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New York StateNew York StateOffice of Mental Office of Mental

HealthHealth

Lessons Learned ConferenceLessons Learned Conference

May 24-25, 2011May 24-25, 2011

Triggers, Warning Signs and Coping Strategies: Beyond the

ICPP

Triggers, Warning Signs and Coping Strategies: Beyond the

ICPP

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What is Trauma?What is Trauma?

The personal experience of interpersonal violence The personal experience of interpersonal violence including sexual abuse, physical abuse, severe including sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence, neglect, loss, and/or the witnessing of violence, terrorism, and disasters. (NASMHPD, 2004)terrorism, and disasters. (NASMHPD, 2004)

It is extreme stress that overwhelms a person’s It is extreme stress that overwhelms a person’s ability to cope or disrupts one’s sense of safetyability to cope or disrupts one’s sense of safety

State ChangeState Change

Parameters that change between statesParameters that change between states

•AffectAffect•ThoughtThought•BehaviorBehavior•Sense-of-selfSense-of-self•ConsciousnessConsciousness

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Learned ResponseLearned Response

► Brain chemistry/development affected by Brain chemistry/development affected by traumatrauma

► Immediate “fight or flight” responseImmediate “fight or flight” response

► Heightened sense of fear/dangerHeightened sense of fear/danger

Between Stimulus and ResponseBetween Stimulus and Response

StimulusStimulus

Sensory Thalamus Amygdala

Cortex

Very Fast

SlowerHippocampus

ResponseResponse

(LeDoux, (LeDoux, 1996)1996)

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Some Common Reactions to Some Common Reactions to TraumaTrauma

Mary S. Gilbert, Ph.D.Mary S. Gilbert, Ph.D.

Physical Physical ReactionReaction

ss

Mental Mental

ReactionsReactions Emotional Emotional ReactionsReactions

Behavioral Behavioral

ReactionsReactions

Nervous Nervous energy, jitter, energy, jitter,

muscle muscle tensiontension

Upset Upset stomachstomach

Rapid Heart Rapid Heart RateRate

DizzinessDizziness

Lack of Lack of energy, energy, fatiguefatigue

Teeth Teeth grindinggrinding

Changes in the way you Changes in the way you think about yourselfthink about yourself

Changes in way you think Changes in way you think about the worldabout the world

Changes in the way you Changes in the way you think about other peoplethink about other people

Heightened awareness of Heightened awareness of your surrounding your surrounding (hypervigilance)(hypervigilance)

Lessened awareness, Lessened awareness, disconnection from disconnection from yourself (dissociation)yourself (dissociation)

Difficulty concentratingDifficulty concentrating

Poor attention or memory Poor attention or memory problemsproblems

Difficulty making decisionDifficulty making decision

Intrusive imagesIntrusive images

Fear, inability to feel Fear, inability to feel safesafe

Sadness, grief, Sadness, grief, depressiondepression

GuiltGuilt

Anger, irritabilityAnger, irritability

Numbness, lack of Numbness, lack of feelingsfeelings

Inability to enjoy Inability to enjoy anythinganything

Loss of trustLoss of trust

Loss of self-esteemLoss of self-esteem

Feeling helplessFeeling helpless

Emotional distance from Emotional distance from othersothers

Intense or extreme Intense or extreme feelingsfeelings

Feeling chronically Feeling chronically emptyemptyBlunted, then extreme Blunted, then extreme feelings feelings

Becoming withdrawn Becoming withdrawn or isolated from or isolated from othersothers

Easily startledEasily startled

Avoiding places or Avoiding places or situationsituation

Becoming Becoming confrontational and confrontational and aggressiveaggressive

Change in eating Change in eating habitshabits

Loss or gain in weightLoss or gain in weight

RestlessnessRestlessness

Increase or decrease Increase or decrease in sexual activityin sexual activity

Self-injurySelf-injury

Learned helplessnessLearned helplessness

Addictive behaviorsAddictive behaviors

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Traumatic stress, when Traumatic stress, when triggered, brings the past to triggered, brings the past to the present.the present.

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TriggersTriggers

►A trigger is something that sets off an A trigger is something that sets off an action, process, or series of eventsaction, process, or series of events (such (such as fear, panic, anger, anxiety or as fear, panic, anger, anxiety or agitation). Examples include:agitation). Examples include: bedtimebedtime room checksroom checks presence of large menpresence of large men yellingyelling people being too closepeople being too close guilt, criticism or put downsguilt, criticism or put downs

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Identifying TriggersIdentifying Triggers

►Trauma AssessmentTrauma Assessment►Risk AssessmentRisk Assessment► Individual Calming Individual Calming

PlanPlan►Clinical InterviewsClinical Interviews► Informal discussionsInformal discussions►On-going processOn-going process

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Triggers are not always Triggers are not always obvious:obvious:

►Particular time of day/night Particular time of day/night ►Particular time of yearParticular time of year►Anniversary of a lossAnniversary of a loss► Internal triggersInternal triggers►Someone who looks/sounds familiarSomeone who looks/sounds familiar►Staff issues/difficultyStaff issues/difficulty►Other idiosyncratic issues related to Other idiosyncratic issues related to

trauma.trauma.Consumers have unique histories with uniquely Consumers have unique histories with uniquely specific triggers – it is essential to ask & specific triggers – it is essential to ask & incorporateincorporate

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Warning SignsWarning SignsWarning SignsWarning Signs

A signal of distress or a physical A signal of distress or a physical precursor to crisis. This may be a precursor to crisis. This may be a manifestation of a developing crisis. manifestation of a developing crisis. Some signals are not observable, but Some signals are not observable, but some are, such as:some are, such as:

► RestlessnessRestlessness► AgitationAgitation► Being argumentativeBeing argumentative► PacingPacing► Shortness of breathShortness of breath► Sensation of a tightness in the chestSensation of a tightness in the chest► SweatingSweating

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Typical Trauma-related Typical Trauma-related SymptomsSymptoms

► DissociationDissociation► FlashbacksFlashbacks► Nightmares Nightmares ► Hyper-vigilanceHyper-vigilance► TerrorTerror► AnxietyAnxiety► Pejorative auditory Pejorative auditory

hallucinationshallucinations► Difficulty w/problem Difficulty w/problem

solvingsolving

► NumbnessNumbness► DepressionDepression► Substance abuseSubstance abuse► Self-injurySelf-injury► Eating problemsEating problems► Poor judgment and Poor judgment and

continued cycle of continued cycle of victimizationvictimization

► Aggression

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Warning SignsWarning SignsWarning SignsWarning Signs

• Atypical Behaviors

• Not always disruptive

• Could be an improvement in behavior

• Something highly idiosyncratic

• Can be extremely subtle

• Not always displayed just prior to crisis

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The Importance of The Importance of InteractionInteraction

►Day to day routineDay to day routine►Establishing rapportEstablishing rapport►On-going assessmentsOn-going assessments►Personal greetings/farewellsPersonal greetings/farewells►Making ourselves availableMaking ourselves available►Using activities as a forum Using activities as a forum

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If I could say anything to all the staff If I could say anything to all the staff in the world it would be this: forget in the world it would be this: forget everything you were taught in everything you were taught in school and be prepared to listen…school and be prepared to listen…don’t criticize and think it’s a lie. don’t criticize and think it’s a lie. Just listen and ask questions and Just listen and ask questions and be kind. Just take the time to be kind. Just take the time to listen…”listen…”

(Interview with a adult trauma survivor (CD), (Interview with a adult trauma survivor (CD), 2005)2005)

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StrategiesStrategies

Strategies are individual-specific calming Strategies are individual-specific calming mechanisms to manage and minimize mechanisms to manage and minimize stress, those things that help to self-stress, those things that help to self-regulate such as:regulate such as:

time away from a stressful situationtime away from a stressful situation going for a walkgoing for a walk talking to someone who will listentalking to someone who will listen working outworking out lying downlying down listening to peaceful musiclistening to peaceful music

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Developing StrategiesDeveloping Strategies

►Highly specific to the individualHighly specific to the individual►Must be practicableMust be practicable►Must be attainableMust be attainable►Need to be practicedNeed to be practiced►May need additional strategies before/afterMay need additional strategies before/after► Sensory modulationSensory modulation► Reward versus copingReward versus coping►Not always what we expectNot always what we expect► Building new cognitive pathwaysBuilding new cognitive pathways

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Coping StrategiesCoping Strategies(Activities that can be self initiated)(Activities that can be self initiated)

Coping StrategiesCoping Strategies(Activities that can be self initiated)(Activities that can be self initiated)

► Reaching out to others for supportReaching out to others for support► Eating comfort foodsEating comfort foods► Focusing ExercisesFocusing Exercises► Stress Reduction and Relaxation Stress Reduction and Relaxation

TechniquesTechniques►Doing things that divert your Doing things that divert your

attentionattention►Doing things you enjoyDoing things you enjoy►Getting sunlight/fresh airGetting sunlight/fresh airThere is a need to identify those things that the recipient has done when There is a need to identify those things that the recipient has done when they begin to Feel “Triggered” or set off by a life event that helps them they begin to Feel “Triggered” or set off by a life event that helps them

self-regulate.self-regulate.

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What May Not Help…...What May Not Help…...► Being aloneBeing alone► Not being listened Not being listened

toto► Being told to stay Being told to stay

in my roomin my room► Loud tone of voiceLoud tone of voice► Peers teasingPeers teasing

► HumorHumor► Being ignoredBeing ignored► Having many people Having many people

around mearound me► Having space Having space

invadedinvaded► Staff not taking me Staff not taking me

seriouslyseriously

“If I’m told in a mean way that I can’tdo something … I lose it.”

-- Natasha, 18 years old

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"We are continually faced with great opportunities which are brilliantly

disguisedas unsolvable problems."

Margaret Mead

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