07/23/2012: New initiatives focused on customer service promise to transform the way everyone does business at CMHC. Trauma-Informed Care is one such initiative. It's a comprehensive approach to mental health care designed to maximize sensitivity to the people who walk in the door each day.
An estimated 90% of clients in public mental health settings like CMHC have trauma histories. In addition, research has shown that rates of trauma are high among people working in the mental health field.
Trauma-informed care encompasses everything including the physical environment, clinical encounters, organizational policies, and the quality of staff interactions—both with clients and with each other.
"The principles of trauma-informed care can be used in almost every decision we make at CMHC," notes CEO Michael J. Sernyak, MD. "This initiative will help make CMHC a more customer-friendly and recovery-oriented place."
"Trauma-informed care requires an organizational culture shift," explains Rebecca O. Wettemann, RN, MSN, Director of Nursing and co-chair of the CMHC initiative. "It starts at the front door, or during intake. You think about what questions you ask, how you ask them, where you ask them. You imagine what it is like for the patient."
What is Trauma?
The word covers a wide range of dehumanizing experiences—including child abuse and exposure to violence—in which individuals experience a profound loss of personal safety and trust.
The Substance Abuse and Mental Health Administration (SAMHA)'s National Center for Trauma-Informed Care website notes that "Trauma includes physical, sexual and institutional abuse, neglect, intergenerational trauma, and disasters that induce powerlessness, fear, recurrent hopelessness, and a constant state of alert."
Almost everyone has experienced at least one traumatic event. The ACE (Adverse Childhood Experience) score measures childhood trauma. (To calculate your score, click here). People with ACE scores of 4 or more have dramatically higher incidence of mental and physical health challenges and social issues. They adopt a range of health risks—including drug and alcohol abuse, smoking, self-injury, and violent, aggressive behavior—to ease their pain.
When care is "trauma-informed," it helps trauma survivors restore their sense of choice, power, and trust by creating an emotionally and physically safe environment.
Speaking to CMHC staff during a training session in June, consultant Raul Almazar, MA, RN, an expert on trauma-informed care, emphasized that in mental health settings, we must (1) assume that everyone has a history of traumatic stress; and (2) exercise "universal precautions" to prevent trauma from reoccurring.
Moreover, trauma-informed care recognizes that broader community issues—such as discrimination on the basis of race, ethnicity, culture, language and gender—can be part of an individual's trauma history. "We need to understand people's contexts," explained Almazar, "otherwise we're scratching the surface."
"An individual who lives in a neighborhood where he hears gunshots—that's trauma,” notes Edna Aklin, CMHC’s Director of Social Work. Through this initiative, she says, "We are becoming more sensitive and careful. We need to have a better understanding of what kind of trauma our clients have experienced."
History of Trauma-Informed Care at CMHC
For years, CMHC clinicians have known about the prevalence of trauma among clients. Debra Bloom, LCSW and Aqil Hashim, LCSW have long run groups for trauma survivors. They're among the few in-house experts on trauma and its pervasive impact on clients.
In 2010, a group of inpatient staff attended a three-day conference, sponsored by SAMSHA and The National Association of the State and Mental Health Program Directors (NASMHPD), entitled "Preventing Violence and Promoting Recovery Through Positive Cultural Change."
The experience, says Wettemann, was transformational. "It brought about a shift in our consciousness," she explains. "The conference was a catalyst that set in motion significant changes, including the creation of comfort rooms and other physical improvements in our inpatient living environments."
Impressively, restraint and seclusion episodes on the inpatient unit dropped 80% during the 2010-2011 fiscal year after trauma-informed practices were implemented.
A recent SAMHSA grant for New Haven-based agencies has made possible additional training and consultation opportunities for CMHC staff. In the spring, the Center-wide initiative was launched. Co-chairs Wettemann and Jenny Noia, LCSW have convened a large committee with representation from every department including inpatient, outpatient, acute services, peer services, public safety, communications, plant operations, and others. Working groups within the steering committee will be tasked with addressing specific aspects of the issue.
How Trauma-Informed Care Works
Trauma-informed care shifts the traditional paradigm of clinical practice. It's not a handbook of rules, but rather an ongoing process informed by a set of values and techniques.
According to Roger Fallot, PhD, a consultant to CMHC and other New Haven agencies through the SAMHSA grant, the core values of trauma-informed care are safety, trustworthiness, choice, collaboration, and empowerment.
Avon Johnson, LCSW, Director of Inpatient Services, says each patient will have an individual treatment plan that takes into consideration his/her trauma history. "Staff will have a much better understanding of how to interact with individual patients," Johnson explains.
Sensory Modulation
On July 18, Tina Champagne, Occupational Therapy Program Director for the Center for Human Development (CHD) Institute for Dynamic Living, offered a training on sensory modulation for staff on the inpatient unit. Sensory modulation incorporates a variety of strategies—such as music, rhythmic repetitive motion, and weighted blankets—to help patients calm down and avoid restraints. Patients in distress are given choices; they decide what works for them.
On the inpatient floor, the Comfort Room will be the primary place where sensory modulation is used. "It will help patients release stress and self-regulate," explains Johnson. "In the lower lounge, we’ll have more sensory elements too, like soft, soothing music during shift changes."
Raul Almazar outlined several proven approaches including simple narrative, emotional and physical warmth, Reiki, therapeutic massage, music and movement, and canine/equine interactions. CMHC is slowly introducing these alternatives to traditional care. Fourth floor patients now enjoy weekly visits with a therapy dog; yoga classes for CMHC staff are underway and are now being considered for people receiving services.
Aklin and Johnson agree that already, the principals of trauma-informed care have heightened the sensitivity of staff. "And not just with patients," notes Johnson, "with each other, too."
"There is great excitement and momentum," says Wettemann. She and Noia welcome input from everyone as they continue the journey toward a truly trauma-informed CMHC.
"It is our responsibility to educate CMHC staff from all disciplines and departments through workforce development in trauma-informed care," Wettemann concludes. "The more opportunities we provide for learning in all departments, the more positive outcomes we will have for those we serve."
If you have questions or ideas about trauma-informed care, please contact Rebecca Wettemann, Rebecca.Wettemann@ct.gov.