de-escalating victims of trauma michelle dodge, jd, msw jmd counseling and therapeutic services...
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De-escalating Victims of Trauma
Michelle Dodge, JD, MSW
JMD Counseling and Therapeutic Services
Stephanie Wilson, MD
Board Certified Forensic Psychiatrist
Urgent Care Clinic
Overview:
Definition of traumaSymptoms/Implications of traumaStress response in victims of traumaIdentifying stress responsesDe-Escalation techniquesCase scenario
What is Trauma?
Real or perceived threat to life or well-beingNot time limitedUnpredictable Impacts all areas of lifeOut of Control
Spectrum of Trauma:
Acute Trauma: A single time limited event Chronic Trauma: Multiple traumatic exposures
and/or events over extended period of time Toxic Stress: Adverse experiences that lead to
strong, frequent, or prolonged activation of the body’s stress response system
Secondary/Vicarious Trauma: Exposure to the trauma of others by providers, family members, partners, or friends in close contact with the traumatized individual
Trauma and Resilience: An Adolescent Provider Toolkit; Adolescent Health Working Group 2013
Stress – Trauma Continuum
NormalSituationalTraumatic
Symptoms of Trauma
DysregulationDissociation (Freeze Response)TriggersPoor Coping Skills/Maladaptive DefensesIrrational BeliefsDistrust
Implications of Trauma:
Changes in brain neurobiology•Amygdala•Hippocampus•Prefrontal Cortex
Adoption of health risk behaviors as ways to cope (smoking, substance abuse, self harm, sexual promiscuity, violence)
Post Traumatic Stress Disorder (PTSD):
Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — (either experiencing or witnessing the event). Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.
Post Traumatic Stress Disorder (PTSD)
Key Symptoms:Re-experiencing the event through nightmares, intrusive thoughts, and flashbacks
Mood symptoms: irritability, depression, impulsivity
Hyper-arousal: being on edge, alert, easily startled
Negative cognitions: blaming oneself, feeling disconnected, negative world view
Post Traumatic Stress Disorder (PTSD)
Children and Adults exposed to trauma are at risk for PTSD
3.5% of US adults have PTSD in a given year (NIMH)
PTSD can develop at any age Median age is 234% Lifetime prevalence in 13-18 year-olds (NIMH)
Trauma in Children: Resiliency
Children not similarly impacted by trauma/abuseFactors include: age, severity, and timeVery young children are not “immune” to traumaChildren do not forget trauma/violenceMitigating Factors: intelligence, environment, supportive person
Effects of Trauma on Children
Sleep difficultiesSomatic symptomsIncreased anxiety about separations from caregivers
Increased aggression/anxietyIncreased distractibility and activity level
Other Common Responses
DepressionOppositional defiant disorderAnxiety disorderAttachment disorder
Adults and Children with PTSD Respond to Stress Differently
Heightened state of arousalLeads to heightened stress response to triggers
Poor Emotional Regulation
Average vs. Heightened Stress Response
Stress Behaviors Indicating Increasing Agitation
Raising voice or using profanityCryingClenching fists or jawRocking Frequent alteration of body positionStanding from a seated positionPacing
De-Escalation
Verbal De-Escalation: Non-physical skills used to prevent a potentially dangerous situation from escalating into a physical confrontation or injury.
Physical De-Escalation: Using non-verbal methods to control the dangerous situation to prevent injury
Therapeutic Holds Medications Physical Restraint
Verbal De-Escalation
De-Escalation goes against our natureFight or Flight Response
We are driven to flee, fight or freeze when confronted with a dangerous situation
Maintain your safetyDo not try to reason with the agitated personFirst priority is to decrease the level of agitation/aggression
Techniques must be practiced
Verbal De-Escalation
Consists of three areas:1. Control of Self2. Physical Stance3. De-Escalation Discussion
National Association of Social Workers Guidelines
Control of Self
Appear calm and self-assuredUse a modulated and low tone of voiceDo not be defensive or try to argue with the client even in the face of insults
Know your resources available for further help. You have the choice to leave, tell the client to leave or call police.
Always be respectful
Physical Stance
Never turn your backBe at the same eye levelAllow extra space between yourself and the clientStand at an angleDo not maintain constant eye contact
Physical Stance
Do not point/shake fingerKeep a neutral facial expressionLimit smiling Do not touchDo not cross your arms or keep them behind your back
Do not place your hands in your pockets
Physical Space
If possible bring to quiet space away from othersDo not meet with an agitated person aloneMaintain 4 times your usual personal spaceAllow both clinician and client access to the door Inform colleagues in advance if there is a possibility for agitation
Know who to call in an emergency
De-Escalation Discussion
No content except to bring the arousal downDo not raise your voice or yell to talk over Respond selectively, answer all appropriate questions
Use clear and concise languageAllow extra time to respondExplain limits in rules in a respectful yet firm manner
De-Escalation Discussion
Provide choices whenever possibleEmphasize with feelings, but not negative behavior
Do not argue Suggest alternative behaviorsGive consequences of inappropriate behavior without threat or anger
Trust your instincts
De-Escalation in Children
Reduce noise and distractionsIsolate child (if possible)Speak softly, but firmlyBe patientAllow child to calm her/himselfTherapeutic hold (if properly trained)
Case Scenario-Dionne
Dionne is 10 years old. She has been in foster care for 2 years. Dionne was removed from her mother’s home after disclosing that she was sexually abused by her mother’s boyfriend. Her mother does not believe the allegations. Dionne’s mother lives with her boyfriend and their two-year-old son. She believes that her daughter is a liar and refuses to allow her to return to the family home. The court has granted supervised visits between Dionne and her mother. Dionne does not want to attend the visits but has been told that they are court ordered so she must attend.
Case Scenario- Dionne
Dionne’s mother arrives 30 minutes late for the weekly visit. She is very agitated. When she enters the visit room, she immediately begins to yell at Dionne for reporting the abuse, destroying the family, and forcing her mother into “the system”. Dionne begins to cry and refuses to speak with her mother. This infuriates her mother who begins talking to herself. She threatens to “kill” Dionne and “beat the devil” out of her. Upon hearing this, Dionne begins screaming at her mother, “I hate you”. The monitor asks Dionne and her mother to “lower” their voices. However, she does not intervene.
Case Scenario- Dionne
Dionne and her mother continue to yell at each other. Finally, the mother sits at the table and begins to text on her phone. Dionne sits on the floor in the corner of the room waiting for the visit to end. After 15 minutes, the monitor announces that the visit is over. Dionne stands to leave. Her mother tells her to sit down because the visit is for 60 minutes and it is not time to leave. The monitor attempts to explain that Dionne’s mother was 30 minutes late so she will not have 30 additional minutes. The mother becomes angry. She begins cursing and threatens the monitor. The monitor leaves the room to find her supervisor. She returns 10 minutes later. Dionne is sitting on the floor holding her face. Her mother is still yelling and refuses to leave the building.
Case Scenario- Dionne
Discuss what, if anything, the monitor could have done differently during the visit.
Identify behaviors (by either Dionne or her mother), which may have indicated that the monitor needed to intervene during the visit?
What, if anything, should the supervisor do to de-escalate the situation?
Questions?
Urgent Care ClinicDC Superior Court
• Mental Health Clinic that is available for persons involved in the legal system. Operated by Pathways to Housing DC and funded by the Department of Behavioral Health.
• Services Provided : Urgent Crisis Management Medication Management Substance abuse assessments Placement into appropriate community based treatment Case management for active clients
Department of Behavioral HealthAccess Helpline
Connects DC residents to mental health services in the Community (also called Core Service Agencies)
Also serves as an emergency hotline for psychiatric emergencies or if a person needs to talk immediately
1-888-7WE-HELP (1-888-793-4357)
Emergency help for Children/Adolescents
Children and Adolescent Mobile Psychiatric Service (ChAMPS) provides on-site immediate help to children facing a behavioral or mental health crisis whether in the home, school or community
(202) 481-1450