NMDOH - NMBHI - Long Term Care - Trauma Informed Care

1. TRAUMA INFORMED CARE
Long Term Care Division
New Mexico Behavioral Health Institute
Prepared by Dr. Jeanne E. Knight, Ph.D.

2. WHAT IS TRAUMA INFORMED CARE?
Trauma-Informed Care utilizes knowledge of the
pervasive impact of trauma and promotes healing
and recovery rather than practices that may tend to
re-traumatize
Approach each person as if they may have
experienced trauma since exposure to various
traumas is very common

3. TRAUMA INFORMED CARE &
TRAUMA’S BRAIN EFFECTS

4. WHY SHOULD WE CONSIDER
TRAUMA?
• Trauma is widespread and impacts many of the people we work with including,
residents, patients, clients, and staff
• Trauma may influence how people respond to us or how certain communication is
received
• Being sensitive to the possibility of trauma helps us adapt our communications and
to understand responses so we do not take things personally and can have insight
into why a certain response might be given
• Sensitivity to people’s possible past traumas can set the groundwork for healing
• Adopting a sensitive approach in our communications with possible trauma victims
helps us to be more effective and gain better cooperation from those we work with

5. UNDERSTANDING TRAUMA
• What is it? A stress reaction to a threatening experience that can occur at any time throughout
the life span and can produce lasting problems for the individual.
• Neurobiology of Trauma:
• Impact on the ANS (Autonomic Nervous System)
• SNS (Sympathetic Nervous System) – Fight or Flight System responds to danger / safety threats with
increased adrenalin and cortisol levels, producing hyperarousal and hypervigilance while preparing the
body to fight or run from danger by constricting blood vessels and pupils, decreasing the blood flow to
the digestive system and increasing perspiration, as well as heart and breathing rates – all physiological
responses to increase likelihood of survival
• Or the body freezes by the process of dissociation - feels numb and disengaged (sometimes fainting)
with a perceived suspension of time and derealization, theoretically preparing the body for camouflage,
increasing the chance of survival through compliance with predator, and/or creating conditions in which
death is not as painful.
• Too much SNS stimulation has deleterious effects on the body and can lead to long-term changes in the
brain systems of memory and the stress response in some individuals.

6. CONSEQUENCES OF TRAUMA
• Self-soothing is a critical function of the right hemisphere that can be disrupted by
exposure to significant stress and trauma in the first years of life.
• Chronic arousal of the SNS fight or flight response can have a negative impact on
the development of the higher brain functions that control impulses and behavioral
response to strong emotions.
• Persistent hyperarousal may permanently alter the SNS adrenalin system; whereas,
persistent dissociation may alter the opoid (e.g., endorphins – the body’s natural
morphine) system.
• The state of arousal may become a more stable trait.
• Poor affect regulation and impulsivity are likely related to decreased cortical
modulation of the emotional response.

7. WHAT IS RE-TRAUMATIZATION
• System (Policies, procedures, “the way things are done”) • Having to continually
retell their story • Being treated as a number • Procedures that require disrobing •
Being seen as their label (ie. Addict, schizophrenic) • No choice in service or
treatment • No opportunity to give feedback about their experience with the service
delivery
• Relationship (Power, control, subversiveness) • Not being seen/heard • Violating
trust • Failure to ensure emotional safety • Noncollaborative • Does things for rather
than with • Use of punitive treatment, coercive practices and oppressive language

8. FOUNDATION TO POSITIVE COMMUNICATION
- Make sure things are appropriate for communication - quiet, good lighting, low distractions
- Get the person’s attention before you start.
- Position yourself where the person can see you as clearly as possible (e.g., with your face
well-lit) and try to be on the same level as the person, rather than standing over them.
- Sit close to the person (but not in their personal space) and make eye contact.
- Make sure your body language is open and relaxed.
- Have enough time to spend with the person. If you feel rushed or stressed, take some time to
calm down.
- Plan what and how to best communicate
- If there is a better time of day where person is more able to communicate, try to use this
time. Make the most of 'good' days and find ways to adapt on 'bad' ones.
Make sure the person's other needs are met before you start (e.g., they're not hungry or in
pain).

9. 5 PRINCIPLES OF TRAUMA INFORMED CARE
1. Safety – Ensure physical and emotional safety
2. Trustworthiness – Providers must be trustworthy. This can be demonstrated via
consistency of boundaries and clarity of expectations
3. Choice – the more choice an individual is offered, the more they will feel independent
and autonomous
4. Collaboration – Endeavor to collaborate with the individual rather than bossing them
around or ordering them to perform
5. Empowerment - strengths and empowering them to build on those strengths while
developing stronger coping skills

10. APPROACH
• Speak clearly and calmly.
• Speak at a slower pace and allow time between sentences for the person to process the
information and respond.
• Avoid telling and adopt an asking approach. Don’t speak sharply, raise your voice, or
order people around.
• Use short, simple sentences.
• Use a conversational approach, not question after question (it can feel like an
interrogation).
• Speak with respect and patience as you would like to be spoken to. Don't talk about the
person as if they are not there or talk to them as you would to a young child.
• Apologize for misunderstandings. Try to laugh together about misunderstandings and
mistakes. Humor can help to bring you closer together, Be sensitive to the person and
don't laugh at them or say what’s wrong with them.
• Include the person in conversations with others. Being included can help a person to keep
their sense of identity and feel they are valued. It can also help to reduce feelings of
exclusion and isolation.

11. WHAT TO SAY
• Avoid asking lots of questions or being too complicated. People with dementia can become
frustrated or withdrawn if they can't find the answer.
• Try to stick to one idea at a time. Giving someone a choice is important, but too many
options can be confusing and frustrating.
• If the person is finding it hard to understand, consider breaking down what you're saying
into smaller chunks so that it is more manageable.
• Ask questions one at a time, and phrase them in a way that allows for a 'yes' or 'no' answer
or ask if they would like to do something or offer limited choice s(eg 'would you like tea or
coffee?').
• Rephrase rather than repeat, if the person doesn't understand what you're saying. Use non-
verbal communication to help (eg pointing at a picture of someone you are talking about).
• If the person becomes tired easily, opt for short, regular conversations. As dementia
progresses, the person may become confused about what is true and not true. Try to find
ways around the subject and look for the meaning behind what they are saying, rather than
contradicting them directly. For example, if they are saying they need to go to work, is it
because they want to feel useful, or find a way of being involved and contributing? Could it
be that they are not stimulated enough?

12. LISTENING
• Listen carefully to what the person is saying and offer encouragement.
• If you haven't understood fully, rephrase what you have understood and check to see if
you are right. The person's reaction and body language can be a good indicator of what
they've understood and how they feel.
• If the person with dementia has difficulty finding the right word or finishing a sentence,
ask them to explain it in a different way. Listen for clues. Pay attention to their body
language. The expression on their face and the way they hold themselves can give you
clear signals about how they are feeling.
• Allow the person plenty of time to respond - it may take them longer to process the
information and work out their response. Don't interrupt the person as it can break the
pattern of communication.
• If a person is feeling sad, let them express their feelings. Do not dismiss a person's
worries - sometimes the best thing to do is just listen and show that you are there.

13. BODY LANGUAGE / PHYSICAL CONTACT
• Non-verbal communication is very important for people with dementia, and as their
condition progresses it will become one of the main ways the person communicates. You
should learn to recognize what a person is communicating through their body language
and support them to remain engaged and contribute to their quality of life.
• A person with dementia will be able to read your body language. Sudden movements or a
tense facial expression may cause upset or distress, and can make communication more
difficult.
• Make sure that your body language and facial expression match what you are saying.
• Never stand too close to someone or stand over them to communicate - it can feel
intimidating. Instead, respect the person's personal space and drop to or below their eye
level. This will help the person to feel more in control of the situation.
• Use physical contact to communicate your interest and to provide reassurance - don't
underestimate the reassurance you can give by holding the person's hand or putting your
arm around them, if it feels appropriate.

14. CRITICAL KEYS TO EFFECTIVE
COMMUNICATION
• Rapport - physical appearance, your level of eye contact with patients or how often you use
their names in conversation can impact rapport
• Explain – Listen to the resident and ask them to tell you what they need, Get them to engage
with you
• Show – show don’t tell or criticize, provide information and guide person
• Practice communication skills not just with residents but with colleagues and friends
• Empathy – don’t judge, encourage both verbally and nonverbally
• Collaborate – Partner with resident, let them know you are here to help, explain what you are
doing, identify barriers such as hearing loss, cognitive impairment
• Technology or other aids – use when appropriate, such as hearing enhancement, or visual
pictures, etc.
• Be Professional – don’t take things personally, maintain your cool, develop professional
distance, remember you are here to provide service to others, not to feel more powerful or
more important than others, manage your ego

15. QUALITIES OF COMMUNICATION
• Treat others like you would want to be treated
• Empathy – imagine yourself in theuir situation “Walk in another’s shoes”
• Empowering with Choice rather than telling or commanding
• Respect – Ask to enter or perform care
• Asking not Assuming or Judging – Don’t mind read others’ intentions
• Patience – Use self talk to calm yourself and let the urgency go
• Time for Communicating – Set aside some extra time to be social
• Using sensitive touch – With permission, a hand on a hand or shoulder
• Appropriate Silences and Allowing Time to Respond
• Clarification and Elaboration – Use simple sentences and one idea at a time
• Summary and Follow Up – Assure understanding and cooperation

16. NON-THERAPEUTIC
COMMUNICATION
• Asking invasive personal questions – Instead be respectful and don’t ask questions that you would not
want asked of you, you don’t need to know everything to help people
• Offering personal opinions or unrelated self-disclosure – it’s not about you, keep focused on the
resident’s needs
• Changing the subject - unless you detect emotional upset and redirection is appropriate
• Automatic responses / Generalizations and Stereotypes – Instead, engage with your resident and provide
them with your full attention
• False Assurances – Instead be genuine and indicate you aren’t sure but will try to find out, then follow up
• Sympathy – Instead be matter of fact and try not to give undue attention to undesirable behaviors
• Asking for Explanations – Instead accept that people don’t want to comply and explain why it is in their
interest to cooperate and offer choices
• Approval / Disapproval – If's not your place to judge
• Defensiveness – Instead don’t take things personally
• Passive or Aggressive Responses – Instead, try to answer questions courteously
• Arguing or “Smart Ass” Responses – Instead be genuine and helpful

17. IN DEMENTIA
• Body language, facial expression, and tone of voice are key - more important than actual words.
• Attend to Non-verbal Cues of Residents. Understanding feelings may be more important than the content.
Acknowledge feelings.
• Keep communication simple. Give one piece at a time. Make eye contact. Keep distractions down, for
example turn off the TV or radio
• Slowness in decisions. So provide choices, "Would you like spaghetti or hamburger for dinner?"
• Keep explanations short and simple. Ability to follow logic is limited.
• Don’t argue – it increases agitation. Walk away and calm down, then return.
• Give positive feedback often, especially for approximations of the desired behavior - shaping.
• Focus on things of interest to residents, as a way to maintain interaction with someone with memory loss.
• Agree with persons with dementia. Using a therapeutic (partial truth) approach can help you to gain
cooperation, for example saying you are going out for ice cream but stopping by for a doctor's
appointment before the ice cream. Rewards work.
• Use distraction /redirection if someone is repeating a question or becoming agitated.
• If instructions don’t work, show the person what you want them to do.
• People often can’t think of the words, like names of objects. Have the person point to or show you what
they are talking about or offer some options to select from.
• Call the person by name and identify yourself: "Hi “Jane”, it's me, “Mary."

18. SELF AWARENESS IN THERAPEUTIC
COMMUNICATION
• Professional Distance - Leave your ego out of it. Don’t take things personally - it’s not
about you!
• Check your feelings – Tone of voice and body language will transmit your feelings to
residents. STOP and adjust so you don’t communicate frustration, anger, fatigue,
impatience, etc.
• Avoid power struggles – disengage from power struggles and acknowledge the
feelings of residents by reflecting back to them a paraphrase of what they have said to
you.
• Keep it - accurate, brief, to the point, continuous, specific, and targeted to specific
person
• Have time for resident communication – pick a time for communication when you are
not rushed so the resident feels you have time for them.

19. TECHNIQUES: DO’S AND DON’TS
• Active Listening
• Silence
• Focusing
• Open-Ended or Multiple Choice
• Clarification
• Exploring
• Paraphrasing
• Restating
• Reflection of Feelings
• Providing Leads
• Recognition, Acceptance
• Summarizing
• Use Significant Self-Disclosure
• Challenge
• Probe
• Change the Subject
• Get Defensive
• Use False Reassurance
• Disagree
• Judge
• Reject / Minimalize
• Stereotype
Do Don’t

20. QUIZ TO FOLLOW
Please print out the quiz that follows. Complete it and
return it to LTC Administration for grading and to
document your completion of this training. If you are
unable to print the quiz, you may pick up a copy from
LTC Administration.