In recent years, there has been a proliferation of attention paid to trauma-informed care. It is not surprising then, at least for our area of New York, that I “grew up” in professional families in which trauma work was spotlighted. I was an extern at a residential facility that had a trauma-sensitive milieu, earned an internship at a hospital with a dedicated trauma track, and currently work under the leadership of a child psychologist who is the recipient of a Category II NCTSN grant. Often, psychology trainees rotate onto the short-term adolescent inpatient unit where I work gung-ho to use their newly learned trauma education and skills on their adolescent inpatient cases.
It is in this context that I frequently consider how we can increase trauma-informed care in this setting. This is with good cause as numerous studies have documented the high percentage of adolescent inpatients that present with exposure to potentially traumatic events (e.g., Havens et al., 2012; Lipschitz, Winegar, Hartnick, Foote, & Southwick, 1999; Weine, Becker, Levy, Edell, & McGlashan, 1997), as well as those that meet actual or likely criteria for a Posttraumatic Stress Disorder (PTSD) diagnosis (Koltek, Wilkes, & Atkinson, 1998; Havens et al., 2012). In fact, we have had numerous patients present to the unit feeling as though their trauma history is at the core of their symptom profile and to not address it is incredibly invalidating. As many trauma treatments require a narrative and all are based on the foundation of a stable therapeutic relationship, a short-term inpatient unit is not the ideal place for this work, so we initially focused our attention on a specialized group therapy program for survivors of various forms of trauma based on the SPARCS protocol (DeRosa et al., 2006). Our experience was that, despite creative problem-solving around how to market and engage patients in the group, it was poorly attended. When we did have regular participants, the patients repeatedly found trauma-specific psychoeducation to be activating as they did not anticipate doing this kind of work during their hospitalization. When we pulled trauma-specific content, we were left with a generic skills group. Despite valiant efforts, we were left resigned: To continue to use our trauma expertise in this setting just causes us more frustration. I guess this just isn’t the place to do trauma work. Or is it?
Focusing on the fact that we “can’t do trauma work” in an acute-care hospital was not helpful to our patients or ourselves as staff. While they are multiple models of trauma-informed care that apply to systems (Attachment, Self-Regulation and Competence [ARC] model, Blaustein & Kinniburgh, 2018; Sanctuary Model, Bloom, 2010), there does not appear to be a well-articulated resource for how cases of adolescents with a trauma history are “handled” on an inpatient unit. The following paragraphs represent an effort to articulate what we are doing that seems to be working well and the hope that sharing it provides guidance for others.
Fostering a Trauma-Sensitive Unit
Psychological safety is promoted in a number of ways. One component includes the use of safe language. We frequently found that patients introducing themselves during our morning Community Meeting or discussing their history in group therapy would use explicit language to describe their maladaptive behaviors. Frequently hearing peers talk about behaviors such as suicide attempts, substance use and purging only seemed to reinforce, and potentially glorify, such behaviors, while possibly triggering some patients. As such, we have adopted the term “MUPs” from the SPARCS manual (DeRosa et al., 2006). MUPs, or Mess-You-Ups, refer to behaviors that seem to be effective in the moment to reduce emotional or behavioral dysregulation but cause additional difficulties later on. We have been effective in promoting a culture shift in which patients announce “I came in for a MUP” or tell a staff member “I MUP-ed” when discussing these behaviors within the community, and reserve a more nuanced discussion for more private patient-staff conversation. A second component relates to unit rules explicitly prohibiting any form of “PC” (peer contact) including hugs and high-fives. Many patients complain about the unfairness of this rule as they wish to express themselves physically after establishing close peer relationships during this sensitive time in their lives (e.g. hugging a discharging patient). However, most patients are able to understand the rationale behind the rule when reminded about the fact that many people are not comfortable with touch (experiencing or witnessing it) based on their prior experiences. Patients are encouraged to find alternate ways of expression (e.g., air-hugs, using their words, making bracelets for each other during an art group). Psychological safety is also promoted through a tight unit structure that blends therapeutic activities, school, leisure activities and family visiting with time for meals and hygiene. Once patients leave their rooms in the morning, their doors are locked and they are expected to follow the day’s programming. Many patients have complained that they prefer other local hospitals where they can “hang out” and “be left alone;” however, our experience has been that structure promotes predictability and safety, and serves as behavioral activation for our patients.
Physical safety is promoted in a number of ways. The most salient ones related to establishing a trauma-sensitive unit involve the use of Coping Cards, behavior plans and coaching to decrease unsafe behaviors and reduce the use of restraints or other physical interventions. Coping Cards are a fancy name for index cards on which patients write their go-to coping skills on admission and add additional skills as they learn them in individual and group therapy. Having the skills written down provides a concrete reminder when they are too dysregulated to think straight and also allows all staff (not just the primary therapist) to intervene effectively. Similarly, coaching refers to attempts to verbally de-escalate patients and avoid use of physical interventions. Since the implementation of our DBT program, all staff on our 24/7 shifts combine validation, problem-solving and skills training along with verbal de-escalation. Finally, specialized behavior plans are frequently used with patients who require increased reinforcement to display more adaptive behaviors. These combined efforts, in addition to hopefully reducing restraint use and the loss of control experienced by patients during physical interventions, also serve to help patients establish a greater sense of self-efficacy in maintaining safety.
Focus on Staff Awareness and Support
Working in a fast-paced setting with youth all presenting with safety concerns is tough on a regular day. In the extreme, such work can contribute to secondary traumatic stress or more generalized burnout. As such, we take care to promote trauma awareness and resiliency in our colleagues. As staff, we consider the relation between trauma and maladaptive behavior, as well as the effect of pejorative language (e.g., “manipulative”) on our ability to optimally work with our patients. Staff members from all disciplines, including front-line staff, are encouraged to join our daily Team Meetings so they can have greater insight into the potential reasons for a youth’s particular behaviors, triggers and more appropriate ways to work with him/her. We encourage impromptu huddles of the primary team when facing a challenging issue (e.g., should a youth have fewer consequences for a maladaptive behavior if it was partially influenced by the youth’s trauma history). This promotes shared responsibility for the decision-making and ensures that no one who is either too stringent or too lenient makes the majority of decisions on the case. We make special effort to coordinate care with the on-site school teachers as behavioral difficulties frequently play out in that setting and it is important to ensure that teachers are providing coordinated care. Finally, we support each other through debriefs after critical incidents, light-hearted lunches and festive parties when there is good news to celebrate. Never underestimate the power of mindful eating!!
Working with Individual Patients
Conceptualize Your Work as Beginning Trauma Treatment
Frequently, we felt as though we were avoiding trauma work. We repeatedly told the same patients who were readmitted over and over that they could “do the trauma work” when they stabilized with a longer-term outpatient provider. However, we realized that we were essentially saying that they may have to wait to do the narrative component elsewhere. Often in individual therapy, we were hitting on the core components of early trauma work: engagement, psychoeducation about trauma and its sequelae, and skill-building. Having a rich milieu, an interdisciplinary treatment team and time to observe patients also allows us to put on our “detective hats” and refine hypotheses about how trauma is at play. As passionate advocates for trauma-informed care, telling ourselves that there was no room for trauma work at our level of care was incredibly frustrating, and modifying this cognition allowed us to focus on what we could do here and do it well.
Know When to Dive In
At times, we do have patients for whom it seems appropriate to embark on a narrative component of treatment. Patients who met this criteria typically were: 1) known to our team based upon multiple prior admissions; 2) had traumatic stress symptoms that seemed to be underlying their current difficulties in functioning; 3) were stable with respect to safety concerns; and 4) would be staying on the unit a few weeks, typically while awaiting a next placement. For example, one patient was seen during her 5th admission in 6 months and it was clear that trauma-related symptoms related to a history of chronic sexual abuse were impacting her emotion regulation and ability to maintain safety. Anecdotally, it seems that completing a trauma narrative helped modify troublesome cognitions (e.g., “it was my fault”) and emotions (e.g., shame), and also helped her make meaning from that difficult experience.
Plan for Future Success
All our patients are assisted in creating personalized coping plans to help them anticipate how they will handle likely triggers they may experience post-discharge. For patients with a trauma history, their coping plans may be further personalized to include traumatic stress symptoms as well as trauma reminders, as well as more generic environmental stressors. These are reviewed in a safety planning session with the patient’s family. Care is taken to provide appropriate referrals for these patients, sometimes for trauma-specific care and other times for care targeting more acute symptoms, such as chronic suicidality or active substance use disorders. We also formulate discharge plans incorporating educational, in-home and child protective services providers where appropriate. A final component of our efforts to plan for future success involves educating professionals involved with the patient and family. We frequently see professionals who impress as well-intentioned but whose efforts are invalidating or detrimental. For example, some local schools tend to recommend home instruction to remove a youth from a school environment with bullying, which may serve to re-victimize the victim. We’ve also had numerous experiences with law enforcement personnel who pressure families and patients to discontinue their efforts to pursue legal measures against alleged perpetrators because they believe the patient will not be able to withstand the pressure of legal proceedings. Although both of these circumstances may be appropriate in some cases, our expertise in trauma allows us to potentially reshape these professionals’ preconceived notions and help patients/families weigh pros and cons of various courses of action.
Theodore Roosevelt once said “Far and away, the best prize that life offers is the chance to work hard at work worth doing.” Trauma work is hard and worth doing. I’m grateful as an inpatient psychologist to have the chance to be part of this prizewinners’ circle.
Blaustein, M., & Kinniburgh, K. (2018). Treating traumatic stress in children and adolescents: How to foster resilience through attachment, self-regulation and competency (2nd Edition). New York: Guildford Press.
Bloom, S. L. (2010). The Sanctuary Model: A Trauma-Informed Organizational Approach to Services for Traumatized Children and Youth. (Unpublished).
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. New York: Guilford Press.
DeRosa, R., Habib, M., Pelcovitz, D., Rathus, J., Sonnenklar, J., Ford, J., et al. (2006). Structured Psychotherapy for Adolescents Responding to Chronic Stress. Unpublished manual.
Havens, J. F., Gudino, O. G., Biggs, E. A., Diamond, U. N., Weis, J. R., & Cloitre, M. (2012). Identification of trauma exposure and PTSD in adolescent psychiatric inpatients: An exploratory study. Journal of Traumatic Stress, 25, 171-178.
Koltek, M., Wilkes, T.C., & Atkinson, M. (1998). The prevalence of posttraumatic stress disorder in an adolescent inpatient unit. The Canadian Journal of Psychiatry, 43, 64-68.
Lipschitz, D.S., Winegar, R.K., Hartnick, E., Foote, B., & Southwick, S.M. (1999). Posttraumatic stress disorder in hospitalized adolescents: Psychiatric comorbidity and clinical correlates. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 385-392.
Weine, S.M., Becker, D.F., Levy, K.N., Edell, W.S., & McGlashan, T.H. (1997). Childhood trauma histories in adolescent inpatients. Journal of Traumatic Stress, 10(2), 291-298.
Madeline McGee, Ph.D. is a Senior Psychologist on an acute-care adolescent psychiatric inpatient unit at the Zucker Hillside Hospital of Northwell Health in Queens, NY. She also holds an appointment as Assistant Professor of Psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Dr. McGee earned her Ph.D. in clinical psychology with a specialization in child clinical psychology in 2008 at St. John’s University, NY. She completed an APA accredited internship, child trauma specialization, at North Shore University Hospital and a postdoctoral fellowship in the child track at North Shore Long Island Jewish Medical Center (now known as Northwell), Zucker Hillside Hospital.