Happy Monday. New week, new prospects. Well I live with PTSD so past trauma is always sticking to me, but I am hoping to at least shed some of last week’s crap. I’m starting to feel better from the interview…and I don’t want to say too much because it’s still up in the air, but…my project may be salvaged yet! Not with that same person, don’t worry, I’m not TRYING to screw myself…my relationship is doing much better too…If you guys missed it, because I don’t usually post on Sundays, I started The S/O Challenge, and I’d love to invite any of you who are in long-term, non-abusive partnerships to join me! Basically, when I was feeling kind of distant and annoyed with my husband, I came up with a list of ten reasons why I love him. And it helped! There’s a snazzy badge, and an opportunity to share links in the comments, so check it out!
TODAY I am super excited to share with you the second installment of my guest post series “Tales From the Other Side.” Blogger Sheila O’Donnell writes from the unique perspective of someone who has had the dual experience of being a trauma patient and a trauma professional. She could totally relate to what I wrote last week about what I learned in the psych ward from her own hospitalization (which, I should add, was voluntary) but she wanted to tell us about a different sort of place, a place which she and I agree should be the model for mental health treatment. She worked at a facility where they provided hands-off, trauma-informed care. That is drastically different than the psych wards where I have vacationed; places where they gave little care as to whether or not it was re-triggering to put a woman in the midst of a hostage flashback into restraints. I am honored and excited to share this guest post with you, which describes the good side of the mental health system.
Oh! And one last thing I would like to share before introducing you to Sheila! As I was visiting around the blogscape, I came across a post from a new mental health blogger. It was posted last week, it’s called “Things I Learned In A Mental Health Ward,” and it even uses the same graphic as my post. She takes a different approach to the post model, but I totally agree with everything she wrote as well. When you’re done here, check out My MH Recovery.
And now, Sheila:
Sheila is a mental health blogger and advocate currently based in Vermont. After five years working direct service mental health and three and a half years studying for her Bachelor’s in Social Work, she was admitted to a psychiatric unit for seven days. She has since been diagnosed with PTSD and Bipolar Affective Disorder, and is learning to cope with and manage the symptoms of these conditions. With the future she thought she had now off the table, she’s returned to her old love of writing and is using her story to raise awareness and fight the stigma around mental health diagnoses. When not blogging about the irony that is her life, she is busy being a single mother to an enthusiastic little girl, dabbling in the world of photography, writing poetry, or geeking out to some sci-fi, fantasy, or tabletop games. You can read more about her journey on her blog, Parallel Dichotomy and you can connect with her via Facebook and Twitter.
Trauma Informed Care
For nearly five years, I worked in the mental health field as a direct service support to individuals in a group home setting. Among other things, my job entailed teaching emotional regulation skills to individuals with co-occurring diagnoses (Autistic/Schizophrenic, ADHD/Schizoaffective Disorder, Fetal Alcohol Syndrome/ Bipolar Disorder, etc.). Nearly every client with whom I worked had experienced developmental trauma somewhere along the line: child abuse or neglect, the foster care system, institutionalization, severe bullying in school, etc. I always considered the environment in which I worked special, and was proud to be a member of a team of truly caring, empathetic colleagues. One of the staples of this group home was a trauma-informed approach.
When you think “group home”, what images do you see? Perhaps a white board with a “level system” of punishment for bad behavior? Perhaps a sterile “living area” with waiting-room like chairs and a glass encased television? Perhaps a kitchen separate from the dining area with a “no clients allowed” policy? When you hear “group home for sometimes violent clients” what do you imagine? Restraints? Staff handing out Benzos like candy? Locked doors?
Whatever you’re picturing, I’m 98% sure it is neither reflective of the group home in which I worked, nor is it reflective of best practice in cases of developmental trauma.
What is Trauma Informed Care? Simply put, it is intentional, mindful interaction with clients in every aspect of their day to day living. It is caution to avoid any type of retraumatization while teaching coping skills to live a happier, fuller life. It is empowering clients to feel in control of their lives and their emotions. The program in which I worked was intentionally non-institutional. A small home with only three clients at any given time, staffed one-to-one, so that each client had access to a support person all day, every day. Clients and staff did household chores together, cooked together, ate together, played ping pong or basketball together, and built trusting professional relationships. There was next to no staff turnover, with most current staff having worked at the group home for five to ten years. A typical client stay is one to three years, with the goal to integrate into the community after graduating the program, either in their own living space or utilizing a Shared Living Provider, or “supportive roommate”, model as a stepping stone to full independence.
The group home had a strict “hands-off” policy except in cases of immediate threat of substantial physical harm, either to a client or staff. When I say immediate threat, I mean it. In my five years working there, I put “hands on” clients two times – once was to break up a fight in which two clients were essentially charging each other with kitchen chairs raised as weapons, and once when a client was standing in traffic, hoping to be hit by a car and die (I guided him out of the road, even then, using a very specific hands-on method called an “escort’ which involves no substantial force and is completed as quickly as possible.)
Aside from those two incidents, whether I was being physically hit by a client, threatened and maneuvering around the kitchen table so that a client couldn’t hit me, being screamed at and called every name in the book, spit on, or intervening in a screaming match between clients to prevent it from becoming physical, I used verbal de-escalation techniques and protective maneuvers which did not involve any physical contact with clients. My entire team did. Why? Because when you are working with traumatized individuals, acting in an aggressive manner can further trigger them (thus making the situation more dangerous), retraumatize them, and/or break any trust you’ve managed to build.
The way to successfully help clients begin to heal from developmental trauma is to help form new neural pathways – to show them through their lived experience, again and again, that not everyone will respond violently to them, that shame is not necessary, that people will continue to show up, shift after shift, no matter their actions when escalated, and, ultimately, that there are safer and healthier methods for them to get their needs met than violently lashing out. There was no level system, as that was deemed restrictive of client rights. There was no use of restraints, physical or chemical (beyond regular and PRN medications prescribed by the client’s psychiatrist, which happened independent of our program, and which clients had every right to refuse taking.)
This is not to say that staff accepted maladaptive or violent behavior; rather, we processed calmly with clients. If a client was screaming profanities and threats at me, I would keep a calm, level voice and say something to the effect of “I can see that you’re upset, but please realize that I am not screaming or swearing at you. I’d appreciate it if you could show me the same respect I’m showing you.” If the client continued to be verbally escalated after a substantial amount of time (45 minutes or more) but was not being violent, staff would suggest that both client and staff take space from each other until the conversation could occur in a more level-headed manner. If a specific staff was the target, or if staff was beginning to lose patience (because mental health professionals are human after all, and sometimes humans lack the patience to be called “stupid c**t” repeatedly), another staff member would “tap in” to avoid an easily diffused situation from escalating further or a loss of patience resulting in a retraumatization of the client. Clients were expected to engage in productive processing with staff after an escalation, and these conversations were the foundation of the trusting relationships clients and staff formed.
Occasionally, the situation would escalate to truly unsafe levels and either the mobile crisis team or the police would need to be called. But these measures were only taken after every other approach failed. And, sometimes, they were needed. Because some truly traumatized and institutionalized clients will escalate as a method of “testing” you to see if you are able to keep them safe at their absolute worst and most threatening. And sometimes, that does mean calling the police or mobile crisis to come evaluate them for suicidality or extreme violence. Taking that extreme measure could serve to demonstrate that, yes, staff are going to keep the situation safe even if it’s beyond their physical ability and extra help is needed.
We know that developmental trauma alters the structure of the brain, and before you can even begin to teach the “higher level” emotional regulation skills, you need to start supporting neuroplasticity based healing at the “lowest” level. For many clients, this means starting at the “reptilian” portion of the brain – helping them regulate sleep, blood pressure, and diet through a combination of medication and behavioral change. Healthy patterns in these areas need to be established before any cognitive skills can truly be integrated. This is where I’ve seen a lot of other programs fail: they interact with people who’ve experienced developmental trauma in a way that expects full cognitive ability to calm down and process rationally even when triggered. This is simply not possible for a traumatized brain. Access to the frontal lobe, which is already smaller than it “should” be due to developmental trauma, is further severed when someone is triggered. They are in “fight/flight/freeze” and all of the energy resources in the body are being diverted to that reptilian, survivalist part of the brain. So, we worked within that. First help co-regulate, by keeping a calm, even tone and relaxed body posture – which, in turn, sends an unconscious message to the client that the environment is safe and they can move out of “fight/flight/freeze”; then, process with the client once they are calm and able to access the reason centers of the brain.
This was the approach of my team. Trauma Informed care all the way. I mentioned before that I always felt my place of work was unique, but I did not understand just how unique it was in the grand scheme of things. While more agencies are moving toward utilizing Trauma Informed models of treatment, and more and more trainings are being offered to mental health crisis support workers, I was shocked to learn first-hand the lack of trauma informed training in crisis stabilization.
On January 2nd of this year, I was admitted to an inpatient psychiatric unit, where I spent 7 days receiving crisis stabilization care for severe PTSD symptoms. In my time on the unit, I had a nurse who flat out stated that “kids must do something to trigger child abuse, because I just can’t imagine a parent doing that for no reason” and “I can’t understand how a woman could have so little self-respect to stay in an abusive marriage.” (in reference to my mother, also knowing that I had just left an abusive marriage myself). Another nurse insisted that I was required to take my night-time medications at 9 PM because that was what the bubble pack said. This being my third night on the unit, I calmly informed her that I’d been taking my meds at 9:50 each night. She said, “Well, then the other nurses aren’t following protocol.” I strongly suspect she was trying to get her patients to go to bed early for an “easy” rest of the shift, but I put up a bit of a fight, because I was very frustrated. She argued back. The conversation ended with me blurting out, “I’m MAP certified, I know medication administration. You have a two hour window to take meds and still be on track. If the bubble pack says 9, I can take them any time between 8 and 10 and still be on track. You’re lying to me right now.” She simply responded, “Why don’t we compromise and you can take them at 9:45?” completely ignoring the fact that I caught her in a lie, and acting as though she was doing me a favor.
I saw psychiatrists who insisted that I needed to physically calm my body from shaking because it was sending a signal to my brain that there was a reason to panic and acting as if my involuntary trembling was a behavioral issue. And, when I was deeply triggered by that nurse who suggested the abuse my mother and I endured was our faults, I tried to talk to another support staff on the unit who told me “I can see you’re getting upset, so how about we don’t talk about this and re-trigger you and I just get you some anxiety meds?” She literally would not let me finish telling her what happened, even though it was very important to me to tell my story, both for myself to process and to let someone know that that nurse either needed some serious training or to be working somewhere else.
While there were professionals on the unit who had an understanding of trauma and its effects, there were others with zero concept of it, and clearly trauma informed practice was not the approach of the team on the psych unit.
When my PTSD symptoms emerged, I had a complete intellectual grasp of what was happening to me physiologically and emotionally, but I had no way to control it. When I was on the psych unit, I had a professional understanding of every tactic that the treatment team was using to “de-escalate” and, honestly, I was doing my absolute best to not escalate at all with them. But I was reduced to a case number, a medical bracelet, and “the one who dissociates and has flashbacks” nevertheless.
My favorite trauma researcher and clinician is actually one of the pioneers of trauma treatment. His name is Bessel van der Kolk and in his book, “The Body Keeps the Score,” he says this:
For a hundred years or more, every textbooks of psychology and psychotherapy has advised that some method of talking about distressing feelings can resolve them. However, as we’ve seen, the experience of trauma itself gets in the way of being able to do that. No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality.
This has certainly been my lived experience. I have years of training and experience in trauma informed care and best practices – but when it came to my own trauma, I was incapable of containing my own downward spiral into flashbacks, panic attacks, nightmares, substance use, and deep depression. More than that, though, I was also not granted the autonomy to truly express myself to the professionals who were there to help stabilize me. Making the jump from mental health support worker to mental health patient is a surreal experience. I was not allowed to advocate for myself in reference to the nurse who had seriously triggered me, because I was the “patient” in “crisis” and therefore I was exaggerating or flat out lying. Don’t get me wrong, the psych unit stay was necessary and likely saved my life; but I, for one, would like to see a more trauma informed approach across the board in mental health, particularly in crisis stabilization treatment.
I hope that you readers found Sheila’s article as interesting and informative as I did. If you did, enter your info under “Join Betty’s Army” on the sidebar to make sure you never miss a post. There’s more great stuff coming in the “Tales From the Other Side” series, and on Betty’s Battleground in general. You don’t want to miss it!
Thank you Sheila for letting me host this thought-provoking piece. It is truly an honor.
Readers! (Yes, that’s YOU). It would mean SO much if you could please take a quick moment and share this on the social media platform(s) of your choosing. Obviously I am a blogger and I want my posts to be shared so that I can grow my audience, but I have a special reason for making this request today. What Sheila described in the bulk of her post is NOT the model for mental health care in the United States. What she described at the end of her post, and what I described in my post, are more telling of the average mental health facility. Even the post I linked to, which is overwhelmingly positive, mentions briefly, that her stay was “traumatizing.” Hospitalization and mental health treatment should be helpful. That being hospitalized for a mental illness is most often traumatic, should NOT be a glibly stated norm. THE MENTAL HEALTH SYSTEM NEEDS TO BE REFORMED. But that won’t happen unless people know and care that this problem exists, and a solution is offered. This post offers a practical solution and that is why I urge you to please share it. Share it somewhere, anywhere, at least once. If enough people do, the right people might see it, and something might actually be changed.
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