Creating Trauma Informed Systems of Care for Human Service Settings

1. Creating Trauma Informed Systems of Care for Human Service Settings Trauma Sensitive Tools: Part I

2. 2 Trauma Sensitive ToolsPart One Outline Identifying and Assessing Traumatic Experiences in Service Users Developing Individualized Crisis Prevention Plans

3. 3 Trauma Assessment So what is the first step that organizations do as they begin to take on their commitment to trauma informed care, in terms of practices? The adoption of a trauma informed policy or position statement is very helpful in terms of providing a direction for everyone. So that�s a very basic piece of trauma informed care. By this we say we�re not going to push this under the rug; we�re not going to ignore this; we�re not going to keep trauma survivors invisible. We�re going to commit to assessing and treating people with trauma histories. I would like to now provide a description of what a trauma assessment is.So what is the first step that organizations do as they begin to take on their commitment to trauma informed care, in terms of practices? The adoption of a trauma informed policy or position statement is very helpful in terms of providing a direction for everyone. So that�s a very basic piece of trauma informed care. By this we say we�re not going to push this under the rug; we�re not going to ignore this; we�re not going to keep trauma survivors invisible. We�re going to commit to assessing and treating people with trauma histories. I would like to now provide a description of what a trauma assessment is.

4. 4 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) The purpose of a trauma assessment is twofold. First to identify past and/or current trauma, violence and abuse and then assess the effects of these experiences. Second, to provide a context for current symptoms that will guide clinical approaches and the individual�s recovery process. The purpose of a trauma assessment is twofold. First to identify past and/or current trauma, violence and abuse and then assess the effects of these experiences. Second, to provide a context for current symptoms that will guide clinical approaches and the individual�s recovery process.

5. 5 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) A trauma assessment is another assessment tool, we are all familiar with clinical assessment tools. And, similar to many of these other tools, it is first suggested that assessment is done by a trained and informed staff person who is aware of the impact of trauma and its long term effects. This does not necessarily mean an advanced practice professional, bachelors level staff can assess trauma quite well. But staff doing this work need to be trained staff that are good at asking the questions and recognizing traumatic life experiences. There is a personal sense of sensitivity, often involving shame and self blame, that affects trauma survivors. Continued follow-up with the same staff person is ideal as it may take several meetings or more to gather the full story. Also, a trauma assessment leads easily into completing the de-escalation preference survey that I will talk about also. Perhaps the most important concept is that the trauma assessment needs to be done on all admissions. In other words, a trauma informed system of care assumes that all people seeking services may have been victims of trauma, just as we assume that all people may have medical or dental conditions leading to a universal physical assessment. Many, children and adults, will not readily disclose a trauma history. Indeed many do not recognize that they have suffered from this kind of experience. And finally, many cultures prize stoicism and reticence. As such, we need skilled clinical staff to provide an venue where it is safe to talk about these experiences. A trauma assessment is another assessment tool, we are all familiar with clinical assessment tools. And, similar to many of these other tools, it is first suggested that assessment is done by a trained and informed staff person who is aware of the impact of trauma and its long term effects. This does not necessarily mean an advanced practice professional, bachelors level staff can assess trauma quite well. But staff doing this work need to be trained staff that are good at asking the questions and recognizing traumatic life experiences. There is a personal sense of sensitivity, often involving shame and self blame, that affects trauma survivors. Continued follow-up with the same staff person is ideal as it may take several meetings or more to gather the full story. Also, a trauma assessment leads easily into completing the de-escalation preference survey that I will talk about also. Perhaps the most important concept is that the trauma assessment needs to be done on all admissions. In other words, a trauma informed system of care assumes that all people seeking services may have been victims of trauma, just as we assume that all people may have medical or dental conditions leading to a universal physical assessment. Many, children and adults, will not readily disclose a trauma history. Indeed many do not recognize that they have suffered from this kind of experience. And finally, many cultures prize stoicism and reticence. As such, we need skilled clinical staff to provide an venue where it is safe to talk about these experiences.

6. 6 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) A comprehensive trauma assessment should include the type of trauma, the age when the trauma occurred and who perpetrated the abuse. They need to be vigilant in inquiring about symptoms such as (the above) to start to determine the behavioral and emotional effects of trauma and how these are affecting the individual�s current quality of life. A comprehensive trauma assessment should include the type of trauma, the age when the trauma occurred and who perpetrated the abuse. They need to be vigilant in inquiring about symptoms such as (the above) to start to determine the behavioral and emotional effects of trauma and how these are affecting the individual�s current quality of life.

7. 7 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) Read slide�Read slide�

8. 8 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) In addition to the four main categories I just mentioned, there are other factors to try and identify. These experiences add to the amount of trauma an individual may have experienced, both in the community and in treatment settings. The last is an attempt to find out if the individual is interested in avoiding conflict, violence and further trauma in an inpatient setting by working on a safety plan.In addition to the four main categories I just mentioned, there are other factors to try and identify. These experiences add to the amount of trauma an individual may have experienced, both in the community and in treatment settings. The last is an attempt to find out if the individual is interested in avoiding conflict, violence and further trauma in an inpatient setting by working on a safety plan.

9. 9 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) There are some concerns that a staff person needs to be concerned about and get more information about. These are (read first two bullets). This information may indicate a need for the professional to collaborate with other agencies. There are some concerns that a staff person needs to be concerned about and get more information about. These are (read first two bullets). This information may indicate a need for the professional to collaborate with other agencies.

10. 10 Individual Crisis Planning Read slide title. Read slide title.

11. 11 Individual Crisis Prevention Plans What are they? Why are they used? What elements make up a plan? Read slide�Read slide�

12. 12 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. Read slide�Read slide�

13. 13 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 Read slide� Read slide�

14. 14 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 Read slide� Read slide�

15. 15 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 Read slide� Read slide�

16. 16 Essential Components 1. Triggers 2. Early Warning Signs 3. Strategies Read slide� Read slide�

17. 17 First, Identify Triggers Read slide� Read slide�

18. 18 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 Read slide� Read slide�

19. 19 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) ________________ Read slide� Only some of the bullets, not all Read slide� Only some of the bullets, not all

20. 20 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 Read slide� Read slide�

21. 21 Second, Identify Early Warning Signs Read slide� Read slide�

22. 22 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 Read slide� Read slide�

23. 23 Early Warning SignsWhat might you or others notice or what you might feel just before losing control? Clenching teeth Wringing hands Bouncing legs Shaking Crying Giggling Heart pounding Singing inappropriately Pacing Eating more Breathing hard Shortness of breath Clenching fists Loud voice Rocking Can�t sit still Swearing Restlessness Other ___________ Read slide� only some of the bullets Read slide� only some of the bullets

24. 24 Third, Identify Strategies Read slide� Read slide�

25. 25 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 Read slide� Read slide�

26. 26 Strategies:What 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?) ______ Read slide� only some of the bullets Read slide� only some of the bullets

27. 27 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 Read slide� read only some of the bullets Read slide� read only some of the bullets

28. 28 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:_____ Read slide� Only some bullets Read slide� Only some bullets

29. 29 Read slide� only some Read slide� only some

30. 30 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 In emergency situations, specific customer preferences are important if identified prior to the event. The identification of interventions such as (read slide) can be helpful in de-escalation attempts also. In emergency situations, specific customer preferences are important if identified prior to the event. The identification of interventions such as (read slide) can be helpful in de-escalation attempts also.

31. 31 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? All of these (read slide) are important to maintain physical safety and help staff intervene appropriately.All of these (read slide) are important to maintain physical safety and help staff intervene appropriately.

32. 32 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 When attempting to work with a service user on the trauma assessment and the de-escalation preference survey certain guidelines are helpful in terms of how the discussion is presented; where this work is occurring and in following up to update and correct these tools throughout a person�s stay or admission. When attempting to work with a service user on the trauma assessment and the de-escalation preference survey certain guidelines are helpful in terms of how the discussion is presented; where this work is occurring and in following up to update and correct these tools throughout a person�s stay or admission.

33. 33 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. An exampleAn example

34. 34 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 An exampleAn example

35. 35 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. An exampleAn example

36. 36 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. An exampleAn example

37. 37 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. An exampleAn example

38. 38 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.� An exampleAn example

39. 39 An exampleAn example

40. 40 An exampleAn example

41. 41 An exampleAn example

42. 42 Common Attributes of Each Plan Individual-specific Linked to the person�s history of trauma Tailored to the environmental resources Encourages creativity Incorporates sensory interventions Needs of the individual supersedes the rules of the institution The common attributes of a trauma informed de-escalation plan include being individually specific, linked to the individual�s history, tailored to environmental resources and that encourage creativity by staff in exploring and diagnosing what might work. The common attributes of a trauma informed de-escalation plan include being individually specific, linked to the individual�s history, tailored to environmental resources and that encourage creativity by staff in exploring and diagnosing what might work.

43. 43 Read slide�Read slide�

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45. 45 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

46. 46 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 Read slide�Read slide�

47. 47 Read slide�Read slide�

48. 48 Summary The universal use of trauma assessments and the implementation of de-escalation and safety plans are foundations in creating trauma informed care systems Read slide. We next will visit trauma informed tools Part 2. Read slide. We next will visit trauma informed tools Part 2.