Truama Informed Care is a pipe dream in acute psych -Change my mind

[puravidaLV]

Rant post:

Its not a new concept but its becoming more injected into mental health care setting, but when the phd's get into the mix there is an unrealistic expectation from nursing staff and MHT staff. Its one of those avenues that sounds great with power point slides, but when the code goes down going back to the chart and referencing that one sheet on admission of "what helps you calm down" NEVER happens. Sorry folks the "i feel when you say" statements work great in group but when the individual is punching you from behind that TIC gets flicked.

I've worked now through the lifespan as it comes to mental health and I've been attacked through the life span as well. I watch RN come in get trained then never come back because they don't feel safe in the field of acute psychiatry. Its gotten to the point i laugh at the residents looking to me a 300lb RN to come follow them to feel safe...sorry i'm not your teddy of protection. Nothing has changed over eight years of dealing with this.

One facility for adolescents completely removed restraints for youths along with seclusion and required staff to do physical holds following the TIC model. It was counter productive since more staff was getting hurt doing holds (RN/MHT) because times would require >30 minute physical holds and transitioning would cause and opening for attacks. Those that were gun-ho on the TIC model of care were never around and always seen closing their door not giving two TICs about the patient or those on the floor doing the physical hold. BTW they got shut down for a while by the fed because of ..“has caused, or is likely to cause, serious injury, harm, impairment or death”. Not saying TIC was the cause but it sure didnt help, but physical holds are not better than mechanical restraints (feel free to to discuss).

Another facility took TIC to a new level of "woke" from pretty much banning anything that might "trigger" a patient. No news programs, movies went to a committee to be determined if ok for a patient to view basically making the individual avoid everything only to have reality hit again on discharge. The TIC Phd wanted to decrease seclusion and restraints. Staff being attacked left and right, management frowned on the attacked but not the attackers, and again that TIC phd closed their door at the first sign of trouble which again left RN/MHT to do the physical work with them coming out afterwards to critic the entire process, yet never lift a finger when they knew the fudge was flying.

If you're going to remove reality from the equation and attempt to make a utopia situation in a world that is avoided by the majority of society (USA) you're not going to even come close to getting to the gates of Disneyland.

None these facilities ever changed physically (safety environment which is stated a lot in the literature), policy (more removal of actual policies and no addition of reflective policies of this model except for the removal of reality from the unit e.g. local news), or care (addition of EMDR or other evidence based care).

Its mostly talk of administration office workers or people that run the other way when codes happen...TIC is a pipe dream.

Side note i do think a lot of the core concepts should be fundamental in pediatric and young adult, but as the age increases and the diagnosis become more complex its not; especially when care quality does not change in a medical model. Majority of psychiatric hospitals do not work on nursing committee style of policy making fairy tale they follow the you have a boss and clock in model.

[verene, MSN]

I think trauma informed care CAN be accomplished in the world of psychiatry including acute high acuity inpatient psychiatry because I've been a part of facilities taking this approach. One of the things you've noted is the active involvement of floor staff - MHTs and RNs in creating trauma informed care that actually works - ground level by in of approach is essential for this to work.

Running to grab a binder of "calm ideas" during a code is not trauma informed care - the moment has already passed. Those ideas should be disseminated to staff and utilized well before the code situation arises - because they are there to help PREVENT the code from occurring in the first place. Debriefing with both patient and staff to understand what led to the situation and how to prevent it happening again can bring things back to a more trauma informed place.

Nor is banning restraints and seclusion alone trauma informed - sometimes these ARE necessary for patient safety and the safety of other patients and staff. Manual holds for 30+ minutes are not safe for anyone -- if your facility thinks this is what trauma informed care is - then I'd say they aren't implementing trauma-informed care at all.

I work in an hospital (with some of the highest acuity psych patients in state) which utilizes trauma informed care and which sees problem solving as collaboration between team and patient - diving down to the heart of problematic behaviors and helping patients (and staff) gain to tools and skills to move beyond them. Since this hospital implemented trauma informed care (about 6 years ago?) our number of seclusion and restraints have plummeted - we are less than 1/3 the number prior to implementation and staff injuries have DECREASED by a similar number as well even as our overall patient acuity has increased.

[TCASII, ADN]

I mostly agree with the OP. I've worked in TIC facilities, and despite not fully knowing the ins-and-outs of TIC, the overall theme seems to be allowing patients to determine how their treatment plays out. In theory, TIC is good on paper. You work collaboratively as a team, thus including the patient in the care plan and treatment goals. This concept makes perfect sense when dealing with select patients who have specific disorders (e.g., hoarding, OCD, PTSD, MDD, eating disorders).

The problem is that most IP facilities are not treating true mental illness as a single Dx. I would say the number of cluster B (e.g., antisocial, borderline, narcissistic, histrionic) substance abusers is approaching 80%. These patients are highly resistant to treatment, and in most cases, do not want to improve. We're assuming that we can impart improvement in 7-10 days to sociopaths, and that's a fantasy. The TIC and recovery model I've encountered seems to put a high emphasis on eliminating seclusion, restraint, or even physical holds. Essentially, you are housing common criminals who spend a fair amount of time in jail or prison, but you have zero leverage for enforcing rules or preventing harm. My current facility has banned S&R and now only allows "standing" CPI-approved holds. The SW, and even AT department, have appointed CPI instructors, and they have been playing a heavy role in running codes. We had a patient in a hold, standing, and fighting aggressively, which was 100% necessary d/t this patient's attempt to assault staff. We were preparing to give IM medications and the SW coaxed the BHTs into letting the patient go. This patient went on to obtain a weapon and threaten staff with harm. This was partially avoidable had we been able to seclude and medicate this antisocial patient who voiced a desire to harm and was not mentally ill. After two events that were very traumatizing to staff, this individual was arrested; however, it took a monumental escalation to even get the police to take this person away.

The bottom line, is that allowing patients to have zero accountability for their aberrant behavior is detrimental to staff and patients alike. This type of free-will attitude perpetuates an atmosphere plagued with negative outcomes. I always ask people who think the patients should be self-directed - "Would you allow your child to run free without consequences?" I'm all for reducing holds and physical intervention, but in some cases it's unavoidable. I managed to rarely do physical holds in an involuntary unit for over one year, but in reality, the notion that you can avoid physical intervention and forced medications is ludicrous.

[hppygr8ful, ASN, RN, EMT-I]

I am actually a big proponent of TIC _ I first started learning about it when I went to an annual conference of the American Association of Psychiatric Nurses. I work almost exclusively with adolescents and when properly applied TIC can and oes work. As others have pointed out once a code is in action the opportunity for TIC interventions has passed. In our facility it is considered a treatment failure when staff has to put hands on a patient.

Two things have to happen for TIC to work. The nurse and MHT staff has to take time to get to know their patient's so that they are enacting TIC at all times. IF I see a patient who is moving towards crises I seek them out and ask "What's happening right now?" never "What's wrong?" or "What's wrong with you?" This gives the patient and open ended way to respond. This is never easy on a busy acute unit with 18/3 ratio (What I had today) but all staff are on the same page it goes a long way to preventing injury to staff and patients.

the 2nd thing is lots of training, rehearsing and teamwork so everyone know their role in crises intervention scenarios.

Hppy

[verene, MSN]

23 hours ago, TCASII said:

This concept makes perfect sense when dealing with select patients who have specific disorders (e.g., hoarding, OCD, PTSD, MDD, eating disorders).

....

The problem is that most IP facilities are not treating true mental illness as a single Dx. I would say the number of cluster B (e.g., antisocial, borderline, narcissistic, histrionic) substance abusers is approaching 80%. These patients are highly resistant to treatment, and in most cases, do not want to improve.

....

The bottom line, is that allowing patients to have zero accountability for their aberrant behavior is detrimental to staff and patients alike.

I think limiting trauma-informed care to only those with hording/PTSD/MDD/etc is limiting the abilities of this philosophy of intervention. I work on a forensic unit - my population is by and large those with severe psychosis, substance use, and personality disorders. Every patient I work with is alleged to have committed a crime - and has served at least minimal jail time - most are looking at more jail and/or prison time. This population can be very challenging to work with, but to write all of these people off as "not wanting to improve" is inaccurate. I think it is more reasonable to say - many have no idea of what improvement even looks like - and that is where trauma informed care comes in.

Remember that personality disorders typically require trauma exposure to form - part of treatment involves helping the patient make the connection between their trauma experience AND their behaviors/world view as adaptive to that previous environment -- with intensive work it *is* possible to reshape these maladaptive coping skills into something more adaptive.

Trauma informed care is NOT about putting zero-acountability on the patient. It is about treating people as human-beings - and helping them learn the necessary boundaries for functional life in society. If a toddler hits for attention we don't just let it be and move on - they may receive punishment but ALSO a discussion of WHY this is wrong and TRAINING of more adaptive tools (e.g. words) to reach their underlying need. This is the same in working with this adult population - what is the need that is not being met? How do we (both staff and patient) know that a need is not being met? What is a more pro-social means of having that need met? How to we empower the patient with these pro-social adaptive tools? What are consequences (that actually matter to the patient -- some patients don't care at all about being put into seclusion) if the pro-social tools are not being used?

I will agree that with someone who is very ill - there may not be as much trauma-informed work that can be done until their symptoms are more under control - and that sometimes seclusion and restraint ARE necessary. However, shifting our mind-set and treating patients as humans worthy of respect can and does effect change. I've seen it happen many times, on a couple of occasions it has wrought miracles. This approach may not be appropriate for, or work for every patient, but it CAN make a positive difference for many.