Triggers, Warning Signs and Coping Strategies: Beyond the ICPP

Originally presented at the PARS Project’s Lessons Learned ConferenceMay 24-25, 2011

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The Essential Components

Most of us have probably heard about the three essential components of an Individual Calming Plan, or Crisis Prevention Plan, or Soothing Plan.

They are: 1) triggers, 2) warning signs, and 3) coping strategies.

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NASMHPD (2006):The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disaster

DSM-5 (APA 2013):The previous edition, DSM-IV, had addressed PTSD as an anxiety disorder.The DSM-5 includes a new chapter on Trauma- and Stressor-Related Disorders. Trauma includes:• direct experience of the traumatic event;• witnessing the traumatic event in person; • learning that the traumatic event occurred to a close family member or close friend

(with the actual or threatened death being either violent or accidental); or • experiences first-hand repeated or extreme exposure to aversive details

of the traumatic event (not through media, pictures, television or movies unless work-related).

What is Trauma?

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If we think about this, trauma is a significant experience in one’s life that is going to have an effect on that person throughout their lifetime. There is a wide range of potentially traumatic events that either happen to a person or are witnessed by them.

Everyone of us are different, and what affects us is different, and how it affects us is different.

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An Example of State ChangeRobert, a 22-year-old man with a history of severe childhood physical abuse, displayed aggressive behavior on the psychiatric unit and was physically restrained.

Calm/Continuous/Engaged

AggressionFear

Dissociation

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Robert had been severely physically abused by his stepfather on a regular basis. He was actually having a good day on the psychiatric unit; everything was going great for Robert. Then he perceived that a male staff member said something demeaning to him. (He said he heard his father’s voice as staff talked behind him.)

What happened? He immediately went from a calm, continuous state to a state of aggression. He lunged at the staff member. What happens when you lunge at a staff member? You get restrained.

Robert was restrained and then he started to re-experience the physical abuse he suffered as a child. He began to dissociate and lose all sense of reality. What was discovered afterwards, through meticulous debriefing, was that when he overheard the staff person say something, he heard it in his stepfather’s tone of voice. Robert perceived it as demeaning. So, he went from a calm, continuous state to three extreme states of emergency. The transition between calm and continuous states and discrete states of emergency are fundamental for understanding trauma and how the brain responds to perceived threat and stress.

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Parameters that change between states

• Affect• Thought• Behavior• Sense-of-self• Consciousness

All of this is built on principles of normal development.

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We must recognize that when triggered, the response of an individual involves changes in a number of parameters.

How we feel can immediately change from calm and content to anything from a sense of uneasiness, to anxiety, to fear, or panic.

As a result this affects what we think - the need to be safe, to protect oneself, to survive

The resulting behavior is being driven by how we feel and we think. May or may not be rational.

Our sense of self is begins to unravel, become less definitive. Often, there is a loss of control.

Consciousness is no longer clear. There is much difficulty in differentiating between past and present, previous trauma and the here and now. Dissociation is common and often used as a coping mechanism.

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►Brain chemistry and development is affected by trauma►Immediate “fight or flight” response►Heightened sense of fear/danger

Learned Response

With persons who have experienced trauma, there is a learned response, essentially a survival mechanism in place.

Scientists have studied the brains of these people and have noted that the ability to regulate response is drastically affected.

They seem to always to be in a state of high alert, ready for “fight or flight” to protect themselves from remembered harmful experiences.This is their automatic, learned response.

There is this heightened sense of fear or danger that is pervasive. Their response to this is often unexpected and can be violent.

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Between stimulus and response

Stimulus

LeDoux, 1996

Very Fast

HippocampusSlower

Sensory Thalamus

Cortex

Amygdala

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The amygdala is essentially our survival mechanism; its response is immediate.

The hippocampus is the part of our brain that is responsible to put the triggering event into context, present the variables.

The cerebral cortex is the decision maker, deciding if I am really in danger here.This all occurs in a fraction of a second.

With persons who have experienced trauma, there are changes to the brain.The hippocampus and cerebral cortex both have shrunk and are not working effectively.

That leaves only the response activated by the amygdala:Fight, Flight or Freeze.

Fight, Flight or Freeze

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Some Common Reactions to TraumaMary S. Gilbert, Ph.D., Grand Rapids, Michigan

Physical Reactions Mental Reactions Emotional Reactions Behavioral Reactions

Nervous energy, jitter, muscle tensionUpset stomachRapid Heart RateDizzinessLack of energy, fatigueTeeth grinding

Changes in the way you think about yourselfChanges in way you think about the worldChanges in the way you think about other peopleHeightened awareness of your surrounding (hypervigilance)Lessened awareness, disconnection from yourself (dissociation)Difficulty concentratingPoor attention or memory problemsDifficulty making decisionIntrusive images

Fear, inability to feel safeSadness, grief, depressionGuiltAnger, irritabilityNumbness, lack of feelingsInability to enjoy anythingLoss of trustLoss of self-esteemFeeling helplessEmotional distance from othersIntense or extreme feelingsFeeling chronically emptyBlunted, then extreme feelings

Becoming withdrawn or isolated from othersEasily startledAvoiding places or situationBecoming confrontational and aggressiveChange in eating habitsLoss or gain in weightRestlessnessIncrease or decrease in sexual activitySelf-injuryLearned helplessnessAddictive behaviors

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Traumatic stress, when triggered, brings the past to the present.Triggers may be sights, sounds, smells, touches, anything that reminds the person of the trauma and causes them to feel unsafe, anxious or fearful.

Persons with histories of traumatic stress often experience flashbacks which are recurring memories, feelings or thoughts that cause the person to re-experience the trauma and all the associated feelings.

The memory of the traumatizing event can trigger a response of intense fear, horror and helplessness in which extreme stress overwhelms their capacity to cope.

Because of their traumatic stress the past comes to the present, dissociation often occurs and the person is again experiencing the traumatic event.

We must be aware of the negative impact exposure to people, places or things that can result in triggering or re-traumatizing. For example, a dark room may trigger a memory of abuse in a dark room. Just hearing a voice similar to the abuser may create a crisis situation for the person.

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A trigger is something that sets off an action, process, or series of events such as fear, panic, anger, anxiety or agitation. Can you think of any examples?

Triggers

People being too

close

Room checks

Presence of large

men

Yelling!

Bedtime

Guilt, criticism,

put-downs

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A trigger is something sets off an action or causes a person to behave in a certain way in response to fear, panic, or anxiety.

Thinks about the examples given on the previous slide. Bedtime: A time when many past abuses occurred Room checks: Reminders of the abuser coming into their room Large men: Think about it. Who often does the restraining?

These examples really need to be in the forefront of our thinking when we look at how our treatment environments are, including the way staff speak to consumers, the words, the cadence, the tone, the attitude that is displayed.

We need to ask if the environment is conducive to self-soothing and self-regulation.

Triggers

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► Trauma Assessment► Risk Assessment► Individual Calming Plan► Clinical interviews► Informal discussions► Ongoing process

Identifying Triggers

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Most of us do a Trauma or Risk Assessment on admission. Some may do a more comprehensive assessment than others, but it’s usually done on admission.

Often, the next step is to develop a calming plan, or crisis management plan. This is where we take the information obtained through the assessment process and make a plan for what to do and not do if a crisis emerges.

Most facilities also conduct discipline specific interviews or assessments. The information is transferred to the clinical record and used to develop treatment strategies.

But is that enough?

Identifying Triggers

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Let’s look at some drawbacks to this process. Studies have shown that when persons are revisiting their trauma history, the Broca area of the brain, the part responsible for speech shuts down.

We count a lot on our assessments but we need to understand that what we get during these formal assessments may not be all that there is. The person may not be able to verbalize the information we are asking them to divulge.

The process must continue on and one that involves everyone on the treatment team and I do mean everyone, from the psychiatrist to the housekeeper, yes and even the food service worker.

Identifying Triggers

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We all know that at the right time and place there are situations that arise that cause the person served to show us or tell us a little more about themselves. It is at those times that we need to listen, we need to ask questions and we need to share this new information with the team.

Then there are other times where we are just observing and we either notice something or we get the feeling something is just not right. We need to act in those situations by either interacting, and setting the calming plan in motion or communicating the information to someone who can.

Identifying Triggers

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

Triggers are not always obviousIt could be…

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So many times we don’t realize that a person has been triggered.We only see the behavioral response.

We need to look for possible triggers which could be:

- A particular time of day, night or of the year.

- Internal triggers, those set off by the person’s disorder or thinking.

- Someone who looks or sounds like someone in their past.

- Let’s not forget about staff, their attitudes, the words they use, how they say them, staff conflicts

- And we can’t ignore the fact that many times the triggers are very difficult to

identify and may be highly idiosyncratic to that person’s trauma history.

We have to ask, we have to be observant, and we have to ask again.

Hidden Triggers People have unique histories with uniquely specific triggers.It is essential to ask and incorporate.

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

► Restlessness► Agitation► Being argumentative► Pacing► Shortness of breath► Sensation of tightness in the chest► Sweating

Warning Signs

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►Dissociation►Flashbacks►Nightmares ►Hyper-vigilance►Terror►Anxiety►Pejorative auditory hallucinations►Difficulty w/problem solving

Typical Trauma-related Symptoms►Numbness►Depression►Substance abuse►Self-injury►Eating problems►Poor judgment and continued cycle of victimization►Aggression

Remember earlier we saw the work that Mary Gilbert did on reactions to trauma. Some of those reactions could be considered warning signs, but we want to be very careful here.What you need to understand is that ……

These “symptoms” are not signs of pathology ...rather, they are survival strategies that have helped to cope

with terrible pain and challenges.

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The key is learn how the behavior developed and teach new coping strategies.

We can’t demand that the person stop doing certain things until we can teach them new more desirable and practicable coping strategies and they are at a point where the new strategy is as effective as the old.

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Warning 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 key here is to identify behaviors/actions that are warning signs and start intervening immediately.

What we need to notice (and it requires us to be observant all the time) is any behavior that seems atypical or unusual for this person in the context of where or when it is happening.

Some get the wrong sense that this is always disruptive or aggressive or self injurious. Nothing can be farther from the truth.

Some times it’s an improvement in behavior; the person appears to be making progress and is no longer displaying behaviors that are targeted for treatment. Maybe - and maybe not - is what I say. The bottom line is that we need to check it out.

There are times where it is so difficult to recognize the warning sign because it is so idiosyncratic to the individual or so subtle it goes unnoticed. Other times, it’s not displayed in close proximity to the crisis. Here is where debriefing is so important. In order to identify these we’ll need to backtrack and look at what behaviors were being displayed just prior to the crisis, and again just prior to that, and so on.

Sometimes it’s necessary to get everyone in a room together and ask them to voice whatever they know about this person’s behaviors. Likes, dislikes, etc.

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The Importance of Interaction

►Day to day routine►Establishing rapport►Ongoing assessments►Personal greetings and farewells►Making ourselves available►Using activities as a forum

It is so very important that staff see their role as craftspeople and not gate keepers or person-sitters or jailers.

The day-to-day routine needs to be person-centered. Every day we should all go home exhausted,not because we have physically exerted ourselves, but rather that we have continually engaged with the persons we serve, interacting, intervening when necessary, providing services, meeting needs, assisting, teaching, helping with coping strategy practice sessions…well, you get the point.

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I am not saying people just stand around……but sometimes there are many opportunities that we miss each day to interact.

We can’t forget basic Psych 101: in order to help anyone, we’ll need to establish rapport, a trusting relationship, a partnership in hope and recovery.

If we’re really service-minded, we’ll make the effort to greet every person served when we arrive on duty and notify them when we leave for the day. It really is beneficial to do this in a manner that asks if there is anything we can do for the before we leave. Just think if we all were doing this. Wow!

Our words need so many times to be “what can I do to help?” and make ourselves visible and available for support.

Our paraprofessional staff need to use activities as a forum for interaction, assessment and discussion.

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If I could say anything to all the staff in the world it would be this: forget everything you were taught in

school and be prepared to listen…don’t criticize and think it’s a lie. Just listen and ask questions

and be kind. Just take the time to listen…”

(Interview with an adult trauma survivor, 2005)

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

…time away from a stressful situation…going for a walk…talking to someone who will listen…working out…lying down…listening to peaceful music

Strategies need to be practicable - meaning doable in times of crisis - and need to work as well as the maladaptive coping mechanisms the person has been using.

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Developing Strategies► Highly specific to the individual► Must be practicable► Must be attainable► Need to be practiced► May need additional strategies before/after► Sensory modulation► Reward versus coping► Not always what we expect► Building new cognitive pathways

Sometimes it’s trial and error.

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Remember, strategies must be doable in the time of crisis. And if we’re teaching a skill that replaces the less desirable one, it must be able to be used once the person leaves the facility.

It can’t be something that we put out of reach. Too many times, the strategy that will work is seen by staff as a motivator for improved or non-aggressive behavior. An example is if the person can calm themselves by listening to their iPod and the rules say that in order to use the iPod the person needs to be calm and non-aggressive for two days, it’s not going to work. The strategy that is the tool to help the person is out of reach.

We can’t wait till a crisis develops to have the person practice the strategy. It needs to be practiced at neutral times - and remember, non-successes are mistakes not failures. Partial successes need to be embraced, and staff use these to further shape the person.

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Sometimes there is a need to employ steps in the process. Sometimes what has been identified as a strategy will only work if it’s part of a process with steps before and after.

With what we’ve learned about sensory modulation, staff need to be thinking in the area of all seven senses.

One major area of concern is that staff often see the strategy as a reward for negative behavior. Our thinking must change here.

Sometimes what we get is not what we expect or want to accept. We need to be careful here and recognize that the behavior being displayed may be a better choice than what could have been displayed.

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Coping Strategies(Activities that can be self initiated)

► Reaching out to others for support► Eating comfort foods► Focusing exercises► Stress reduction and relaxation techniques► Doing things that divert your attention► Doing things you enjoy► Getting sunlight/fresh air

Too many times, we feel we need to be involved. But once discharged, the person needs to be able to self-initiate their coping strategies and know who they can count on for assistance.

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Being alone

Not being listened to

Being told to stay in my room

Loud tone of voice

Peers teasing

What May Not Help…...

“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 disguised as unsolvable problems.“

Margaret Mead

No one ever said the job would be easy, or that it would not seem impossible at times. But for those thoughtful people who have embraced the Six Core Strategies, it is working across the country, and it’s working because they refuse to give up.

I know, I know. Many of us think of our jobs as scary, really difficult to do day in and day out, not so safe, really dangerous, emotionally draining. Well………….

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…Really?!