to go out
and shoot baskets after meals and not clean up.
He would rather clean the floors after everybody
else has left the kitchen. (It was later
discovered that his father beat up his mother
after dinner.) Institutional Obstacle We do
not have staff who can stay in the kitchen. All
chores need to be done by 700 p.m.
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Example of Successful Prevention Planning
Raymond (continued)
Effective Strategies Raymond is first allowed
to go out and shoot baskets after meals and clean
the floors after everybody else has left the
kitchen. Over time, he chose to bring the basket
ball with him into the kitchen and have it with
him when he did chores. He was allowed to carry
the basketball everywhere.
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Common Attributes of Each Plan

• Individual-specific
• Linked to the persons history of trauma
• Tailored to the environmental resources
• Encourages creativity
• Incorporates sensory interventions
• Needs of the individual supersedes the rules of
  the institution

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Individual Crisis Plan Guidelines for use

• Condense and make usable
• Clear staff communication system
• Kardex
• Blackboard
• checks sheets
• Service users keep own copies - own their tool
• Re-visit if unable to do on admission
• Some youths prefer to fill it out by themselves
• Revise and re-tool after escalation using all
  de-briefing information

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Individual Crisis Plan Additional
Guidelines for Use

• Communicate/document successful use
• Review at every treatment team
• Acknowledge relationship between trauma history
  and triggers
• Teach about the impact of external and internal
  triggers and stressors learn new skills to
  manage reaction
• Support in coping skills group

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Individual Crisis Plan Additional Guidelines
for Use

• Help people practice strategies before they
  become upset
• Conduct training with staff and customers
  regarding guidelines for development and use
• Make sure a safety tool is filled out and placed
  in the record to help ensure individual
  preferences about what is helpful and what is not
  in times of stress

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Individual Crisis Plan Additional Guidelines
for Use

• Strong preferences or considerations can be
  posted on the cover of the medical record like an
  allergy alert
• Information gathered could be used for education
  groups in future

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Individual Crisis Plan Population-specific
Considerations

• Fully adaptable across the lifespan
• Consider strategies that are developmentally
  responsive population specific
• Adolescents may need intense physical
• work-outs or write rap music
• Children use pictorial descriptions of difficult
  states and strategies may not be language based
• Adults need attention to what they have learned
  to use to self sooth and calm down

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Summary

• The universal use of trauma assessments
• and the implementation of de-escalation
• and safety plans are foundations in creating
• trauma informed care systems