Child Youth & Family Mental Health Services Jan. 08 /2011 Elaine Halsall

1. Child Youth & Family Mental Health ServicesJan. 08 /2011Elaine 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