Establishing 'Safety" in TIC Programs for Clients, Staff, and Administrators

[Susan Salasin]

One of the core requirements for establishing trauma-informed care is the issue of establishing basic safety. The focus of such discussions is often centered on safety for clients - physical, psychological, social, moral, and intellectual - but often does not necessarily address the issue for staff and administrators. "Seclusion and restraint" is a set of responses and practices that visibly harms and diminishes those who are its recipients, but often may do so less visibly to the organization in which it is practiced. NCTIC welcomes your responses to this issue, and encourages you to share how you may have sought to address it in your own experiences.

[Natalie: MT Coalition Against DSV]

Most safety topics are indeed for the client. However, one of the most common concerns we hear when we talk to shelters about serving survivors of DSV trauma who also have a mental illness and/or substance abuse is the safety of the staff and others in the shelter. This is stigma and a strong need for education and collaborative efforts.

In our trainings, we discuss that those with mental illness are no more likely to be violent than any others and that the myth is propagated by the media. We discuss the ADA and FHA legal obligations and reasonable accommodations, but hear that the limited resources of staff and time are major issues as most of the shelters are not staffed 24/7 and they need funding to expand these services. Yet for confidentiality and advocate privilege, the data is not tallied such that a description of the magnitude of the issue can be given to potential funders... We discuss improving crisis response, de-escalation and motivational techniques and the use of screening tools for appropriate service referrals (versus "clinical" assessment) as well as medication concerns and behavior management tips. We have researched TIC. We give resources for best practice protocols and models.

Shelter policies tend to include strict "no substance use" while receiving shelter services. Rather, when such a client comes, they may put them in a hotel for a short period of time. Access to MH and substance abuse services are quite limited and have long wait periods. They too are under-staffed and under-funded. Great rural distances are a major barrier. Most of the shelters do not have therapists in-house and refer out with little to no follow-up. There are no written contracts or MOU's for services with these other providers. The result is a return to the offender or a falling through the cracks over and over.

Still the safety issue comes up due to fear and a lack of understanding. We encourage collaboration and MOU's with the nearest mental health and substance abuse providers and can provide TA to help them achieve this. We ask them to consider the above information and review their policies and practices to see what they can do to improve services to these clients. We ask them to follow-up and make sure that the client can truly access any referrals (transportation, childcare, etc). All of this is met with reluctance... We all know that social change is a slow process.

We are trying to address these issues and make any door the right door for access to appropriate services. We really appreciate tools like the "Beyond Labels" manual from SafePlace, Austin TX and the "Safe and Sober" Manual from Alaska's Coalition. We attend several mental health-related councils and state meetings to advocate for TIC; we would like the state to require their MH contracts to provide their services in a TIC manner.

We are just starting implementation in 2 pilot sites that works on all of the above with the DSV programs and Mental Health providers. Our Annual Conference this Sept is looking to bring in a TIC expert and we are talking with NCTIC to do so. I am attending the upcoming Dare to Transform Conference.

What else can we do? What other resources are available? I say "we" as an organization, but its really just one person...

[Susan Salasin]

Thank you so much for your very cogent and insightful response. The issues you have identified as barriers or blockades to better serve women who suffer both domestic violence and symptoms of mental illness are all very real and not very tractable without some policy changes at all levels of the system. What is seldom noted is that not only are domestic violence providers not prepared to accept women who may also appear to be mentally ill, but mental health providers are, by and large, not comfortable with women who are victims of violence. Neither group has had this "duality" highlighted as an issue for which appropriate steps should be taken because neither group has received training to guide them in what to do. Fear is one of the natural consequences of lack of understanding of a problem,and lack of training in how to respond to it.

What we worry about is that these women live in a kind of "no man's land" when it comes to services and treatment - neither domestic violence nor mental health accepts them into services. CMHS has supported some policy work by the Council of State Governments(CSG) in this area which defines many of these issues more precisely, and this work has been published by the DOJ's Office of Violence Against Women in a new monograph. This publication will be posted on Ning shortly, and a more comprehensive policy manual is under development by CSG about helpful steps that are being undertaken in various sites and programs around the nation that will also be available soon.

Establishing the safety that you talk about for people who work in domestic violence programs is very important, and we want to understand better - through training and other key types of assistance - how this can best be done. Both the women served and the people serving them must feel safety or moving to trauma-informed care is not really possible.

Thank you again for your personal contribution to our knowledge and discussion on this critical issue.

[Beth Filson]

I do believe that institutionalized violence has a negative impact on the organizations that utilize it for the purpose of control. The practice not only diminishes my humanity – as the person restrained or secluded – but the humanity of the health care professionals restraining/secluding me. What a terrifying contradiction – to believe that one is there to help, and what a terrible metamorphosis of soul to have to see violence as a form of “helping.” It seems to me that healthcare professionals involved in such practices - past or present - need opportunity to find healing from the impact of such sanctioned violence – but likely will not be able to until the issue is addressed as a system failure and not a moral failure. Healing and recovery in the context of abusive/control-initiated services can become a shared event. Thanks so much for this topic –
b

[Susan Salasin]

I would love to know if staff, when being hired to work in these settings, are ever advised that it is a condition of employment/job description to carry out seclusion and restraint activities, and/or if entering the hospital as a consumer/survivor information is provided that hospitalization includes these contingencies if one's behavior is very disruptive. Do you have any information about that?

[Beth Filson]

I don't know the answer to this question (new state) but will ask my colleagues working in this system. Likely it’s different in every state? The issue that concerns me is how the peer workforce comes in contact with such policies…as employees.

[Charlene Reeves]

I was in a trauma hospital which knew most of my tricks. Georgia hospitals can never dream of living up to RiverOaks Hospital in my opinion. Safety was spiritual, physical, moral, and mental which compassed the whole person. Physically I ran (dissociated) into a bathroom, turned off the light, and locked the door thinking or not thinking really just reacting to someone in the Isolation room which was never locked-beating the walls. The staff had a key to the bathroom, but they came in and held me and comforted that little child and came out in the end holding her hand. Needless to say the staff was numerous and well trained and actually loved me back to life. Safety had 3 levels: 1 Sit with a person and watch their every movements, 2 Allowing the person to walk around and go to trauma meeting, but always within sight of staff, and 3 Able to leave the building, but confined to a locked yard with pleanty of room.

[Charlene Reeves]

I haven't been back in the hospital for trauma issues even though I have been through a living hell for months. Family members who continue to abuse us along with others continually trying to show they're influence by proving the fact that I can't live without their daily control in my life yet it is always my fault for causing all the pain and trauma. I am so very tired of always being in the wrong and not being good enough yet while being told I couldn't do this and that I preceeded to do it and made an A & B. For me I was happy and that was all that mattered. To be continually put down I set a choice and now am paying greater consequences. I went to the local Gateway and offered to help them with my experiences in trauma education start a new and better help for consumers of Georgia. I'll call you......... Then I heard about the cost of the meeting $250 a person yet I was never called, yet the meeting never took place. The sad saga continues always caring so deeply for our consumers so much we will provide the very best training, hospitals, therapists, psychiatrists. So many promises so many failures. I'm glad that I serve a God that never failes me.