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