It is well established that traumatic events (i.e., experiences that threaten one's sense of integrity or survival) can be associated with a variety of psychiatric symptoms for which victims may seek mental health treatment. These symptoms include behavioral and emotional tendencies manifesting in self-injury, assault, suicide, substance abuse, impaired interpersonal relationships, repeated victimization, and pervasive disturbances of mood and self-esteem.
Research suggests that a substantial number of all men and at least half of all women treated in psychiatric settings possess a history of physical abuse or sexual abuse, or both. Data on children and adolescents in psychiatric settings suggest even higher percentages.
Failure to recognize, understand, and respond appropriately to a survivor's symptoms may result in services that do not meet the needs of the client, and may result in the client's re-traumatization (e.g., through unintended consequences of the use of bed restraints).
For all clients, and especially those clients with a history of trauma, assessment processes are needed to include the client in (i) identifying specific circumstances that elicit potentially harmful behavior, and (ii) understanding what responses can help the client de-escalate and avoid restraint.
These clinical Trauma Guidelines have been developed in order to assist clinicians with addressing these issues, and to provide guidance in meeting JCAHO requirements for identification and assessment of clients with a history of abuse or neglect (MHM 1995, PE.1.15).
The Trauma Guidelines were initially recommended by a task force focusing on clients with a history of trauma. However, because many of the principles (e.g., the assessment of clients and assessment forms described below) apply equally to all clients, the Trauma Guidelines have been broadened to apply more generally to all clients, except where explicitly indicated otherwise.
Assessment of Clients
As part of a facility's intake assessment process, staff should seek to determine from each client, from the client's record and, where necessary, from other treating clinicians the following information:
- whether the client has a history of being physically or sexually abused;
- what particular approaches or strategies will be most helpful to the client in order to reduce agitation and distress, and avoid using restraint or seclusion;
- what kind of restraint or seclusion, if needed, would be most helpful and least traumatic for the client; and
- the gender of staff, if available, who should administer and monitor restraint or seclusion, if used.
For children who are too young or unable to provide this information, much of the information may be available from parents or guardians, rather than from the client directly.
Two assessment forms are available in PDF and Microsoft Word formats, and may be downloaded from the bullets below:
- Trauma Assessment for DMH Facilities/Vendors(PDF)
- De-Escalation Form for DMH Facilities/Vendors(PDF)
These forms are provided by the Department of Mental Health (DMH) for guidance (not necessarily for use in their present formats) to assist clinicians in gathering information that may be relevant to (1), (2), (3) and (4) above. As in all assessment processes, information obtained through the forms should be reviewed by the treatment team to determine its clinical relevance and then incorporated into the client's treatment plan.
In order to assist the facility to consider new approaches, it may be helpful to use the forms to elicit client preferences for interventions not currently offered by the facility (e.g., pounding clay, strenuous exercise or use of a papoose board). But, if certain suggested client preferences (e.g., having a hug) are not consistent with the facility's clinical policies, these preferences should be dropped from the form.
Both forms are written so that they may be completed either by the client or by staff. If a program chooses to have the client complete the form (e.g., because this may enhance disclosure), staff may need to review the client's responses and make appropriate inquiries to clarify and/or expand upon the answers given on the form.
In order to minimize the likelihood of traumatizing a client (or re-traumatizing a client who is an abuse survivor) through restraint, facilities and programs should seek to identify and have available a variety of interventions so that the option most helpful and least intrusive for a particular client may be used. Mechanical restraint requiring the client's legs to be spread apart should not be used on a client with a history of sexual abuse, unless client preference or practical necessity dictates otherwise.
A client who is menstruating should be given the opportunity to apply to herself fresh pads or tampons at least every 2 hours unless the client is a violent threat to herself or others.
Observation of a Clock
Clients in restraint should be able to either continually observe a functioning clock, or, be able to find out the time by asking staff in attendance.
Staff Persons in Attendance During Restraint
If the client has a history of sexual abuse, the staff person(s) in attendance during restraint should be the opposite gender of the perpetrator(s) of abuse, unless client preference or practical necessity dictates otherwise.
Training and Supervision
Staff should receive training and supervision, as necessary and appropriate, regarding (i) the prevalence of abuse survivors among DMH priority clients, (ii) the psychological, medical and behavioral consequences of abuse, and (iii) the spectrum of appropriate interventions.
This information is provided by the Department of Mental Health