Trauma-Informed Care

1. Trauma-Informed Care Barbara Barnes, Claudia Meyer & Martha Williamson

2. Trauma-Informed Care (TIC) A change of practice to consumer- driven care; based on hope, self-determination, and empowerment. TIC will stress the importance of listening to and hearing the lived experiences of trauma survivors.

3. System of the Lived Experience • First and foremost, a consumer-driven system means one which is guided by people with a lived experience. They know better than anyone else what helps and what hurts in recovery. • To transform the system to a recovery-based one, C/S/Xs (consumers/survivors/ex-patients) will need to almost completely redesign it. (Fisher, D., 2007)

4. STEP UP • STEP UP: Consumer-Driven Services, Training, Evaluation & Policy: United for Power S: Services and supports need to be consumer-driven T: Training needs to be consumer-driven E: Evaluation and research needs to be consumer- driven P: Policy and planning needs to be consumer-driven (Prochaska, J., Norcross, J. & DiClemente, C., 2009)

5. The Stages of Change Model • The idea behind the Stages of Change Model (SCM) is that behavior change does not happen in one step. Rather, people tend to progress through different stages on their way to successful change. • Each person must decide for himself or herself when a stage is completed and when it is time to move on to the next stage.

6. Stages of Change • The stages of change are: • Pre-contemplation (Not yet acknowledging that there is a problem behavior that needs to be changed). • Contemplation (Acknowledging that there is a problem but not yet ready or sure of wanting to make a change). • Preparation/Determination (Getting ready to change). • Action/Willpower (Changing behavior). • Maintenance (Maintaining the behavior change). • Relapse (Returning to older behaviors and abandoning the new changes). • Transcendence -Eventually, if you "maintain maintenance" long enough, you will reach a point where you will be able to work with your emotions and understand your own behavior and view it in a new light. This is the stage of "transcendence”. In this stage, not only is your bad habit no longer an integral part of your life but to return to it would seem atypical, abnormal, even weird to you.

7. Guiding Values in Trauma-Informed Care

8. Trauma-Informed Care Highlights • TIC allows services to be delivered in a way that will avoid inadvertent re-traumatization and will facilitate consumer participation in treatment.

9. Trauma-Informed Care Highlights • Increase understanding of trauma and its impacts on health, mental health and social well-being. • Raise awareness of the role of internal and external stigma as it affects the disclosure of childhood abuse experiences and as it exacerbates traumatic impacts over the life span; and incorporate the stories of persons with lived experience of abuse and trauma.

10. Trauma-Informed Care Highlights • Trauma recovery must be consumer-driven; be based on hope, self-determination, and empowerment; and stress the importance of listening to and hearing the lived experiences of trauma survivors. • Care is peer driven and evaluated

11. Trauma-Informed Care Highlights • Incorporate trauma into the development of individualized plans of care for every adult and child with serious mental health and/or substance abuse problems. The plan should be developed in collaboration with the consumer, and should address trauma; its impact on the individual; the prevention of re-traumatization; the provision of, or referral to, trauma-informed and trauma-specific treatment and supports; and the integration of trauma, mental health and substance abuse in counseling and treatment programs.

12. Recovery • Individualized & person-centered • Empowerment-based • Personal responsibility-based • Holistic • Peer support • Hope-based • Strength-based • Non-linear • Self directed & collaboration • Dignity & respect-based

13. Core Strategies for the Reduction of Seclusion and Restraint • Six Core Strategies for the Reduction of Seclusion and Restraint. These include: leadership toward organizational change; use of data, workforce development; use of S/R reduction tools; consumer roles in inpatient settings; and debriefing activities.

14. Procedures to Avoid Re-traumatization and Reduce Impacts of Trauma • An effort should be made to reduce or eliminate any potentially re-traumatizing practices such as seclusion and restraint, involuntary medication, etc. Training should cover dynamics of re-traumatization and how some practices could mimic original sexual and physical abuse experiences, trigger trauma responses, and cause further harm to the person. Specific policies should be in place to create safety; acknowledge and minimize the potential for re-traumatization; assess trauma history; address trauma history in treatment and discharge plans; respect gender differences; and provide immediate intervention to mitigate effects should interpersonal violence occur in care settings (Glover, R. W. ,2005).

15. Sensory Rooms The use of sensory rooms as a tool in care. • A place to be calm • A place to be quiet • A place to remove stimuli • A place for therapy • A place to pray • A place to regulate emotions

16. Sensory Rooms The sensory room can be useful for: • Developing a therapeutic relationship. • Admission interview- set up the room with music, a blanket and a comfortable place for the patient to feel in control. • A relaxing place before bedtime. • A safe place for an agitated, anxious, and escalating client. • Meetings with a contact person or therapist.

17. TIC-Change of Culture at BHD • TIC helps all services at BHD join together to provide trauma-informed care by the inclusion of all employees.

18. TIC-Change of Culture at BHD • Acknowledge that trauma and compassion fatigue experienced by staff impacts their willingness to change. • Acknowledge that patient and staff safety have to be key point for staff. • Acknowledge that the “management vs. front line staff” attitudes and perceptions have to change.

19. Core Principles of Practice for Employees • Safety: Ensure physical and emotional safety of staff throughout our system of care. • Trustworthiness: Administration must consistently relay procedures and expectations. • Choice: Enhance staff choice in the control of the day to day work. • Collaboration: Maximize collaboration and sharing of power. • Empowerment: Provide skill building, find ways to empower staff and provide needed resources.

20. Core Principles for Patients • Safety: Ensure physical and emotional safety of patients throughout our system of care. • Trustworthiness: Make tasks and expectations clear and maintain appropriate boundaries. • Choice: Enhance patient choice and control • Collaboration: Maximize collaboration and sharing of power with patients. • Empowerment: Provide skill building, find ways to empower patients, and provide needed resources.

21. Consumer Care Develop key trust points to share with patients. • Be on time. • Take time to talk and listen. • Work together on a plan for expectations and consequences. • Inform consumers of changes in care before they happen.

22. Administration • Be a model for change. • Use data to monitor change and inform practice. • Develop attitudes, behaviors and core competencies. • Assess risk for violence. • Be present on the units to model and witness change. • Use tools to teach self-management of illness and emotions. • Rigorously debriefing analysis of events that do occur. • Complete inclusion of consumers in their own care. • Recognize peer support as a vital component of the spirit of recovery.

23. Unit Staff • Be open to change. • Assess for risk for violence and need for seclusion and restraint (BVC). • Use tools to teach self-management of illness and emotions. • Rigorous debriefing & analysis of events that do occur. • Complete inclusion of consumers in their own care. • Peer support is a vital component of the spirit of recovery.

24. TIC Teams • Each unit to have 2-3 TIC volunteers (RN, Peer Specialist, OT, PhD ). • Teams to be the go to persons in TIC values and practice. • Each team to develop one TIC project from the guiding values list (see slide 25) with a timeline for action. • TIC committee to offer support, feedback, guidance e.g. literature search.

25. TIC Introduction to the Units • Roaming poster on each unit for one week. • Poster to describe core TIC values & guidelines. • Staff to have a chance to take a risk assessment for compassion fatigue and take the time to be “self” trauma informed. • Staff can fill out a questionnaire about Trauma Informed Care and what positives and challenges there are in creating this system at BHD. • Staff to have a contact person for questions.

26. Circle of Care in TIC

27. Thoughts from Helen Keller • The extraordinary Helen Keller, despite being blind and deaf, achieved so much in her life. She once said:“The world is moved not only by the mighty shoves of the heroes, but also by the aggregate of the tiny pushes of each honest worker.”Each of us is a “honest worker” caring and giving so much of ourselves to help others. If we all push a little we can move mountains and ourselves. We are so intertwined, we caregivers and care recipients, that rules and regulations that are aimed at helping them also help us, and rules and regulations that are designed to help us also help them.

28. References • Fisher, D. (2007) How consumers step up to design a truly recovery-based mental health system. National Council Magazine (3). • Glover, R. W. (2005) Special Section on Seclusion and Restraint: Commentary: Reducing the Use of Seclusion and Restraint: A NASMHPD Priority. Psychiatric Services. 56: 1141-1142 doi: 10.1176/appi.ps.56.9.1141 • Jennings, A. (2004) Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific Services. U.S. Department of Health and Human Services. Retrieved from www.theannainstitute.org/MDT.pdf • Prochaska, J., Norcross, J. & DiClemente, C. (2009) Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. Retrieved from www.addictionInfo.org