Creating a Trauma-Informed Mental Health Service System

“So You Want To Change The World! Creating a Trauma-Informed Mental Health Service System!” Presented by Gary J. Parker, CPS, MSEM May 7, 2015

Gary’s Story • Gary’s personal story of trauma • Support from school and parents • Graduated with honors, despite illness • Began career with conditions I set forth • Success in career • Personal losses • Adult system results in seclusion and restraints. • Re-traumatization from the system • Change of careers.

Kansas Consumer Advisory Council for Adult Mental Health TIC Curriculum • CAC recognizes the need to educate peers, providers, and first responders about the need for becoming a Trauma Informed Care Society • CAC receives funding from SAMHSA (Substance Abuse and Mental Health Services Administration) . • CAC creates a curriculum that can be utilized by many different entities.

CAC Implementation • CAC reaches out to four Community Mental Health Centers to do training for their staff. • Consumer Run Organizations (CROs) begin to receive training for TIC • State of Kansas recognizes the importance of the curriculum

Where to begin? • Definitions • The Adverse Childhood Experiences (ACE) Study • Creating Culture Change to Reduce Seclusion and Restraint • Starting Up Conversations about Trauma, Seclusion, and Restraints. • Roles of Certified Peer Specialists

Definitions - Recovery • Recovery is often about finding new purpose and meaning in our lives despite events that have already taken place.

Definitions – Transformation • Transformation is a way to talk about who we were, and how we have changed as well as who we hope to become. • Transformation is about finding some raw material in past experience that I can use in building the life and personhood I want for myself today. • Transformation is about moving toward the life I want to live. • Transformation begins the moment we choose to engage in creating and re-creating the lives we want to live in relationship to one’s self, others, and to one’s spirit

Definitions -- Healing • Healing in a community of our peers and those around us takes place when each of us is trustworthy – creating a sense of safety in relationship to one another. • Healing is when we use our voice in the knowledge that each voice will be heard. • Healing is when we create choice for one another through non-coercion. • Healing is living the truth that each person is the expert of his or her own experience. • Healing is when we support each other in courageous action through each person’s personal power.

Definitions – Trauma Informed Care (TIC) • Traumatic experiences can be dehumanizing, shocking or terrifying, singular (just one event) or multiple compounding events (one experience after another) over time and often include betrayal of a trusted person, institution, and a loss of safety. • Trauma can result from experiences of violence.

TIC - Continued • Trauma includes physical, sexual and institutional abuse, neglect, intergenerational trauma, and disasters that induce powerlessness, fear, recurrent hopelessness and a constant state of alert. • Trauma impacts one’s spirituality and relationships with self, others, communities and environment, often resulting in recurrent feelings of shame, guilt, rage, isolation, and disconnection. • Healing is POSSIBLE!

Core Principles of Trauma-Informed Peer Support • Voice – I am the expert of my experience. Only I can tell you if the services or supports you provide are helpful or not. We can work together so that my voice is taken into account in the services you provide. • Choice – rather than coercion. Another way to talk about choice is non-coercion. • Trust – Creates a sense of safety in relationships. When we are trustworthy, then our peers can feel good about entering into relationships of healing and hope.

The Adverse Childhood Experience (ACE) Study • The ACE Study is an ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente. • Led by Co-Principle Investigators Robert F. Anda, MD, MS, and Vincent J. Felitti, MD. • The ACE Study is perhaps the largest scientific research study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life. • www.Acestudy.org

The ACE Study Questionnaire

ACE Scores explained • The lower the ACE score, the lower the risk of adult health issues. • Score of 0 – no trauma whatsoever in your background. • Score of 1 – some trauma with some risk. • Score of 2 – trauma with increased risk of adult health issues. • Score of 3 – higher increased risk of adult health issue, including early mortality. • Score of 4 or higher – definite risk of adult health issues and increased early mortality.

ACE scores have a strong Influence on: • Adolescent health • Reproductive health • Smoking • Alcohol abuse • Illicit drug abuse • Sexual behavior • Mental health • Risk of re-victimization • Stability of relationship, homelessness • Performance in the workforce

ACE study data and facts • Initial Study: • Study targeted mainstream, middle class patients in a weight-loss clinic. • Study determined that: • Adverse Childhood Experiences (ACEs) well concealed but unexpectedly common. • ACEs have a profound negative effect on adult health and wellbeing a half century later. • Are a prime determinant of adult health status in the USA. • All patients should be screened for a trauma history.

Concepts in Reducing Restraints and Seclusion • Validation • Remember, the consumer is the expert of his/her own experience. Listen to them. Ask them, “What happened to you?” This simple question may prevent a person from being put into seclusion/restraints! • It is VERY IMPORTANT to remember the consumer voice and the consumer perspective! • Remember: Recovery, Transformation, and Healing must happen in ourselves to prevent putting others in restraints and seclusion. • We must become Trauma-Informed!

Creating Culture Change to Reduce Seclusion and Restraint • Impacts on the individual with past trauma history • Utilizing Certified Peer Specialists to assist in minimizing the usage (or preferably, elimination) of seclusion and restraints.

How can leaders create culture change to reduce S/R? • Leaders must make and keep seclusion/restraints reduction a high priority. • Create a plan for S/R reduction/elimination. • Reducing or eliminating organizational barriers. • Provide the necessary resources. • Hold people accountable for their actions. • Identify and value champions who are committed to this work.

Key leadership principles to creating culture change • Commitment • Mission, vision, and values. – “A shared organizational vision is like a magnet, it attracts people with its special characteristics.” • Clarifying organizational values. Looking at Program Policies, Program Procedures, Treatment Activities, Rules, Schedules, Historic Practices, Traditions, Beliefs, and Unspoken Rules that persist. • Using Respectful Language that recognizes the person.

Starting Up Conversations About Trauma, Seclusion, and Restraints • Identify who needs to be at the table for discussions. • Share personal stories. • Identify the experts! (the consumer!)

Informational Feedback • Kansas requirements upon intake screening make it a challenge to be “Trauma-Informed” and “Trauma-Aware”. • Changes must be made at the state administrative level. • Lack of funding proves to be a challenge in being able to hire enough staff to be able to fully implement the program. • People ARE very supportive – Desire to continue to learn more about TIC.

Certified Peer Specialists in a Hospital Setting • With a new patient from the very moment of intake. • Supports the patient throughout his/her entire stay, relating their own personal stories as a person with a mental illness. • Being a person who can be trusted, and helping the patient find his/her own voice to make choices that will benefit him/her upon discharge. • Intervene – helps reduce the need for restraints and seclusion. Can communicate far better with a patient than other staff.

Peers Play A Vital Role • Peers, such as CPSs, can be utilized for educating first responders, co-workers, and professionals in a community mental health center/mental health hospital. • Peers being used to intervene to prevent someone from being placed into seclusions/restraints. • Peers being present when someone is being placed in seclusion or restraints

What is a cps? • A CPS is a person with lived experience, having a mental illness. • Has taken appropriate CPS training. • Has passed a certification test.

Impact of trauma on our lives • All CPS’s receive training on Trauma. • Most CPS’s have had trauma sometime during their life. • Can share their stories with people being served in the mental health setting.

Five stages of recovery

Building a relationship trust • CPS’s often are the first person encountered when entering a hospital setting. • Create a Comfort room – A safe place where one can talk in private with the CPS to build trust. • A CPS can be used during the orientation process. • Shares “Personal Medicine” (not a pill, but something that you do that you enjoy, that makes you happy) • Helps with establishing Recovery Goals

Starting up conversations around s/r with cps • Utilize the CPS for their expertise! • Intervention – CPS’s often can prevent a situation from getting out of hand because of trust, and can help keep a person out of seclusion and restraints. • A CPS should be present from the moment a person is put in restraints/seclusion, until that person is out. Then, a team meeting MUST be held to discuss what went wrong to prevent that from happening again! CPS can often be the lead person in this.

Educating others about seclusion and restraints • CPS’s should be used to train staff that they work with about the harm of seclusion/restraints. • Share personal stories. • Train staff about Trauma-Informed Care. • Discuss the harms of seclusion and restraints, especially re-traumatizing an individual. • Do role playing. Put key staff people in seclusion and restraints in order to have a better understanding of the feeling of hopelessness, being violated, the feeling that everyone is against you.

Cps’s can prevent seclusion /restraint! • CPS’s have a special trust/bond with the people that they serve. • CPS’s often pay attention to environmental happenings (temperature, music, volume, clutter, weather, etc.) that other staff does not, and that can make a difference on preventing a person going into seclusion/restraints. • Mental Health Techs need to spend more time on the floor, interacting with people, rather than hiding in the office cubicle/staff back rooms!). They can learn from the CPS, and interact better with those that they serve!

Misconceptions • A person is dangerous! Sometimes a person just needs to yell and scream to get frustrations out, and then that person is fine. • All people with a mental illness need to be locked up and put away! People with a mental illness can live normal productive lives. Many are teachers, doctors, your next door neighbor, etc.

Being Accountable • We ALL must hold ourselves and the system accountable for reducing the usage of seclusion and restraints. • Advocates are needed to educate the system about the harms that seclusion and restraints cause, especially to those with a trauma background. • Discussions in reducing restraints and seclusion usage must be made with all parties (consumers, family members, professionals, first responders, etc.) at the table • Nothing About Us Without Us!

Conclusions • Peers play a vital role in the education about trauma, and trauma informed care. • Many misconceptions about seclusion and restraints. • We all must hold ourselves and the system accountable for reducing the usage of seclusion and restraints. • We must become Trauma-Informed and Trauma Aware in order to reduce Restraints and Seclusion usage. • Must be committed to the cause, and follow through with plans of action.

Conclusions (cont) • Peers play a vital role in the education about Seclusion and Restraints. Listen to them! • Utilizing CPS’s in training other staff personnel can be enriching and encouraging to all. • CPS’s should be consulted and utilized to their fullest potential. • CPS’s can prevent someone from being placed into seclusion/restraints. • Remember: VOICE, CHOICE, TRUST.

References • National Association of State Mental Health Program Directors (NASMHPD) Position Statement on Seclusion and Restraint (www.nasmhpd.org) • SAMHSA • CAC (www.kansascac.org) • President’s New Freedom Commission Report on Mental Health • National Center for Trauma-Informed Care. • www.Acestudy.org

Creating a Trauma-Informed Mental Health Service System