1. Child Youth & Family Mental Health Services Jan. 08 /2011 Elaine Halsall Transitioning from a Traditional Inpatient to a Trauma-Informed Practice Model

2. Pre-2005 How It Was… Privilege or behavioural model used Compliance sought Staff were set up as enforcers of rules Tendency to label clients as manipulative, non-compliant, needy, attention–seeking. Sense of power over (time outs, seclusion & restraints) Set program (6 weeks)

3. Need For A Paradigm Shift… Using what we know-practice grounded in current research (Bloom, 1997; Duncan, Miller & Sparks, 2004; Fallot & Harris, 2006; Green,1997; Hodas, 2006; Levine & Kline, 2007; Perry & Szalavitz, 2006). – Growing recognition that many of the children and youth served had significant trauma in their backgrounds. – Recognition that hospitalization can be a re- traumatizing experience. – Move to least restrictive environments.

4. Shift In Philosophy: 2005- introduced two Trauma-Informed models to inpatient program: – Sanctuary Model (Bloom, 1997) – Engagement Model (Bennington-Davis & Murphy, 2005) 2007- introduced Trauma-Informed Practice to outpatient program. 2011-All programs using modified Trauma- Informed Care (adaptation of Sanctuary & Engagement models).

5. Trauma Informed Care “Trauma Informed care involves the closely interrelated triad of understanding, commitment, and practices, organized around the goal of successfully addressing the trauma-based needs of those receiving services” (Hodas, 2006)

6. Throwing Out The “Rule Book” not the Boundaries and Limits! Focus on safety (be safe, feel safe). Focus on child/youth identified goals. Consider what’s underneath the behaviour, not what’s wrong, but what happened? Recognize the role of trauma in a child’s life (small T and big T). Recognize coercive interventions can cause traumatic responses and may re-traumatize (rules, restriction, directive language, privilege systems, shaming, humiliating, S&R, Keys).

7. Introduction Of Model … Education for staff Role Modeling/Champions of the model Culture of safety for clients and staff Creating safe and welcoming environments Involving consumers in designing and evaluating environments Attention in policies, practices and staff relational approaches to safety and empowerment (seclusion & restraint policy).

8. Develop approaches to reduce anxiety. Sensory issues–kids exposed to trauma are hypersensitive to external stimuli, are highly hypervigilent, and experience a persistent stress-response state. Recognize the clients’ need for involvement, pacing, choice and control in decisions affecting their care.

9. Does not require disclosure of trauma; rather services are provided in ways that emphasize the need for emotional and physical safety. Negotiation- setting a limit not coercive Confrontation avoided (Collaborative Problem-Solving Model - Ross Greene). Language (direct care, vs front line). Frontloading to avert crisis. Use approaches to reduce anxiety, with a focus on safety planning.

10. Challenges… Required a significant culture shift in the program. Had to be infused incrementally into practice- staff not chastised. Rather, the challenge of this practice shift recognized. Staff had to learn about the effects of trauma. This piece was critical to success. Developed a milieu that assists clients to maintain a regulated state (non-aroused). Learned skills to allow more adaptive choices.

11. Challenges… Clear boundaries (part of life, predictable), different from “no rules” interpretation. Requires calm, compassionate staff attuned to issues underlying client’s behaviour and to their own sensitivities. Incorporate ritual and routines. Move towards safe, structured, consistent, predictable, organized program. Service community perception /education

12. Practical Positive Examples… Developed Safety plans (triggers, coping skills) All clients and staff are members of a community, with daily community meetings Responsive environment (OP youth waiting room) Comfort rooms instead of time-out rooms Sensory rooms to explore sensory modulation Child specific trauma informed NVCI training Emergency Seclusion & Restraint Policy Reduced Seclusion and Restraint episodes Reduced staff injuries

13. Door to Comfort Room

14. Comfort Room

15. Sensory Room