Mental Health Awareness and DeEscalation: PACER Integrative Behavioral Health

Foreign. Welcome everybody to today's episode of Integrated Behavioral Health. Today we're talking about mental health awareness and de escalation. And then at the end we're going to talk some about mental health hygiene. I AM your host, Dr. Donnelly Snipes. Now this presentation is really designed for the average person. For non clinicians, if you're a clinician, it's a, you know, hopefully will be old hat review. But a lot of people interact with loved ones or even people that they work with who are in crisis or who are starting to develop some level of mental health issue. So let's talk first about some signs of distress and these are not going to be surprising to you. Anger and irritability. Fear, depression, a sense of hopelessness and helplessness. Guilt, grief. I don't even have that one on here. Difficulty concentrating and insomnia. If you are dealing with somebody who is what we will call dysphoric, they are not in a happy place, then it's important to be aware that they may have something situational going on that's contributing to their anger or their irritability or their depression. Depression. However, there are steps that we can take to help them feel acknowledged and accepted and validated and supported. And when people feel that way, it often helps them to start improving the next moment. We need to recognize that dysphoric symptoms, your unpleasant symptoms represent an emotional reaction to, to a threat. You know, these symptoms are our body's way of saying, hey, something is not right in the hen house here. So we need to take a look at what's going on. And as I've talked before many times about this system that we have, our HPA axis mainly is not 100% accurate. It's like a smoke alarm that goes off when, you know, it thinks there might be a fire. Doesn't necessarily mean there is a fire. It could be that, you know, you put something on the, on the stove top and it's not catching fire, it's just smoldering a little bit and getting, getting smoky. Or in our house, for some reason, when there are really, really strong winds, our fire alarms go off. I don't know why, but when that happens, it's important to check that alarm is an indication. Not necessarily that or a fact, always a problem, but it's an indication that there might be a problem. And you need to check it out either way. When people are dysphoric, their HPA axis, their fight or flight response is activated. And it's important to recognize that that activates in response to a perceived threat. When we feel threatened, we often feel a loss of a sense of safety and control. We feel unsafe, disempowered, maybe unsupported. So you know, those are things that we really need to recognize. Maslow, Abraham Maslow, many, many, many, many years ago created this hierarchy of needs. And the base of the pyramid is our biological needs. We need food, we need water, we need medical care. The next level is safety. If we are hungry, if we are sick, if we are in pain, if we are not getting enough sleep and we don't feel safe, guess what? Working on things like relationships and self esteem and all that kind of stuff, that's kind of unimportant. So those, the things in the base level of Maslow's hierarchy are really important. And when people feel a threat, a lot of times that threat is to at least that safety level. People feel unsafe for some reason. Another reason people can feel dysphoric, unhappy is because of a loss of something that was important. When we feel depression, when we feel grief, sometimes that's our body saying, hey, that thing was really important and you're sad it's not here anymore. You know, it's not something that we can go go get or go do anymore. So that is an emotional reaction to a loss of control and a loss of something that was important to you. What we're really talking about today is the best way to try to interact with people who are in crisis or who are in a unpleasant state of mind. If somebody is irritable and you go at them and you tell them how they should feel and what they should do or just to let it go or whatever, it's probably going to make them feel more out of control and it's probably going to contribute to increased irritability. So some key phrases that can trigger people to be feel less supported and feel more threatened include things like I understand when somebody is really upset and you tell them I understand a lot of times their response is you have no idea. Or my least favorite is calm down. When someone is upset and they're in that fight orf flight mode, they're in their emotional mind, they want to calm down. If they could calm down, they would. At that point in time, they are feeling oftentimes very powerless, very threatened and very hyper vigilant because that threat is right there. It's important to help them figure out how to calm down, recognize that they're safe and then overt invalidation. When I was giving birth to my son, he was a micro preemie so, you know, we were rushed into the hospital and we were rushed into labor, and I, I'm sitting there, you know, trying to give birth, and I'm telling the doc, I can't breathe. And his response to me was, if you can talk, you can breathe, just push. And I was just like, oh, no, you didn't. But of course, I wasn't in a position to fight at that point in time. But my son is now 21 years old, and that is still something that is right in the forefront of my mind because that was so incredibly invalidating at that point in time. When people are in distress, we want to help them regain a sense of safety. That's the first thing. Help them get a safe sense of safety. And that may mean. Also mean helping them feel empowered to do things, to get themselves safe, helping them figure out what they can do to de escalate at that point in time. Instead of telling somebody, you need to calm down, talking with them and saying, I can see that you are really upset right now. And, you know, you're breathing so fast. I'm, you know, I'm afraid that you're going to get dizzy. I'm afraid you're going to pass out. You know, can we sit down? Or would it help if you took a deep breath? Tell explaining to them even that when you breathe deeply and in for four, hold for four, out for four, it helps trigger a relaxation response so they can catch their breath. You want them to breathe. You're not telling them that their hyperventilating is irrational. You're telling them you're worried about what's going on with them. You want to empathize and validate their current thoughts and feelings. Even if you don't agree they are in crisis. That is their reality at the moment. And coming in and telling them that their reality is wrong is only going to make them feel more attacked, more edgy. So it's important to empathize and validate with what they're going through right now, what it must be like for them. And so they can feel supported once. They. A lot of times, once people feel like you understand and you've got a clear picture of what's going on, they feel like you've joined with them against this threat or that you can be more supportive. So you can say things like, I can see that you are feeling angry. I can see that you are depressed, grieving, you know, I see it. It doesn't mean I feel it. But when I say that I can see that, then I am Validating. I am telling you I'm being responsive and saying I'm noticing how you feel. And the person will say, yes. Or they may say, you know, if you say it seems like you're kind of upset. And they may say, well, I'm way past kind of upset. Okay, well at least that's opened a door and they're, you know, communicating to try to welcome you in, to help them and to support them. You can say things like, this situation feels very terrifying or must feel very terrifying. I remember, you know, with my son, the one time, one and only time I've ridden in an ambulance, it was from one hospital to another because they had, since he was so preemie, they had to transfer me to a hospital that had a higher level neonatal intensive care unit. So in this 10 minute ride between hospitals, I was absolutely terrified about what was going on and everything else. So just saying to somebody, you know, this must feel very terrifying, or it feels very terrifying for you, validates how they're feeling. Even if you're the paramedic sitting there going, we got this covered. The patient probably has never been through that before. You may have been through it 50 times and you're like, yeah, no biggie. But the patient's never been through it before. So they may be feeling very terrified. And it's important, instead of explaining to them how they should feel and it's not a big deal to paraphrase how they feel and ask them, what can I do to best support you? You can also say things like, I can imagine how scary it feels to not have control in this situation. If you're dealing with a parent, for example, who has a child that was diagnosed with cancer or even a person who was diagnosed with cancer, you know, one of the things there may feel is a lot of rage at what's going on because they may feel like they don't have control of over what's going on with them. I've created, y' all know I love my acronyms or mnemonics. The mnemonic craves. When you're dealing with somebody who is in crisis, calmness is very helpful. And I'm not sure if that's even actually a word, but it worked here. Being calm, if you get upset, then they're going to pick up on that. Even if you're trying to hide it, if you get upset, they're going to pick up on it and go, oh, there must be something to this. And they may escalate further. So being calm is essential. Being responsive to Them, if they are in crisis, they may be getting cold, they may be hot, they may want to move around, not have to sit still. Just asking them, what can I do to best assist you, to best support you right now? A stands for acceptance. Accepting their thoughts and feelings and experiences as they're experiencing them. You may have a very different perception of what's going on. But if they're terrified right now, then we need to kind of join with them and, and try to understand what it's like in their head. We're not going to stay here forever. But in order to develop that connection and develop some rapport, the first thing is to help the person feel accepted and have their feelings validated. You know, I can imagine how terrifying it must be to, you know, one of my friends a few years ago used to race motocross and, and he took a jump too high and fell or crashed or whatever you call it. And he had compound fractures of both legs, both tibias, both fibulas in both legs. And, you know, they didn't know if he'd ever walk again. And it was absolutely terrifying for him and his wife. And it's important to, to validate that, you know, I accept how you're feeling right now, and, you know, I don't blame you. I can imagine how scary this must be. E stands for empowerment. Once you've kind of joined and the person says, feels like, okay, this person understands what I'm going through or has a better inkling of what I'm going through, then moving to empowerment. And I kind of put empowerment and safety together. Remember, one of the first things we want to do with people or help people do when they are in crisis, is help them establish a sense of safety. Now, the first steps that you did, the responsiveness and acceptance and all that, that helped establish emotional safety and cognitive safety. Because you're not afraid, you're not being put off by their anger, you're not being freaked out by their depression. You are sitting there with them. You're not invalidating them. So that gives them a sense of emotional and cognitive safety that you're not going to tell them how they're wrong, and you're going to be there to kind of empathize and support them. Then we move to physical safety, and it's important to help people figure out, you know, sometimes, all right, what is the next thing that you need to do for you in this situation and, and how can I assist with that? So, you know, for example, when I was in the, in the ambulance on the way to the hospital. The paramedic was very good about, you know, reminding me when I would have a contraction to breathe. It was one of those things I was kind of forgetting at that point in time. And he was very calm the whole time. I was like totally freaking out, but he was calm and, and empowering. He was reassuring about, you know, the, and he would tell me, he'd give me updates periodically. We're almost to the hospital, it's only a couple more minutes. So I felt like there was a light at the end of the tunnel. So that was, that was really good. When people are in distress, let's just say in distress because it's not necessarily in crisis. Helping them feel a sense of safety and personal power often helps get them unstuck so they can get out of their emotional mind, get out of their reactive mind and start thinking more broadly about okay, what are, what's the next thing? What are the next things I need to do in order to improve the next moment? This moment sucks. I don't want to continue to have this moment over and over again. So what can I do to improve the next moment? And it is important to. When you're talking with them and you're being responsive, if you're saying something and they're starting to get more agitated, acknowledge that it seems like what I'm saying is upsetting to you or it doesn't seem like you're feeling comforted or whatever is appropriate to say at that moment, that's fine to say. And the person can say yeah, that you're darn tootin. And then you can respond by what is it that I can do to best help you at this point in time? And if they don't know, that's okay. Try to have a couple tools in your toolkit. Specifically, the slow breathing can be very helpful. For some people. They may want to hold your hand. Other people won't want to be touched. Ask permission before touching. They are already on, on edge. So it's important to kind of step back and put them in the driver's seat and, and ask them sometimes, is it okay if I touch your hand? Or you know, would you like to hold my hand? Would you like a hug? Not everybody wants a hug. Some people do and, and go from there. And their responses are perfectly what they need at that point in time. And you can tell, you can get a feeling from their, especially from their non verbals about whether they are calming down and de escalating or they're not. And if they're not de escalating. You can ask them questions like, what is it that you are most fearful of right now? So that helps you understand exactly what they're focusing on. Paramedics can do that after a crisis, after a disaster, when first responders are on scene after a tornado or something. You know, asking people, what is it that I can best do for you? Asking them, you know, for example, what are you most afraid of right now? But also using your knowledge. First responders know that people who've had an extreme trauma are likely in a kind of a shocky, hazy sort of thing. So it's important to help them stay safe and, and you know, get them, get them blankets and make sure that they're drinking water or what have you. So those are things that you can also remember. A lot of people who are, who are first responders. You know, you don't get a lot of training on this, but it is helpful to know that, you know, you're in a position to be able to lead the person. You don't want to do things to them if you can help it. You want to lead them and say, would you be willing to. Can I help you buy. Do you think it would help if we got up and walked around for a minute? Those are all things that allow the person to feel empowered and give them choice. And that is the next step they need. After they feel safe, then they need to feel like there's some level of choice. Now I see a few questions have come in. Oh, and mental hygiene. I did promise we would talk about that. Mental hygiene is a way of, or a strategy for maintaining and promoting mental health. And it's important to recognize. We talk about hardiness a lot. Recognizing, know in the big scheme of things, all of the things that you have right now that are. That you're committed to, that make your life rich and meaningful. So being grateful for what you've got, even the stuff that's going crappy, but recognizing that most of the time your entire life is not going crappy. There are parts of it. Recognizing what you can control, what aspects of the situation you can control, to nurture the good and to address the bad. And viewing challenges, viewing problems as challenges instead of barriers can also be very helpful. Hardiness was something that Kabasa proposed back in. I think it was 1978, if you're interested in looking at the wiki on it. So that's one step, but it's also really important. Important. And I am doing a whole series on integrative behavioral health right now. But it is really important to make sure that our body factory is functioning optimally. Because when our body is physically under stress, it contributes to distress and low mood, low energy, difficulty concentrating, lots of things that are symptoms of anxiety disorders, mood disorders, or even cognitive decline. So we do need to pay attention to that. On an affective note, we need to add in the positive. Think about life, if you will, as a box. Because we all, you know, want to get out of our box sometimes. But think about life like a box. And if you have in that box a bunch of unpleasant stuff, stuff, you know, broken toys, and you want to get all those broken things out, all that unpleasantness out, well, that's great. But if all you do is eliminate the bad, take out the broken stuff, and you don't put in the good, then when you finish eliminating the bad, you're left with an empty box and you're like, what? What's this? So it's important to add in positive. So when you get to the bottom, there are some not broken toys. There are some really awesome things there. The other analogy I make about mental hygiene and affect is thinking about life, thinking about health, like a bath and anxiety, distress, anger, those things are hot. And, and, and, and when our cortisol levels are up, that's like, hot. When we are doing things that we enjoy, things that make us happy, things that help us relax, those are like cold. You don't want to be in a bath that is too incredibly hot because it would burn you. And in life, it's just very unlikely that you're going to have a bath that's completely cold. So what you're trying to do most of the time is, is regulate the temperature so it doesn't get too hot. In acceptance and commitment therapy, Hayes talks about the fact that it is unreasonable to expect life to not have pain. Pain is an essential part of life, cognitive pain. You know, we lose things that are important to us. We may feel distressed, we may have physical pain sometimes, and that's just reality. It's not reasonable to expect we will have a life without pain. But it is reasonable to consider the fact that you might be able to have pain and a rich and meaningful life. People who have rheumatoid arthritis, for example, can have rheumatoid arthritis and still do a lot of things. They can address that as well as possible so they can have a rich and meaningful life. They have to live life a little bit differently in order to, you know, keep the arthritis from flaring up. But they still can have A rich and meaningful life. So that's. Affectively, we want to do things that encourage us to feel happy, that encourage the dopamine and the serotonin. Cognitively, we want to address our thoughts. And this is where mindfulness can come in really, really handy. A lot of times we automatically fall back on negative thinking styles, cognitive distortions, whatever you want to call them, and that puts us in a negative frame of mind. If we're always scanning for the negative, for the threats, then guess what? We miss the positive. So part of mental hygiene can be being mindful of our thought patterns and practicing radical acceptance. When you see a negative in something, also trying to find, you know, the positive. It may not be in that exact same thing, but like, few, few years ago, it got really snowy here, which, you know, I love snow. So that was awesome. But we couldn't get out of our neighborhood for almost a. And the kids and the animals and everybody were all kind of trapped at the house. And that felt a little suffocating at times. But it was also a really amazing time because we got to go out and snowboard down the hill in the backyard and do some other things. So recognizing. Would I like to be able to go to the gym right now and get to the office and do those sorts of things? Well, heck yeah. However, I can't. What's. What is the good I can get out of this? So that can be. They. Sometimes people call it cognitive restructuring. Sometimes they call it radical acceptance. Whatever you want to call it, trying to focus, turn your attention to what is going well in your life, what is right about this situation, instead of looking at all the things that are wrong about it. Another thing with mental hygiene, and we talked about this in the episode on dementia, is to make sure that you're working your brain. It's not really a muscle, but it is important to continue to regularly work your brain to develop cognitive resources. Think about it as just like a pantry that you would stack up and make sure that you had plenty of food reserves in the event of a hurricane or a. Or a blizzard or something like that. The same sort of thing is true with your brain. If you build up some of those cognitive reserves, then they hypothesize that activating more aspects, more areas of your brain provides you more flexibility when you do start aging and evidencing, you know, inevitable cognitive decline, you can stave it off if you've got more resources. You don't start starving as quickly if you've got plenty in the pantry. Environmentally, mental hygiene is it's important to evaluate your environment to make sure that it is as relaxing and as safe for feeling as possible. You know, no sense having extra distress around. And then interpersonally focusing on developing a few healthy, supportive relationships. Not everybody is going to be healthy and supportive, but especially in this time of high stress, you know, it's important to think about things and ask yourself, is what I'm doing now helping me feel happier and have a more rich and meaningful life, or is it contributing to my distress? I was flipping through channels the other night and it occurs to me how awful it is for, for a lot of people right now that, you know, generally on the holidays, some of those Hallmark Christmas movies can be painful anyway because people see this Hallmark Christmas and they're like, I never had that. And then they start feeling like they missed out on something, like everybody else has this and I don't. So that contributes to feelings of resentment and depression and grief, when in reality, you know, the number of people that actually have those Hallmark Christmases, it's probably pretty small. Those are idealized, but it increases people's distress. And during this particular holiday season when there's a lot of travel restrictions and there have been a lot of people that have gotten sick and died, there's even more distress out there. So having all of those glorified holiday movies on can be really challenging. So the question is, if somebody turns it on, is watching this going to help me go to a happy place and imagine what life could be like and increase my pleasure? Or is watching this going to make me feel grief stricken and depressed? And if it's the second turning it off, making sure you do things for your mental fitness as well as your physical fitness. Because if your body is out of sync, if your body is sick in some way, then your emotions are probably going to follow not too far behind. But by the same token, if your body is healthy, that HPA axis, HPG axis, HPT axis, if all that stuff is healthy or healthy ish, then your mood is probably going to follow not too far behind. With the exception of when there is some sort of situational thing that comes up. You experience a loss in your life, you experience something stressful. Well, okay, when that happens, if your body is, your body factory is functioning at optimal levels, then it's cranking out those hormones and neurotransmitters and everything like it needs to. So you have the resources to deal with distress when it happens, you have the extra in the bank, so to speak. Whereas if you weren't practicing Mental hygiene. If you weren't taking care of your mental health leading up to it, then your pantry was empty. And a lot of times you don't have the resources to cope as well. And you're right, Nick. Many helping professionals do lack a bedside manner, especially. Well, I'm not going to call out particular professions, but there are some professions and in the helping field that tend to be more. Tend to be less focused on the warm and fuzzy and more focused on the facts. So it is important to recognize how important and how that can really help with understanding what's going on with a person. And this is true not just of health professionals, but of firefighters, of paramedics, of law enforcement. It doesn't take a lot of time, but a lot of times it. It actually speeds up the process. If you can go in there and quickly establish rapport. If you spend the first 10 minutes kind of struggling to see who's going to have power in the relationship, you're. You're wasting a lot of time. If you get in there and, you know, help the person feel heard and understood and safe, you're going to be able to gain a whole lot more traction more quickly, regardless of what your profession is or where you're at. And this is true for supervisors, too. This isn't just first responders. You know, if you've got a staff member who is starting to show signs of dysphoria, you know, it's not just today John is in a bad mood, but for the last three weeks, John has been, you know, on a tear. Then these skills can also be super helpful to initiating a discussion that may end up in, for example, a referral to the employee Assistance Program. And it is important, you're right, Nick, to try to be as careful as possible responding to people based on their age, their gender, their cognitive ability, their culture, they may respond differently to. To different people and to different situations. So you can't assume that any two people are going to respond exactly the same way. And, and that's a really good point that you want to just let them come in. Some people may come in like. Like my friend who had the two broken legs. Some people may come in and, you know, they've broken lots of bones before, and this isn't a huge big deal. I mean, it's stressful, don't get me wrong. But they're not like, super freaked out about it. Other people may come in with something that seems pretty minor and they are in terror about it. For example, my mother, unfortunately had kidney. We're not sure where it started, but kidney cancer. And you know, she had low back pain and that was the first sign that she had kidney cancer. She put off going to the doctor because she thought she just hurt herself working out. Lo and behold, she goes in, she's stage four. So what do you think my reaction was? For the first year after mother got her diagnosis, whenever I would get low back pain, you know, my first thought would be, oh my gosh. And then I would have to kind of talk myself down and be like, okay, realistically you were, you know, squatting with 150 pounds yesterday, so not surprising your low back sore today. And it was important for me to be able to back up and look at that. But having a professional, a caregiver of some sort, a doctor say, oh, you know, there is no chance that you have this. And, and dismissing my concerns could have been very invalidating and not comforting at all if I didn't feel like I was taken seriously. And yes, I would love to do a future lecture on the effects, cognitive effects on the hippocampus and amygdala due to abuse and chronic stress. If you have not read it already. The Body Keeps the Score by Bessel van der Kolk is a, is an amazing book. I believe it's by Bessel van der Kolk. Let me see if I can pull it up here for you guys. Yep. So evidently it's on Audible on Amazon, but the Body Keeps the Score is one of those foundational readings if you deal with people who experience trauma. And I have another article that I can share with you guys. I will put it in the comments section after we finish today's presentation that you can look at if you're interested in some of the wide ranging changes that occur as the result of PTSD and trauma in the brain, in the body. So it's, it's not just a thinking thing. There are a lot of physiological alterations that happen as a result of trauma. So I'll pull up that article. It's one of my favorites and I can share that with you. You can also actually find it. I've done a couple of videos on the YouTube channel on the neurological impact of trauma. Are there any other questions? As I said, I've been working on a series on integrative behavioral health and I'm just learning so much about how things like testosterone levels and estrogen levels impact thyroid levels and neurotransmitters and how sleep and nutrition and, you know, actually lack of enough fat or lack of enough carbohydrates can add stress to the body. And, you know, obviously the, the. The whole gut brain axis thing and talking about leaky gut and how an unhealthy gut can also contribute to distress and how distress, how cognitive distress and emotional distress and unhelpful thinking styles can trigger that HPA axis and actually make the body sick. So, you know, I think it's a really fascinating system that our body has, although imperfect. Alrighty, everybody. Thank you so much for being here with me today. I appreciate you taking time out of your day to join me. As always, if you have further questions after I sign off, the chat quits pretty quickly, so I can't respond to a whole bunch of stuff. So if I haven't responded to something that you've put in the live chat after I end the stream, you can also put comments below the video and we do respond to those comments as quickly as we can. So thank you for being here. I look forward to seeing you on Monday. Have a fabulous weekend. Figure out some awesome things to put in that box, not just unpleasant things to take out.