Professional Documents
Culture Documents
They are:
1) triggers,
2) warning signs, and
3) coping strategies.
3
What is Trauma?
NASMHPD (2006):
The experience of violence and victimization including
sexual abuse, physical abuse, severe neglect, loss,
domestic violence and/or the witnessing of violence, terrorism
or disaster
DSM-5 (APA 2013):
The previous edition, DSM-IV, had addressed PTSD as an anxiety disorder.
The DSM-5 includes a new chapter on Trauma- and Stressor-Related Disorders.
Trauma includes:
• direct experience of the traumatic event;
• witnessing the traumatic event in person;
• learning that the traumatic event occurred to a close family member or close friend
(with the actual or threatened death being either violent or accidental); or
• experiences first-hand repeated or extreme exposure to aversive details
of the traumatic event (not through media, pictures, television or movies
unless work-related).
4
Calm/
Continuous/
Engaged Dissociation
6
Robert had been severely physically abused by his stepfather on a regular basis. He
was actually having a good day on the psychiatric unit; everything was going great
for Robert. Then he perceived that a male staff member said something demeaning
to him. (He said he heard his father’s voice as staff talked behind him.)
Robert was restrained and then he started to re-experience the physical abuse he
suffered as a child. He began to dissociate and lose all sense of reality. What was
discovered afterwards, through meticulous debriefing, was that when he overheard
the staff person say something, he heard it in his stepfather’s tone of voice. Robert
perceived it as demeaning. So, he went from a calm, continuous state to three
extreme states of emergency. The transition between calm and continuous states
and discrete states of emergency are fundamental for understanding trauma
and how the brain responds to perceived threat and stress.
7
We must recognize that when triggered, the response of an individual involves changes in a
number of parameters.
How we feel can immediately change from calm and content to anything from a sense of
uneasiness, to anxiety, to fear, or panic.
As a result this affects what we think - the need to be safe, to protect oneself, to survive
The resulting behavior is being driven by how we feel and we think. May or may not be
rational.
Our sense of self is begins to unravel, become less definitive. Often, there is a loss of control.
Learned Response
►Brain chemistry and development is affected by trauma
►Immediate “fight or flight” response
►Heightened sense of fear/danger
With persons who have experienced trauma,
there is a learned response, essentially a survival
mechanism in place.
They seem to always to be in a state of high alert, ready for “fight or flight” to
protect themselves from remembered harmful experiences.
This is their automatic, learned response.
Slower
Hippocampus
Sensory Thalamus
Very Fast Amygdala
Stimulus
LeDoux, 1996
11
The hippocampus is the part of our brain that is responsible to put the triggering event into
context, present the variables.
The cerebral cortex is the decision maker, deciding if I am really in danger here.
This all occurs in a fraction of a second.
With persons who have experienced trauma, there are changes to the brain.
The hippocampus and cerebral cortex both have shrunk and are not working effectively.
Nervous energy, jitter, Changes in the way you think Fear, inability to feel safe Becoming withdrawn or
muscle tension about yourself Sadness, grief, depression isolated from others
Upset stomach Changes in way you think Guilt Easily startled
Rapid Heart Rate about the world Anger, irritability Avoiding places or situation
Dizziness Changes in the way you think Numbness, lack of feelings Becoming confrontational and
about other people aggressive
Lack of energy, fatigue Inability to enjoy anything
Heightened awareness of Change in eating habits
Teeth grinding Loss of trust
your surrounding Loss or gain in weight
(hypervigilance) Loss of self-esteem
Feeling helpless Restlessness
Lessened awareness,
Emotional distance from Increase or decrease in
disconnection from yourself
others sexual activity
(dissociation)
Intense or extreme feelings Self-injury
Difficulty concentrating
Feeling chronically empty Learned helplessness
Poor attention or memory
problems Blunted, then extreme Addictive behaviors
Difficulty making decision feelings
Intrusive images
13
Persons with histories of traumatic stress often experience flashbacks which are
recurring memories, feelings or thoughts that cause the person to re-experience
the trauma and all the associated feelings.
The memory of the traumatizing event can trigger a response of intense fear, horror
and helplessness in which extreme stress overwhelms their capacity to cope.
Because of their traumatic stress the past comes to the present, dissociation often
occurs and the person is again experiencing the traumatic event.
Presence
of large People
Bedtime men being too
close
Triggers
A trigger is something sets off an action or causes a person to behave
in a certain way in response to fear, panic, or anxiety.
Thinks about the examples given on the previous slide.
Bedtime: A time when many past abuses occurred
Room checks: Reminders of the abuser coming into their room
Large men: Think about it. Who often does the restraining?
These examples really need to be in the forefront of our thinking when
we look at how our treatment environments are, including the way staff
speak to consumers, the words, the cadence, the tone, the attitude that
is displayed.
We need to ask if the environment is conducive to
self-soothing and self-regulation.
16
Identifying Triggers
► Trauma Assessment
► Risk Assessment
► Individual Calming Plan
► Clinical interviews
► Informal discussions
► Ongoing process
17
Identifying Triggers
Most of us do a Trauma or Risk Assessment on admission. Some may do a more
comprehensive assessment than others, but it’s usually done on admission.
Often, the next step is to develop a calming plan, or crisis management plan.
This is where we take the information obtained through the assessment process
and make a plan for what to do and not do if a crisis emerges.
Identifying Triggers
Let’s look at some drawbacks to this process. Studies have shown that when
persons are revisiting their trauma history, the Broca area of the brain, the part
responsible for speech shuts down.
We count a lot on our assessments but we need to understand that what we get
during these formal assessments may not be all that there is. The person may
not be able to verbalize the information we are asking them to divulge.
The process must continue on and one that involves everyone on the treatment
team and I do mean everyone, from the psychiatrist to the housekeeper, yes and
even the food service worker.
19
Identifying Triggers
We all know that at the right time and place there are situations that
arise that cause the person served to show us or tell us a little more
about themselves. It is at those times that we need to listen, we need to
ask questions and we need to share this new information with the team.
Then there are other times where we are just observing and we either
notice something or we get the feeling something is just not right.
We need to act in those situations by either interacting, and setting the
calming plan in motion or communicating the information to someone
who can.
20
Hidden Triggers
People have unique histories with uniquely specific triggers.
It is essential to ask and incorporate.
So many times we don’t realize that a person has been triggered.
We only see the behavioral response.
Warning Signs
A signal of distress or a physical precursor to crisis.
This may be a manifestation of a developing crisis.
Some signals are not observable, but some are, such as:
► Restlessness
► Agitation
► Being argumentative
► Pacing
► Shortness of breath
► Sensation of tightness in the chest
► Sweating
23
Remember earlier we saw the work that Mary Gilbert did on reactions to trauma.
Some of those reactions could be considered warning signs, but we want to be very careful
here.
What you need to understand is that ……
Warning Signs
• Atypical behaviors (not always disruptive!)
The key here is to identify behaviors/actions that are warning signs and start intervening immediately.
What we need to notice (and it requires us to be observant all the time) is any behavior that seems
atypical or unusual for this person in the context of where or when it is happening.
Some get the wrong sense that this is always disruptive or aggressive or self injurious. Nothing can
be farther from the truth.
Some times it’s an improvement in behavior; the person appears to be making progress and is no
longer displaying behaviors that are targeted for treatment. Maybe - and maybe not - is what I say.
The bottom line is that we need to check it out.
There are times where it is so difficult to recognize the warning sign because it is so idiosyncratic to
the individual or so subtle it goes unnoticed. Other times, it’s not displayed in close proximity to the
crisis. Here is where debriefing is so important. In order to identify these we’ll need to backtrack and
look at what behaviors were being displayed just prior to the crisis, and again just prior to that, and so
on.
Sometimes it’s necessary to get everyone in a room together and ask them to
voice whatever they know about this person’s behaviors. Likes, dislikes, etc.
27
It is so very important that staff see their role as craftspeople and not gate keepers or person-sitters or jailers.
The day-to-day routine needs to be person-centered. Every day we should all go home exhausted,
not because we have physically exerted ourselves, but rather that we have continually engaged
with the persons we serve, interacting, intervening when necessary, providing services,
meeting needs, assisting, teaching, helping with coping strategy practice sessions…
well, you get the point.
28
We can’t forget basic Psych 101: in order to help anyone, we’ll need to establish
rapport, a trusting relationship, a partnership in hope and recovery.
If we’re really service-minded, we’ll make the effort to greet every person served
when we arrive on duty and notify them when we leave for the day. It really is
beneficial to do this in a manner that asks if there is anything we can do for the
before we leave. Just think if we all were doing this. Wow!
Our words need so many times to be “what can I do to help?” and make ourselves
visible and available for support.
Strategies
Strategies are individual-specific calming mechanisms
to manage and minimize stress, those things that help
to self-regulate, 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
Strategies need to be practicable - meaning doable in times of crisis -
and need to work as well as the maladaptive coping mechanisms the
person has been using.
31
Developing Strategies
► Highly specific to the individual
► Must be practicable
► Must be attainable
► Need to be practiced
► May need additional strategies before/after
► Sensory modulation
► Reward versus coping
► Not always what we expect
► Building new cognitive pathways
Remember, strategies must be doable in the time of crisis. And if we’re teaching a
skill that replaces the less desirable one, it must be able to be used once the
person leaves the facility.
It can’t be something that we put out of reach. Too many times, the strategy that
will work is seen by staff as a motivator for improved or non-aggressive behavior.
An example is if the person can calm themselves by listening to their iPod and the
rules say that in order to use the iPod the person needs to be calm and non-
aggressive for two days, it’s not going to work. The strategy that is the tool to help
the person is out of reach.
We can’t wait till a crisis develops to have the person practice the strategy.
It needs to be practiced at neutral times - and remember, non-successes are
mistakes not failures. Partial successes need to be embraced, and staff use
these to further shape the person.
33
Sometimes there is a need to employ steps in the process. Sometimes what has
been identified as a strategy will only work if it’s part of a process with steps before
and after.
With what we’ve learned about sensory modulation, staff need to be thinking in the
area of all seven senses.
One major area of concern is that staff often see the strategy as a reward for
negative behavior. Our thinking must change here.
Coping Strategies
(Activities that can be self initiated)
► Reaching out to others for support
► Eating comfort foods
► Focusing exercises
► Stress reduction and relaxation techniques
► Doing things that divert your attention
► Doing things you enjoy
► Getting sunlight/fresh air
Peers teasing
36
No one ever said the job would be easy, or that it would not
seem impossible at times. But for those thoughtful people who
have embraced the Six Core Strategies, it is working across
the country, and it’s working because they refuse to give up.
…Really?!