1. NOPH Orientation for Trauma Informed Care

2. (SAMHSA, 2012)Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well- being. What is trauma?

3. Safety Trustworthiness and Transparency Peer Support Collaboration and Mutuality Empowerment, Voice, and Choice Cultural, Historical, and Gender Issues SAMHSA’s Six Key Principles of Trauma Informed Care

4.  High percentage of public health clients have trauma history; prevalence  Will help you to better understand our patients and how to treat them more effectively Why is it important to be informed about trauma at NOPH?

5.  Adverse Childhood Experiences  Provided research linking trauma experiences to later high risk behaviors and emotional and physical health problems  i.e.- Anxiety, depression, diabetes, drug use, heart disease, pulmonary disease, liver disease, STDs, gynecologic cancer  This research provided awareness of funding for training and interventions  ACE Questionnaire- 10 questions ACE Study

6.  Resilience- an individual's ability to adapt to stress and adversity  Research has shown Top 5 resilience factors are:  Having power over one’s own life  Having a sense of self and self worth  Having external supports  Being affiliated with a group  Having positive experiences with safe adults, esp adults in positions of authority. (Show resilience questionnaire) We’ve all been through bad experiences, how come we have coped better than some of the patients?

8. Effects of Trauma Thinking Feeling Acting

9. ThinkingFeelingActing Distrust of others, self, world Guilt, shame Low self-worth; lack of identity Dissociation Loss of hope Feeling Unsafe Depression, Anxiety Dys-regulated Emotions Reactive, Impulsive Hallucinations/ Intrusive Memories Cutting, self injury Aggressiveness Interpersonal difficulties Impulsive Hyper-vigilance, alert Keyed up, excitable What are the effects of trauma?

10.  Neurobiologic Effects of Trauma Toxic Stress Derails Healthy Development 1:52 YouTube video  Trauma during developmental period produces an overactive stress response system (fight/flight/freeze)  Brain is always on high alert, impulsive and reactive, in protective mode due to perceived dangers  Less able to develop positive coping responses, problem solving skills and communication skills What are the effects of trauma?

11.  Even treatment can be triggering/traumatic:  Loss of freedom  Loss of privacy  Loss of coping techniques (smoking, using, support system)  Intrusion from other patients  Restraint/Seclusion  Hospitalization can address precipitating crisis and re- stabilize; outpatient treatment best for long-term trauma treatment Hospitalization and Trauma

12.  Powerlessness/Lack of Control  Feeling Unsafe  loud noise, fighting, threats, getting too close, people coming up behind them, patients’ scary symptoms  Lack of Predictability  Specific reminders Triggers

13.  Know the patient’s triggers  Know your triggers  Know team member triggers INTERVENE Know Triggers

14.  During hospitalization- we can help contain emotional reactions and work to improve coping skills  Seeking Safety is a great resource for teaching skills and for core groups. Recovery from Trauma

15. Behind Closed Doors Video Time!

16.  He’s being manipulative.  She just wants attention.  There’s no reason for him to get upset.  She doesn’t want to change.  He is resisting.  She’s too needy.  He’s just playing games.  I’ve tried what works for everyone else, it should work for them.  It isn’t fair to the other patients, they shouldn’t get special treatment. Blaming the Victim Actual Staff Statements

17. Reminder “We take away everything they would use to handle the world and ask them to behave like angels.”

18.  Think… “What happened to you?” Not “What is wrong with you?”  Understand maladaptive behavior from a faulty coping style (sick) perspective rather than from a volitional (bad) perspective.  You do NOT “understand”  “I’m trying to better understand you.”  “Thank you for sharing that with me.”  “How can I support you?”  Recognize their difficulties, AND THEIR STRENGTHS!  Acknowledge their truth in what they are saying/experiencing How do we understand maladaptive behaviors we see in patients from a Trauma Perspective?

19.  Help patient to develop and use their Comfort Plan and comfort items available on the unit  Meet the patient’s needs/Be present and attentive  Good staff/team communication to minimize splitting  Set limits in a firm but kind manner; be consistent  Work with team/unit staff to develop a unified Safety Plan for high risk situations  Allow the opportunity for the patient to re-gain control without coercive measures How do we respond in a trauma- sensitive manner?

20.  Do NOT assume we “know what’s best.”  Give choices and alternatives  Ask their opinions  Emphasize what IS allowed  Reevaluate practices if they are always challenged Share Power

21.  Model healthy/adaptive interactions, emotional stability, good coping skills, problem solving skills  Unit milieu is very important – a functional team models teamwork, good unit dynamics  Debriefings are important – debrief staff and the patient after a code  Do not take verbalizations/actions personally- keep a professional empathic boundary How do we respond in a sensitive manner?

22.  Comfort Plan- Review with patient, clarify what may help, encourage use of safe coping strategies  Comfort Box materials- explore comfort box/weighted blanket  Safety Plans – being aware and preventative, anticipatory  Headphones  Distraction items such as Sudoku, Crosswords, Word Search  Talking/Venting  Sensory items, lotions  Respectful Communication with each other and the patient  Good utilization of Bad News Protocol, pre-planning and foresight Tools to use for early escalation, pre- crisis intervention

23.  Pay attention to personal emotional well-being and coping  Understand what secondary trauma is, burnout, and compassion fatigue  Learn to process with supervisor/colleagues – debrief  Take advantage of coaching options Staff Self-Care and Wellness

24.  Trauma causes long-lasting problems  Do not blame the victim. Not everyone charged of a crime is a criminal.  Everything you do either helps or hurts  Ask “What happened to you?” not “What’s wrong with you?”  Validate and accept them while supporting change  They are trying to cope. We want to teach them healthier coping.  Remember to give choices and control whenever you can.  Know yourself: check in regularly with your self, colleagues, friends and family.  Patients First. Patience First. Take-Aways

25. Thank you!