The Highs and Lows of Trauma informed care

The Highs and Lows of Trauma informed care Forensic Services Sarah Robinson – Trauma Lead Dr Emma Groves – Principal Psychologist

2001 WHERE THIS JOURNEY BEGAN

Hold on Tight

SECURE MENTAL HEALTH CULTURE

SECURE MENTAL HEALTH CULTURE

SEEK FIRST TO UNDERSTAND

Do not sit on the patients chair

ALTERNATIVE TO DEBRIEF

TRAUMA INFORMED CARE FOR ALL

WHERE DO WE START?

SANDPIPER

TRAUMA INFORMED CARE • • • WROTE THE PROPOSAL (got the buy in from leads) Measures taken 2 day away day training Core stabilisation skills sessions 2 x per day Incident reflection 24 hours post incident] Staff supervision weekly CAT reflective and trauma CFT based • Service user meetings to explore incidents and experiences (came later) • Incentive based stages

TRAUMA TRAINING Day 1 • Why do we need TIC? • What did the psychometrics tell us? • Vicarious trauma and staff wellbeing– why are we all burnt out? • Understanding why we & our ward can trigger someone's trauma

DAY 2 • • Compassion, building on what we have Patients narratives (hard hitting) 3 stages of trauma work (focus is safety) Skills Training Incident reflection Stages (passport system) Implementation

CORE STABILISATION SESSIONS • • RUN TWICE PER DAY- NO DEVIATION MIXTURE OF DISCLIPLINES CO PRODUCED STAFF SIGN THE SKILLS SHEET RE ATTENDENCE AND PARTICIPATION • ATTENDENCE IS ENCOURAGED FOR 1 SESSION PER DAY • ENGAGEMENT IS EXPLORED IN MDTS • ENGAGEMENT IN SESSIONS = INCENTIVES

• • • • STABILISATION INTERNAL SAFETY Emotional awareness Emotional regulation Emotional containment Emotional normalising Emotional expression in a positive way Secure compassionate relations Developing a set of skills for interpersonal effectiveness Awareness and management of triggers Mindfulness Physical exercise Art therapy Spiritual discussion/expression Investment between all parties Healthy eating Encouragement/positive reinforcement

• • • • STABILISATION EXTERNAL SAFETY Safe environment Stable routine Consistency in rules Limited deviations Structure and routine Similar staff structure All MDT working together Shared journey a space for patients to feel valued Occupational Therapy Routines for each patient (unchanged) Reduce incidents/impact of them Debrief for all

7 DOMAINS OF SKILL DEVELOPMENT MINDFULNESS GROUNDING EMOTIONAL REGULATION DISTRESS TOLERANCE INTERPERSONAL EFFECTIVENESS MEANINGFUL ACTIVITY (art, music) OT/GROUPS/GYM/EXERCISE/PEER CONNECTION/RECOVERY COLLEGE

INCIDENT REFLECTION • TO INCREASE REFLECTION AND TRY TO HELP UNDERSTAND REDUCE CONSTANT CYCLE OF INCIDENTS • TO CREATE A SPACE FOR STAFF AND PATIENTS POST INCIDENT TO TRY TO UNDERSTAND WHAT HAPPENED AND WHAT THE FUNCTION OF THIS COULD BE • TO BUILD COHESION AND OPPORTUNITIES FOR COMPASSIONATE & CORRECTIVE EXPERIENCES

SUPERVISION • STAFF – WEEKLY TRAUMA/COMPASSION FOCUSSED • STAFF 2 WEEKLY CAT RELATIONAL SUPERVISION • ALTERNATIVE TO DEBRIEF • SERVICE USERS – AD HOC WITHTHOSE WHO FELT THEY NEEDED IT POST INCIDENT • STAFF OFFERED 24 CONTACT TO ALL WHO MAY HAVE BEEN AFFECTED BY INCIDENTS – CONTACT NURSE

SWEMWEBS Differences in SWEMWBS average metric scores across time 30 26, 74 25 19, 67 Metric score 20 15, 39 15 SWEMWBS average metric score 10 5 0 Baseline Midpoint Timepoint Endpoint

ESSEN Differences in average ESSEN scores across time 40 37, 3 37, 1 35 30 Average score 25, 5 25 20 Average ESSEN scores Score 15 10 5 0 Baseline Midpoint Timepoint Endpoint

ESSEN SUBSCORES Observed differences in ESSEN subscales across time 18 16, 7 16 14 12 Average t-score 13, 8 12, 8 13, 2 11, 2 10 10, 5 9, 5 8 7, 8 6 5, 8 Patient Cohesion Experienced Safety Theraputic Hold 4 2 0 Baseline Midpoint Timepoint Endpoint

PROQOL Changes in average compassion satisfaction scores over time 49 50 49 48 46 Score 44 42 41 40 38 36 Average baseline Average t-score midpoint t-score endpoint t-score Timepoint Compassion satisfaction

PROQOL Changes in average staff burnout scores over time 70 60 50 62 55 42 Score 40 30 Burnout 20 10 0 Average baseline t- Average midpoint Average endpoint score t-score Timepoint

PROQOL Changes in average secondary traumatic stress score scross time 64 64 42 Score 70 60 50 40 30 20 10 0 Secondary traumatic stress Average baseline tscore Average midpoint tscore Timepoint Average endpoint tscore

DATA OUTCOMES Number of DATIX incidents recorded from February 2018 to Sepetmber 2018 70 Number of incidents 60 50 40 30 20 10 0 Feb/March/April/May May/June/July/Aug Aug/Sept Deliberate self-harm 54 60 57 39 30 27 28 Violence against object 10 17 23 16 4 14 6 Violence against patient 8 6 10 2 1 2 0 Violence against staff 8 0 5 2 2 14 8

SDG MEETING

ROLL OUT

ASSESSMENT & SCREENING

FORMULATIONS

TRAUMA INFORMED CO PRODUCED PLANS

STAFF WELLBEING

TRAINING

PHYSICAL INTERVENTIONS • TO REVIEW THE CURRENT CURRICULUM FOR MOVA AND ENSURE IT IS TRAUMA INFORMED • TO ENSURE ALL PATIENTS HAVE ADVANCED DIRECTIVES IN PLACE AROUND CRISIS PLANS AND USE OF PHYSICAL INTERVENTIONS AND MEDICATION /RAPID TRANQ • TO ENSURE ALL TRAINING AROUND PHYSICAL INTERVENTIONS IS CO FACILITATED AND PRODUCED • TO ENSURE STAFF UNDERSTAND THE BALANCE BETWEEN MANAGING RISK AND TRAUMA INFORMED INTERVENTIONS

CO PRODUCTION

PHYSICAL HEALTH INTERFACE • TO HAVE SYSTEMS IN PLACE FOR IMPROVED COMMUNICATIONS BETWEEN PHYSICAL HEALTH AND WARDS • TO HAVE SCREENING IN SITU FOR FREQUENT ATTENDERS TO HEALTH CENTRE • FOR PHYSICAL HEALTH STAFF TO BE TRAUMA INFORMED • TO REVIEW CURRENT PHYSICAL HEALTH PLANS AND AGREE HOW THESE CAN BECOME TRAUMA INFORMED

INFORMATION AVAILABILITY AND ACCESSIBILITY • PARIS SYSTEM TO BE ADAPTED TO INCLUDE TRAUMA HISTORIES CLEARLY • SHARED DRIVE FOR SECURE SERVICES (CORE SKILLS, TRAUMA STANDARD PROCESSES, SCREENING TOOLS, ASSESSMENTS (INCLUDE COMPLEX TRAUMA ASSESSMENT) • ADVANCED DIRECTIVES • CO PRODUCED NARRATIVES WITH TRIGGERS AND MODIFIERS FOR NEW STAFF OR BANK STAFF

ENABLING ENVIRONMENTS • TO DEVELOP AND SUTAIN A PLACE WHERE THERE IS A FOCUS ON CREATING A POSITIVE AND EFFECTIVE SOCIAL ENVIRONMENT AND WHERE HEALTHY RELATIONSHIPS ARE SEEN AS KEY TO SUCCESS. • THIS REQUIRES COMPASSION AND UNDERSTANDING AND IDENTIFICATION OF ISSUES IN A CURIOUS NON PUNITIVE WAY • THAT WE SEE ALL EXPERIENCES AS POTENTIALLY CORRECTIVE

WORK IN PROGRESS

DISCUSSION • QUESTIONS