Person-Centered ScreeningBarbara Ganzel PhD, LMSWIthaca College Gerontology Institute

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Brief Pause

To look at the trauma in the room

Ganzel 11.22.19

Based on SAMHSA, TIP-57 (2014) and Key, Kramer, Schumann, & Schiller (2019)

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Meet

Screening

Precautions

Universal Precautions for Trauma-Informed CareWhen the Team Knows Nothing About Trauma History & Triggers

Trauma-Specific PrecautionsWhen the Team Knows (or Guesses) More

Person-Specific PrecautionsWhen the Team Knows THIS PERSON’S

Clinically-Relevant Trauma Triggers

Requires Person-Specific Screening

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The Model

Trauma-Informed Care and the…

Trauma-Informed Organization

• Realizes the prevalence & impact of trauma

• Understands how to assess and treat the signs & symptoms of trauma

• Integrates this information into its policies and practices• To Prevent client re-traumatization• To Promote client/staff empowerment in a

culturally sensitive framework

SAMHSA: http://www.samhsa.gov/nctic/trauma-

interventions Ganzel 11.22.19 6

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Person-Centered Screening

•DIRECTLY or INDIRECTLY assess prior history of trauma

•Identify trauma-related triggers

•Identify trauma-related symptoms & behaviors

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• NOTE triggers/symptoms in clinical notes and review in team meeting Ganzel 11.22.19

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DIRECT Person-Centered Screening

• PAST EXPERIENCES, e.g., The Stressful Life Experiences Questionnaire or ACEs (packet)

• CURRENT SYMPTOMS, e.g., the PC-PTSD Screen

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When the individual has the competence and capacities of the average behavioral health client

Ganzel 11.22.19Chapter 4: SAMHSA TIP-57 (2014)

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DIRECT ScreeningCURRENT SYMPTOMS: The PC-PTSD Screen

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In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…

1. Have had nightmares about it or thought about it when you didn’t want to? YES / NO

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO

3. Were constantly on guard, watchful, or easily startled? YES / NO

4. Felt numb or detached from others, activities, or your surroundings? YES / NO

Prins et al. (2004). Public domain.

Advantages• Short• Non-specific• Non-threatening

(to screener)

Disadvantages• Non-specific

(respondents will not be cued to remember)

• One definition of trauma

• No ACEs

NEED EXAMPLESCombat, Sexual Assault, Mugging, Death of a loved one, Serious Illness or Treatment …

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CURRENT SYMPTOMS: The PC-PTSD Screen

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In your life, have you ever had any experience like that was so frightening, horrible, or upsetting that, in the past month, you…

1. Have had nightmares about it or thought about it when you didn’t want to? YES / NO

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES / NO

3. Were constantly on guard, watchful, or easily startled? YES / NO

4. Felt numb or detached from others, activities, or your surroundings? YES / NO Prins et al. (2004)..

“We need to talk briefly about stressful things that may have happened to you in your life -- for example, military combat, a sexual assault or mugging, the death of a loved one, serious illness or intense medical treatment, being parted from your parents when you were a child.

Is that ok?” (if they say no, back off but note it)

If yes - Are you ok with sharing what has been bothering you lately?

(if they say no, back off but note it)

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● DO respond with validating language. For example, “I’m really glad you told me – this will help us take the best possible care of you.”

● DON’T try to investigate or ask for details right away -- but let them talk about it. ● If they are getting upset or seem to be going deep into disturbing material, gently

close the conversation and follow up with a clinical referral right away.

● DO document any reported traumas and inform the clinical team. Include all known or suspected triggers associated with the disclosed experience. This helps the team avoid those triggers.

● DO tell the resident that you will need to let a few key staff members know about “what happened” so that staff can avoid doing things that raise difficult memories.

● DO refer to the disclosed experience in general terms. Avoid naming “what happened” unless the resident defines it in a given way.

● DO tell the resident know that they won’t need to talk about “what happened” if they don’t want to -- but they may find that they do want to talk about it as time goes on. Let the resident know that there can be someone for them to talk to if and when they are ready, including right away. Follow up.

● DO uphold the resident’s privacy, even if the information is unusual.

● DO assess current safety. Was it a recent event or far in the past?

adapted from Onyejiaka (2018)

If a resident discloses something

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Barriersto Direct Screening

• Not enough time

• Not part of standard intake

• Underestimation of the impact of trauma

• Not knowing how to respond to client’s report of trauma

• Fear that trauma inquiry will be too disturbing to the

client

• Concern that client will require treatment that the

program cannot provide

• Untreated trauma symptoms of the screenerSAMHSA (2014). TIP-57, p. 100

RememberThey have probably been living with this for a long time

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JackStage 4 bladder cancer. Bladder removed. Poorly controlled pain. Fatigue. Nightmares & depression

More – Jack is a 93-year-old WW II (Pacific Front) vet. He was a gunner on a destroyer and later became a pilot in civilian life. His war and aviation exploits are a large part of his life story. His family has been concerned that his mood and energy level are declining. He cries easily now.

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JackStage 4 bladder cancer. Bladder removed. Poorly controlled pain. Fatigue. Intermittent delirium. Nightmares & death anxiety.

During the PC-PTSD screening, Jack revealed that he was depressed and upset and is having nightmares about a combat trauma. He was manning his antiaircraft gun fending off an attack of Japanese aircraft, when one flew close enough for him to see the pilot's face at the moment before he shot him down.

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Person-Centered Screening

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WHUPS!

What if the resident DOESN’T have the competence and capacities of the average behavioral health client

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There’s decreased capacity due to illness, fatigue, pain, delirium, cognitive impairment, or distress

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INDIRECT Screening

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• In plan of care, identify all potential trauma symptoms and triggers.

• During intake and day-to-day care, pay attention to comments or behaviors that could indicate symptoms of traumatic stress or trauma triggers

• After trust has been established, ask permission to discuss previous comments.

• If there are indications of traumatic stress, ask if they want to speak to someone about that. If they do, make a referral. If not, make a note.

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• Begin where they are: “How’s your

life?” “What’s important to you today?”

What’s different?

• Assess current stressors/traumas/symptoms• Chart; interdisciplinary team; maybe family• Patient interview: “How’s your life?”

• Assess and address current concerns first

• Assess lifetime trauma, adversity, triggers• Directly, for some; INDIRECTLY, for many

• Patient interview or Cautious life review

• Assess capacity : cognition, illness, prognosis• Chart; interdisciplinary team; maybe family• Patient interview

Ganzel 11.22.19 17Capacity determines strategy, not exclusion

INDIRECT Screening

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Re-Experiencing • Unwanted upsetting memories

• Nightmares

• Flashbacks

• Emotional distress @ trauma reminders

• Physical reactivity @ trauma reminders

Trauma-Related

Arousal/Reactivity • Risky or destructive behavior

• Hypervigilance/Heightened startle

• Difficulty concentrating

• Difficulty sleeping

• Irritability or aggression

• Generalization of trauma triggers

to panic and phobia-like behavior

Avoidance• Trauma-related reminders

• Trauma-related thoughts or feelings

• Emotional & social demands

Negative Thoughts/Feelings • Overly negative thoughts about

oneself or the world

• Inability to recall key features of

the trauma

• Exaggerated blame of self or others

about the trauma; Preoccupation

• Negative affect

• Decreased interest in activities

• Feeling isolated

• Difficulty with positive feelings SAM

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Know These Signs & Symptoms of Delayed Reaction to Trauma

Physiological Symptoms of Stress (post-trauma or current stressor)

++ pain, muscle tension, headache, teeth grinding, ++ blood pressure, ++ heartbeat,

increased or decreased appetite or sleep, ++ urination, diarrhea/constipation,

nausea/stomach ache, tremor, dry mouth/difficulty swallowing, ++ somatization

REMEMBERTriggers Can Be

• Multi-sensory (sight, sound, smell, taste, touch)

• Inner and outer physical sensations (e.g. heat, pressure, constriction, belly ache, bowels)

• Memories, thoughts or images

• Emotional states (e.g. fear or helplessness)

• Situations (e.g. being crowded or immobilized)

Ganzel 11.22.19 19Adapted from Anderson, Ganzel, Janssen (2018)

Identify Trauma Triggers

Casting a Wider Net of Awarenessmedical care loss of meaningful roles and routines impaired physical function emotions of self or others cognitive impairment ruptures in personal boundaries falls relocation/institutionalization hospitalization being stuck in bed pain, shortness of breath, racing heartbeat, gastric distress, physical weakness, difficulty swallowing loud noises medication effects physical examination smells nightmares direct personal care; e.g., being touched, dressed/undressed, toileting differentials in power being naked in front of others strangers looking down at you in bed the dark troubling thoughts - “I’m alone”; “I’m not safe”; “I’m going to die”; “I’m a burden” times of year associated with painful events difficult conversations, e.g., about needing help with personal care, treatment planning, disease progression, hospice care, funeral arrangements life review death, loss, separation impaired communication or inability to make needs known loss of independence and increased dependency loss of privacy a sense of being under threat loss of meaning and/or control being treated or talked to “like a child” impairments in visual or auditory acuity... Janssen (2018)Ganzel 11.22.19 20

In Indirect

Assessment:

You are the

Detective

When assessing

and trying to understand

a resident’s “behavior”

Could it be related to a trauma?

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ARE YOU SEEING CLUES THAT SUGGEST there are TRIGGERS? ARE YOU SEEING SYMPTOMSof traumatic stress?

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EnidMid-to late-stage Alzheimer’s. Language deteriorating. Has become combative during personal care.

More - Enid has had an appropriately playful and teasing relationship with a young caregiver and loved bantering with him as if he were a grandson, according to her daughter. As her dementia progressed, she has become far less verbally expressive and has begun to exhibit what seems like rage when the caregiver whistled while performing his duties.

Medical check - revealed little change in Enid’s medical condition and no obvious physical cause for her behavioral changes.

Next - Staff reached out to the family to see if there may be a reason that whistling may be triggering for this resident.

EnidMid-to late-stage Alzheimer’s. Language deteriorating. Has become combative during personal care.

When asked, the daughter reported that Enid had been molested by an uncle as a young girl, and that he whistled as he did so.

Enid’s usual coping skills were less available as her dementia progressed. As she faced a more confusing and unfamiliar world, a man entering her darkened room whistling while she lay in bed was frighteningly familiar (a trigger) and re-traumatizing.

Solution = Avoid the Trigger. The caregiver stopped whistling around Enid and adopted a softer, quieter approach that once again left her smiling and laughing when they interacted.

Case courtesy of Carla Cheatham

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ShirleyCHF and COPD with 24-hour O2, significant frailty, and spinal stenosis. Wheelchair-bound. Recently, Shirley has stopped sleeping at night. No significant dementia.

More: Stays up until daylight watching TV in the living room or sitting in the hall closest to where staff congregate. If she is made to stay in her room, she turns on all of the lights and wakes up her roommate. Napping on and off during day. Less participation.

Medical check: No significant increase in pain. Staff reports she has become incontinent at night. No significant other changes.

Staff are getting frustrated.

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Late at night, in talking with a trusted staff person, Shirley said that she’d been thinking a lot about a puppy she had as a little girl.

She loved that puppy.

But one day, it peed on the floor and her mother told her father to take it out and shoot it. Which he did.

Life Review Can Be Tricky

“Thoughts about mortality and impulses to look back on one’s life may uncover painful memories of trauma that trigger feelings of sadness, fear, or vulnerability.”

Trauma-Informed Care http://www.todaysgeriatricmedicine.com/news/ex_022719.shtml

Scott Janssen MA, MSW, LCSWUniversity of North Carolina Hospice

Chapel Hill, NC.

Slide courtesy of Paige Hector

Benefits of Life Review

• Meaningful aspects of one’s life

• Lessons learned

• Accomplishments

• Challenges overcome

• Legacy

• Therapeutic value: improve mood, foster enhanced sense of meaning and purpose, strengthen sense of connection with others, fortify a sense of life having been worthwhile

• Can be a source of healing, perspective and even transformation if done sensitively in a trauma-informed way

Life Review – Therapeutic Opportunity by Scott Janssen, MSW, LCSW https://www.socialworktoday.com/archive/exc_1217.shtml

Slide courtesy of Paige Hector

Life Review Can Also Turn Up Posttraumatic Wounds

• Places of pain, self-doubt, or issues about meaning, regret, grief, or shame

• Person can become overwhelmed by emotions, intense physical sensations

• “Simply inviting the sharing of such memories can easily escalate into difficult-to-manage emotions, feelings of being overwhelmed, even retraumatization.”

Life Review – Therapeutic Opportunity by Scott Janssen, MSW, LCSW https://www.socialworktoday.com/archive/exc_1217.shtml

Slide courtesy of Paige Hector

“Anyone doing this kind of life review must be familiar with the dynamics of posttraumatic stress

and ways to help the person stay grounded.”

• Shirley did not connect her own incontinence with her puppy’s. • She did not fear that the staff would shoot her.

Trauma doesn’t go away just because we get older

• BUT she was still distressed and she was staying up all night to be sure that she would use the bathroom properly

• It wasn’t working very well, which made her more anxious

JUST KNOWING ABOUT THE PUPPY helped the staff feel

less frustrated and think more productively about ways to help.

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MortyDouble amputee with Type 2 diabetes. Well-liked by staff. Has three children in the area. None visit or are involved in care.

More – during a phone confrontation between a frustrated staff person and one of Morty’s children, the adult child told the staff person that Morty had sexually abused all three children, which was why they did not visit Morty nor engage in his care. Nor would they.

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MortyDouble amputee with Type 2 diabetes. Well-liked by staff. Has three children in the area. None visit or are involved in care.

The staff person reported this to her clinical supervisor, who now has a lot to think about:

• Is Morty a threat to other residents?

• Should she add this information to Morty’s medical record, where it may be seen by other clinical staff? The concern is that someone may react punitively to this resident (especially if they have their own history of trauma)?

• Morty may himself be a survivor of sexual trauma and may need support as such.

Based on SAMHSA, TIP-57 (2014) and Key, Kramer, Schumann, & Schiller (2019)

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Meet

Screening

Precautions

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