Verbal Crisis De-Escalation with Dr. Dawn-Elise Snipes

Hi and welcome to your course on client and personal safety and verbal crisis de escalation brought to you by allce.com first thing that we need to do is define crisis. Crisis means people are facing an untenable obstacle to life's goals. People's life cycles are significantly disrupted because of this untenable obstacle and the person has no response to deal with the situation. So basically they feel helpless. Something's going on that has overwhelmed all of their coping skills, all of the resources that they can think of to use at this point and I emphasize that they can think of to use. When people are in crisis, they often forget some very logical resources or coping skills that normally they would think about. Generally when people are in crisis it relates more or less to one or more of the six basic fears. The unknown. A lot of people get really antsy when they're doing something and they have no idea they're launching on a new career, they're moving to a new place. There's something unknown, causes a lot of stress. If they're already in that stressed out place and something else happens, it could be the straw that broke the proverbial camel's back. Loss of control or power. If your spouse leaves you and files for sole custody of the children, basically taking what you perceive to be your control, that can throw people into crisis. Rejection. Pretty self explanatory there. Isolation. Feeling like nobody understands you, nobody gets it. Nobody has ever been through anything like this before. Feeling terribly unique, terribly alone. Failure. This is a big one in American society and maybe others, but definitely in American society where we put a high priority on success. A lot of people over generalize a single failure to I am a failure and instead of, you know, I'm not so good at that or I didn't do that well and death. Something that could cause death or something that resulted in either somebody else's death or imminent death to you. Maybe getting diagnosed with a terminal illness. All these things can throw you into crisis. Crisis means that you've got to get up off your duff and do something. That means there's the presence of opportunity and danger. It's great if you go to the side of opportunity. You have the opportunity to explore the unknown and make something new. You have the opportunity to figure out what you really need to control in your life. You have the opportunity to make choices and figure out how you're going to deal with this crisis. But there's also danger if the person feels completely overwhelmed and doesn't believe that anything that they can do will Make a difference, then they rapidly may become suicidal or homicidal. It's important to remember that change causes crisis and crisis causes change. Change in your environment causes a little or a lot of a crisis because you've got to adapt. Crisis tells you, well, I can't stay in this state forever. I need to find my equilibrium again. I need to change or adapt. When someone's in crisis, if things start happening that increase anxiety, they will revert to more primitive coping skills or reactions, kind of like the cat in the corner, and they may become very violent. It's vital to remember during, for instance, hostage negotiations or when you're talking to someone who is suicidal or homicidal, that you need to try to help them feel a sense of control and get grounded again. Because right now, most of the time they're in some sort of chaos. Crisis can be complicated. Generally, there's not one simple cause. Jim lost his job. Sally's husband left her. Generally, there's a lot of other things. Maybe Sally's husband left her, but now that means she doesn't know how to pay the bills. She doesn't know what's going to happen with child support. She doesn't have a job, so she's going to have to go out and try to find something to pay the bills. All of these are unknowns and things that to date, she hasn't had to control. So life seems very overwhelming at this point in time. These precipitating events may impact many different areas of life. Finances, health. We know when we get stressed, we start to feel sick to our stomach, start to have migraines, backaches. However, your body says, dude, you're under stress. These all may happen, which impact your sleep. Then you start not getting enough rest, which makes it even harder to deal with life on life's terms. So we need to take the person and start at the very beginning. You've heard me talk before about Maslow's hierarchy. Make sure that they have those foundation needs met, they have food, they have adequate medical care, they have adequate housing. Start there, and then we can start building on the rest of the stuff and trying to figure out how to put their life back in order. But if Sally over here is worried about losing her house and not being able to feed her kids, it's going to be hard for her to focus on much of anything else. Life's going to seem very pressured and urgent and chaotic. When people are in crisis, there are no panaceas or quick fixes. What we need to do is help them Realize that I can't fix this for you right now. I wish I could, but I can help you get some temporary relief and make a plan in order to step by step walk through this crisis and make whatever changes you deem necessary. You do want to, however, make sure you don't make the problem worse. Don't lie. Don't tell them that you can do something that you can't do. Don't make promises that you're not sure that you can keep. Don't minimize their feelings. All of these things might make things worse. If you tell them it's not as bad as they think, that's potentially going to be a problem. When people are in crisis, there's a necessity of choice. What does that mean? That means they've got to do something. They cannot exist in this state for a long period of time. They can either choose not to act and whatever happens, happens, or they can choose from a variety of other options. It's very valid to choose not to act. Then other people end up making the decisions for you. For some of our patients, they choose not to act because they want to be able to not have to take responsibility for what happens. If we make the decision for them, then they can blame us. Whenever possible, empower the client to identify what would make things better, what would they hope the resolution would be? Then you can start talking about possible ways to make that happen or what Jim Bob can do right now in order to get control and make it until four hours from now. We're not talking about make him feel better so he doesn't have to come back for a week. Generally, when people are in crisis, if you can do four hour well being checks, that's helpful. If they will make future plans, that's helpful. It means that they haven't given up all hope. There are lots of different types of crises. Developmental crises are normal or abnormal events causing dramatic changes in physical, cognitive or social development. For example, if someone has a stroke, if someone has a car accident and ends up with brain damage, that may cause. Not always. It may cause a developmental crisis because they are thwarted at that point in time until their brain heals and they may have to relearn some things. Situational crises are like the ones we've been talking about up until now. Sally's husband leaves her, Jim gets fired from a job. Some sort of situation causes the person to feel rejected, isolated, out of control, and have no idea what the future holds that unknown. The more of those fears that you have stacked up, the more challenging or the more Overwhelming this can feel to a person. Existential crises are those arising from questions of purpose, responsibility, independence and commitment. Why am I here? What is death? What happens when I die? All of these existential crises are things that people occasionally will go through periods. Midlife crisis, and sometimes later in life when they hit a later birthday, 75, 80 something in there. A lot of times people will review their lives and go, wow, I really haven't accomplished half of what I wanted to do. So it's at that point we have the ability to help them use it to propel them to start doing things that they want to do and focus on the possibilities instead of the regrets. Ecosystemic crises are disasters. Hurricane Katrina, perfect example. Hurricane Andrew, I'm from Florida, so hurricanes automatically come to mind when I think of a disaster. Floods, earthquakes, anything that causes mass casualties or massive loss can create a crisis. Not only is that person in crisis, but all of the resources that they would normally go to their church, their neighbors, their friends very well may be in crisis too. So now where do they turn? Ecosystemic crises are just as valid when we talk about crises as an individual person who's in crisis, which is why we see a lot of depression and a lot of suicidal ideation after some sort of a natural disaster. It's important to get in there, and Red Cross does a good job of getting in there and starting to lay down the groundwork for providing support to people who are in a completely abnormal situation. Models of crisis intervention, equilibrium, stabilization. This is sort of the basic one. We need to help somebody feel grounded again so they don't feel like they're a fish out of water. They don't feel like they're walking a tightrope or whatever analogy you want to use. We need to help them get stabilized and go, okay, I'm freaking out right now. I need X, Y and Z to happen, and I have no idea how to get there. That's when we come in and we say, I can help you, I can help you. At least make a plan for how to approach X, Y and Z. I can't guarantee that that is going to be the outcome, but let's talk about what you've got and where you want to go. And let's make a plan. 95% of the time. When people feel like they've got a plan and they've got direction again, and they're not just flapping around out there having no idea which way to go, the emotional reaction starts to decrease. We also need to be able to talk with them to Help them get out of that crisis stage where their body is just pumping these stress chemicals for fight or flight, because they're not going to think, well, as long as they've got adrenaline and cortisol and all that stuff running through their head. We need to help them catch their breath and figure out exactly what it is that can help them. Right now, at this very moment, the cognitive model of crisis intervention helps people gain control by changing their thinking. We used reality therapy or rebt. Someone who's in control because they feel like a complete failure and nothing they've ever done has ever worked. Well, you can take those irrational thoughts and you can start asking them questions about, okay, I hear you've made some mistakes. I hear you've had some failures. Are there any successes that you've had? Is there anything that you're proud of in your life? A lot of times children come up accomplishments from long ago. Maybe Jim Bob hasn't done a whole lot recently, but he may have done something in the past. You need to judge the crisis and judge the person in the moment to figure out what the appropriate approaches. We don't want to minimize his feelings and say, come on, you know, you've done a lot of stuff. You're not a failure. That puts up the wall. I've just negated his feelings. You can also ask him if he's saying he's a failure and he's failed at everything and yada, yada, yada, ask him who he's close to. We're not talking anything about successes or failures. Who are you close to? Who is it that is meaningful to you? How do they feel about you? That's one way to approach it. Now, if you don't know who the person is close to, for example, in a hostage negotiation situation, you could be opening a door that you don't want to go through. Maybe the only person he was close to was his wife and she just left him. Okay, probably not going to help you out there. Try to not ask questions that you don't have some idea of the answer to because you don't want to make it worse. Psychosocial model. Assess internal and external exacerbating and mitigating factors and choose workable alternatives. Ask him, Jim Bob, help me understand how we got to this point. You got up this morning, then what did you do? Give him a temporal anchor to start telling you how he got from getting up and eating his Wheaties to being suicidal? What happened? How did we get there? What was different this morning? Are there any reasons that this might not be the best choice and what are the workable alternatives we can develop together. One of my favorite shows is a show called Flashpoint. It's actually filmed in Canada, and they keep saying they're going to cancel it and not cancel it and cancel it, but anyway, it's about a hostage negotiation team, and they do an excellent job modeling some of these behaviors with developing rapport, getting to know the person, not being judgmental. That's huge. This. Jim, have you lost your mind? What are you doing taking 30 people hostage? That's probably not going to work very well. If you're in a residential setting and two of your patients start going at it. This is a crisis. You're not going to be able to rationalize with them at this point. You need to build rapport and try to understand what it's like in their head. Understand what it's like in their head. Is it scary? Is it dark? Is it terrifying? Is it hopeless? What point of view are they coming from? Because that's going to color how they interpret everything else. Do they feel like they can trust you? Important points to remember. Crisis presents danger and opportunity. It's not for the faint of heart. But a lot of us find ourselves thrust into this position, even when it's not necessarily something that we would normally choose to do. I think probably half a dozen times when I was working in community health, we would get a call from someone who was actively suicidal and have to talk to them while they were or while we were waiting on law enforcement to show up because they were at an undisclosed location. So we'd have to trace the call and do all that kind of happy stuff. Crisis is time limited, but may be recurring. Most people cannot endure a crisis state for very long. For some people, it's hours. For some people it's a few days, but not much more than that. You can't be hurting that bad for very long before you have to do something. It may be recurring. They may put a little band aid on it and go, okay, I got this now. And then two weeks later, something else happens. Their dog gets sick, and all of a sudden they're in crisis again. I do want to point out at this point in time that crisis for one person may not be for another. My grandmother is a perfect example of this, and I love her dearly. But since my grandfather's past, he always used to take care of everything around the house. And now when something goes wrong, she just, like, freaks out. And it could be something as little as a leak or the air conditioning going out or something like that. But as soon as something bad starts to happen, it's just everything goes crazy for her. It's unpleasant. True. When the air conditioner goes out in Florida in the summer, however, a lot of people would just be irritated. So you need to be able again to get into that person's head and go, why is this? Or understand why the situation is so overwhelming for them. And for my grandmother, she starts worrying about finances and, you know, then she starts missing my grandfather because he used to take care of everything. There are a lot of things that feed into the crisis. And then she starts worrying about, okay, what's going to happen next. Because the house is like 50 years old. It's important to try to intervene when you can. My uncle goes over, he calls the repairman. But then we need to check up on her every day for the next week or so in order to make sure that nothing else has gone bump or made a weird noise or anything because she's on alert now. Many of our patients are like that. Once one bad thing happens, they're just basically in anticipation of the next bad thing. Crisis is complex. It's not one thing, one situation. It's probably one situation that set it off, but is impacting a lot of other things and. Or all those negative tapes from the past coming back. I'm letting my parents down. I'm letting my spouse down. I will never be good at anything. Whatever those internal critic messages are, those start coming out whenever there seems to be a crisis. That's the time that critic really likes to run his mouth. Life experiences of workers, that's us, enhance our effectiveness. Not to say that somebody who's 22 and brand spanking new out of college can't help someone in crisis, but it does help if you do kind of understand what it's like to have a premature infant or to lose a parent or to have bills that are due again, you don't have to have gone through it, but it helps. Not only with you being able to get inside their head and go, yeah, I've kind of been there before to yourself. Or. And. Or it gives you some credibility with the patient. If they see somebody who's 21 and never been married and just got out of college and never had a house payment and they're getting foreclosed on, their spouse left them and their children were just put in foster care, There's a pretty big gap in life experiences. So they may have trouble trusting that this person gets it. Not impossible, but it's going to be an uphill battle in the rapport building area. Crisis does cause people to make choices, and choosing not to act is a valid choice. If someone's in crisis because their substance use has basically caused them or led them to lose everything, they have the choice to stop using or to keep on doing what they're doing because changing isn't going to help anyway, or at least that's what they perceive. So no change or no action is a valid choice. It's important to remember that there's no one normal range of behaviors. I come from a family where my stepfather was Italian. He spoke with big gestures. I come from a family that's not necessarily by blood Italian, but we're loud. We're loud and we speak with big gestures. That can be intimidating to some people. Being overly emotional or what we consider overly emotional. See, and that's my cultural perception. Being very emotive is normal in many cultures. So just because somebody is crying and falling to the ground and just absolutely overwhelmed with emotion doesn't mean that they're in some suicidal crisis. It may just be culturally accepted to emote. Individuals are not necessarily the basic building block of society. Again, in some cultures, it's a very family centric environment. It's not the needs of the individual, it's the needs of the family. This is important to remember. We can't just take somebody who is from a culture that values family and puts a high priority on it and say, you know, your family sounds kind of, you know, not healthy, so maybe you should cut ties from them. No, no, that's not culturally sensitive. This is why we need to ask people, what do you think the best resolution of this would be and what's realistic? What do you think could happen? What could change? Problem definitions can be interdisciplinary. Even if the worker is not. I'm mental health. But the problems may be mental health and physical and financial and social and spiritual and whatever else. There may be a lot of things going on for this person. I can help them get grounded. I can help them by developing rapport and developing a plan. And then I can help them find people who can help them out with the other areas. A financial counselor, a physician, a pastor. Wherever the needs are, whatever domains those needs are in, I can help them make those linkages. People in crisis won't pick up the phone 85% of the time. They're too overwhelmed. They're barely getting by just getting out of bed. So saying, okay, here's a list of 15 names that you can call to try to get help with these different areas. Most people aren't going to be able to do that if they're in crisis. You're setting them up for failure, which is going to make them feel worse. Sit in the office with them and go through the list. Even if that means dialing the phone and handing it to them and saying, okay, I need you to talk to the caseworker at child support. You dial the number, get the person on the line and hand the phone to the patient. That's a lot easier than them having to call and figure out what buttons to push and what extension and go through all those menus. Those menus will put people in crisis. And I don't just mean at child support enforcement. I mean just about any automated menu. So don't take somebody in crisis and get them stuck in a never ending. Press 5, 4, press 3, 4. No. Language is not always interpreted in the same way. We have idiosyncrasies, we have certain things that we say. One of my sayings that I use a lot is knee high to a grasshopper. Now if you're not from the south, you look at me like I've got three heads and what does a grasshopper have to do with it? But where I'm from, when you talk about somebody who's real small, they. They're knee high to a grasshopper. Sometimes that breaks tension because they just start laughing at me. And that's okay too. I am perfectly fine being laughed at if that's going to help break the tension in the room. The value of independence and dependence varies between people and cultures. That goes back to that needs of the individual versus needs of the family. Not every culture values independence. And it's important to remember that not everything can be explained in a linear fashion. A doesn't always lead to B to C to D. So things may happen, there may be a detour. You may have to go, oh, perfect example, when I was in college, A to B to C. I got accepted to college. I enrolled as pre med. I took my first calculus class. I withdrew from my first calculus class. So we stepped back a little bit. Now if I would have listened to my father, I would have gone to the community college and taken calculus there where it wasn't a weed out class. So you may have to back up and detour around a little bit in order to get to your final goal. It's important for clients to realize that there's no shame in saying, oops, I went too far too fast. Maybe I need to back up and Relook at this. We need to accommodate the client's needs as best as we can. And there's a difference between needs and wants. It's important to help your staff understand that. It's important to help the client understand that they need food, they need shelter, they need medicine. They may want to talk to their estranged spouse, but that might not be something that we can make happen. Past history certainly impacts current events. If they have become suicidal and gotten themselves worked up in crisis and somebody else has come in and saved the day and solved the problems, yeah, you know what? They're probably going to be hoping the same thing happens again. It's important to recognize again that not everybody interprets things the same way. We need to be aware of our personal assumptions. Are we assuming this person is crazy? Are we assuming this person's violent? Are we assuming this person's high on drugs? What are our assumptions about what's going on here? Are we assuming this is a no win situation? Are we assuming we're right? That's a hard one because we all like to be right. But you know what? The client is the expert on himself or herself. In their own way, they know what they need. It's up to us to help them figure out what that is and help them make steps toward achieving that goal. In verbal crisis de escalation, you start by defining the problem. Listen to identify the person's orientation, whether they want to talk about feelings for a little while. When my husband and I first started dating, many, many, many years ago, he's a thinker. I'm a feeler. If you've done the MBTI or the Kiersi temperament sorter, you know what I'm talking about. When something bothers him, he thinks about it for a second and then he wants to talk about how to fix. Doesn't mean it bothers him any less. But he doesn't emote me. Oh, you need to acknowledge how I'm feeling before we even move on to solution problem solving. I can solve my own problems just fine. But I need to know that you understand, that you hear that I'm angry, that I'm sad, that I'm scared. Once I understand or once I believe that you understand what I'm going through and that we're on the same page, then I'm freed up to start solving the problems. But I need you to hear how I'm feeling when I talk to him and he's having a bad day. If I say, wow, you seem like you're really depressed, he usually looks at me and says, don't bring that counseling crap in here, okay? So I approach him and I say, you know, you seem really quiet today. Anything going on? That's a different approach. When you're dealing with someone in crisis, if you're trying to get them to talk about feelings and they don't want to, you're not hearing them, and that's going to irritate them and it hurts your rapport. Reactions are just as valid as feelings. I feel like I got punched in the gut or my first reaction was to run. I don't need to paraphrase that and say, oh, okay, so you were scared. That breaks that rapport right there. Because all of a sudden I'm putting a feeling word in where it may not be the appropriate time, and it may communicate to the person that they're being weak. And not to say that feelings make us weak, but there are a lot of people that really don't like to talk about feelings because it makes them feel too vulnerable. And are they visual, auditory, or kinesthetic? If they're visual learners, they'll talk about seeing things, not hallucinations. But I see how this could be whatever, or I would like to see this happen. Auditory learners talk about hearing things, and they like to talk, they like to converse because that's meaningful. Visual people want to read it. They will give you a list of things. They will write things down for you. Kinesthetic people like working with information. And so if you can give this person something active to do to help solve the problem, it's going to help sort of rebalance their energy a little bit. When we get anxious or angry, we have that fight or flight response. Our body dumps all these chemicals so we can react. And if it dumps all those chemicals to prepare us to react and all we do is sit on our butt in a chair, then we get the sense that we're going to climb out of our own skin. When you get that adrenaline dump, your body's going, hello, get up. Come on, chop, chop. And you're not paying attention, so your body doesn't know what to do. It's like, er. And then you start experiencing other symptoms. Your anxiety goes up, things get worse because the body's still nudging you on to try to do the right thing. So once you've established how to communicate with a person in verbiage that's meaningful to them and in a way that's meaningful to them, then it'll be easier to communicate and develop rapport. Most of Us as counselors kind of do that automatically. We use our clients phrases when we're talking to them, when we paraphrase. So that probably is something that comes pretty naturally to you. But think about it next time you're doing it and see if you are changing and using the client's learning style and point of view or still maintaining your own. Empathize to see the problem as the client does. Even if you think he's wrong, even if you know he's wrong, it doesn't matter. That's his reality right now. I worked with a client who had schizophrenia. Nice man, very nice man. But when his meds were not right, he believed that anytime somebody said the word the, it was this horrible affront to him and they were basically cursing him out. Try talking for five minutes and not saying the. It's difficult. And most of you are sitting there going, that makes no sense. Well, yeah, in our reality it doesn't make any sense. And what my supervisor at that point told me was it doesn't matter if it makes sense to us, it makes sense to him. So we need to enter into his world and try to fix it from that point of view. Ask open ended questions. Are you feeling suicidal? That's a yes or no. That's a closed question. John, how did we get to this point today? That's an open ended question. When people are in crisis again, remember to give them temporal anchors. The question, John, how did we get to this point today or how did you get to this point today? He's I don't know. So give him a place to start. That's like when somebody comes in and sits in your office for the first time. You say tell me about yourself. And they look at their watch, they're like, well, how much time you got, Doc? I'm 40 years old. Give them an anchor point, Give them something to focus on so they understand what you're trying to say. And it gives them a framework to try to articulate what's going on and pay attention to verbal and nonverbal messages. If you ask, and I don't even know that I can do this, if you ask somebody if they're suicidal and they go, no, that's a clue. If you ask them a question and they divert their gaze before they answer it, that may mean they're ashamed of the answer or that may mean they're lying to you. There are lots of non verbals that you can be aware of that may indicate somebody is not telling the whole truth or hiding something or saying what they think you want to hear, but it's not what they really believe. When they're in crisis, it's not the time to call them out on it and go, I think you're lying. But it is important for you to understand and maybe come back and paraphrase something to the effect of, you know, I hear you telling me that you're not suicidal, but I'm still really concerned because it seems like you're still upset. It's hard to do without a client in the room. But you want to paraphrase and just kind of put it out there that you realize that something's going on, and if they want to talk about it, that's cool. But you're not going to call them out and call them a liar because that's taking their control. When someone's in crisis, give them as much control as possible where you can still stay safe. Assess how they're doing, the ABCs. Look at their affective state. What are they feeling like? Are they sad? Are they depressed? Are they happy? Are they being incongruent? They're acting happy, yet they're still saying they're going to kill themselves. What's their behavioral functioning? Are they agitated? Are they calm? Are they angry? Are they pacing? What's going on behaviorally, cognitively? Are they thinking straight? If they're not thinking straight, then you can either approach with the cognitive interventions and help them address irrational cognitions. You can choose just to try to help stabilize them. You can help them try to understand what's going on, or get a handle on what's going on by entering into their world, not telling them that their world is wrong, but trying to understand where they're coming from and what's the severity of the crisis. Do they have a plan? A means future plans, and are they putting their affairs in order? We need to ensure clients have personal safety. Remove them from a situation if possible. Let them know that you want to help. But it's hard for you to focus while they are waving a knife around threatening to kill themselves. Pardon me. We had one client when I was working at one place who would call and he would basically play Russian roulette while he was talking on the phone with you. And if you said the right thing, then he would stop trying to shoot himself in the head. And if you said the wrong thing or if the bullet came around, he would fire the gun. Now, thankfully, the times that he did fire the gun and he worked with several of us, he fired it into the air, not into himself. However, that Is one of those behaviors that makes it really hard for you to help because he's putting you on the spot. If you look at it from his point of view, he was trying to make you feel as urgent and as helpless and as in dire need of something as he was. He was turning up the fire underneath you too. Maintain an environment free of hazards such as scissors, letter openers, heavy objects. Always maintain a clear path to the door. Don't meet with clients in isolation. Now, one on one in an office is fine as long as there's other people in the building. The next office over, something like that, you don't want to meet with them at 8 o' clock at night on a Saturday in a 10 story high rise office building with nobody else there. That's just dangerous. It doesn't matter who the client is because every client has the ability to become violent. Psychological remove bystanders, audiences add fuel to the fire and reframe the situation with the client not being bad. You're hearing how much he's hurting right now or how out of control everything feels. Not have you lost your mind? You came in here and took hostages or you're waving this gun around or see, there's a big difference in the interpretation. Our job is to understand the motivation behind the current behaviors. The current behaviors are probably bad, but we're not going to focus on that. We're going to focus on what the motivation is, what propelled this person into this crisis. That's what we need to focus on. Provide support. If they're thinkers, remember thinkers versus feelers. Say things like it sounds like you're stuck or at your wit's end, I'm hearing you're out of options or life seems out of control right now. If they're feelers, you can say the ones that come easy to you from counseling 101. You feel overwhelmed. I'm hearing that it feels like things are helpless and hopeless right now. Those words are going to have meaning to a feeler. They're not going to have as much meaning to a thinker. See, I see that. Or you look like you're in pain right now. For your visual learners, when you get to making solutions, write things down. Say things like let me see if I understand what you're telling me. Hearing I hear that you've done everything you could. Or you sound like you are at a point of complete desperation. Doing that's those action words. Sam, I know you want to get out of this situation and I really would like to help you. You regret making the choices you made till now. So let's work together to see what plan of action we can develop to get out of this safe and sound acting. Acknowledge the situation and or the client's feelings. Seek help from the client in understanding what's going on. I've talked about that some, so I'm not going to belabor it here. We need to let them inform us. They are the experts. We have no idea what's going on that got Jim Bob to this point. Ask for information. We're not the experts. Own your feelings. Just like in therapy, but amped up 10 times. People in crisis tend to be very sensitive to your feelings and reactions, even if you're not saying them. So if you have something going on and it's obvious or, or even if it's not obvious, if you need to state your feelings, state them, but own them. John, I'm feeling really scared right now, or I'm really scared for you, or it frightens me when you are flailing this knife around. Own your feelings. This is what's happening with me. I'm not saying you are doing this to me. I'm telling you what's happening to me. It's semantics, but there's a big difference. You are making me afraid. Puts blame on somebody who's already in crisis, which could set them off. So saying I'm really afraid when this is going on. I'm wondering if you might be willing to give them an option. You've stated a problem, you, you're afraid, you're uncomfortable, you're angry, whatever. Provide them with a solution or two. I'm wondering if you might be willing to blah. Be aware of transference and countertransference. If you look like his wife who just walked out on him, he's probably going to react differently to you than he may to the lady sitting next to you or the guy sitting next to her. Countertransference is when your own stuff starts getting involved. Maybe your brother committed suicide and you can't get that out of your head long enough to focus on what's going on with Jim Bob. With clients in crisis, we can't say, you know, I don't know that I can deal with this right now, so let me transfer you. That doesn't work. However, you do need to be aware that you've got stuff. You need to be aware that your stuff is influencing you. And to the best of your ability, you need to seek input, consultation. Hopefully you've got a partner somewhere, either in an earbud or next to you or Somewhere who can help you through some stuck points if you get there. It's also important to be aware of these during your debrief. If you're having extreme countertransference reactions during the crisis situation, it's going to be something you're going to have to deal with in a debrief. Convey understanding, but don't say I understand. 99 times out of 100, if you tell somebody, I understand you're upset right now, their response is going to be, you don't understand anything. Mm, okay. You don't. You don't understand. In reality, you want to understand, but you don't understand. So say, I hear that this is going on. You can, even if the timing seems right, say, I would like to understand what's going on. Can you help me understand? But don't say, I understand. If you can at all help it. Provide positive reinforcement for positive behaviors. Thank them for sitting down. We had two clients in the residential place where I used to work go at it in the day room, and they were going to pummel each other until one was a bloody pulp. Thankfully, we were able to get them separated, and I had one client walk outside with me and we walked around the compound. The first thing I did when we got outside was say, thank you for coming out here with me. Now let's walk around and help me understand what just happened. Avoid value judgments. Just because you may not feel that saving face is worth getting into a fight about, that may not be true for your client. Whatever led up to this point may not be something you agree with, but that's not at issue right now. What's at issue is it's something that's important to the client. It is important to set limits and not tolerate controlling or aggressive behavior. With the two clients I was talking about, the one person that I took outside happened to be, you know, six foot three and 300 some pounds. He was a big boy. I'm five four. And he was a good head and shoulders above me, tapped him on the shoulder and asked him in a calm voice to go outside. And at first he did not comply. And then I used his name and we'll call him Jim Bob because we've been talking about Jim Bob. And I said, jim Bob, you need to come outside with me now. And he said, okay. And he walked out with me. When clients are in crisis, they're not necessarily going to respond to sort of requests. You need to give something of a stand statement. It's not. Well, if you wouldn't mind, would you come Out. No, you need to come out with me now so we can talk and figure out what's going on. I wasn't upset, I wasn't angry. I really wasn't scared. It was just a calm, assertive. Any of you who've watched the Dog Whisperer know a common assertive looks like. But I had a calm, assertive presence about me and that helped bring the client out. He didn't feel like this was the end of the world. I wasn't angry. I wasn't going to call the cops and have him kicked out. Or at least at that point he was leaving all options open and he wasn't assuming the worst out of me. Reduce tunnel vision to increase focus. The more adrenaline in the system, the narrower that tunnel gets. So help them reduce tunnel vision. Have them tell you about things that are important to them. If you can find out if they've got kids, if they're married, if they have a job, understand a little bit about them and start understanding them as a three dimensional person who has a life that helps them. Not focus so much on this one thing right here, right now, but start remembering that there is more going on. Examine alternatives to the current behavior. What supports do you have? What coping mechanisms have worked in the past when you've gotten angry or when you felt like committing suicide? What has stopped you in the past? What made you change your mind or what helped you feel better? Look at thinking patterns, if they're willing. A lot of times in crisis, people really don't want to examine their irrational beliefs. So that's for later. We want to look at what we can provide for them right now. This is triage. This is get them stabilized and get them to a place of safety. And then you can start talking about whatever else needs to be discussed. Promote mobilization, which means make plans for achieving whatever it is Jim Bob really thinks he needs and help him implement order in his life. We're here right now. This is ground zero. How do we get to ground one? I don't know where you go from ground zero, but I digress. Implement order. Help him understand what, what the next step is he needs to take. He needs to do this, this and this before he goes to sleep tonight. And then when he gets up in the morning, what's he going to do? Probably call you or if you're committing him to a jail or psychiatric facility, then he will talk to somebody else. Obtain commitments with assertion statements like the client that I took outside. I need you to do this right now. And you can say, please, there's nothing wrong with please that doesn't show weakness. But don't give an option. Don't say, would you mind? I need you to do this. Most of the time when people are in crisis, if you state something like that, they're going to do it. It's like, oh, okay, here, I'll put the gun down, or whatever. You have to have rapport before you start giving orders or assertion statements. You can't just walk up to somebody who's in complete crisis and tell them you need them to do all these things. With my client, I already had rapport. He'd been in the facility for a couple of weeks. He knew who I was and he trusted me to a certain extent. If this is somebody you don't know from Adam's house cat, then build rapport. Before issuing orders or edicts, start understanding the person first. For further reading, you want to look at client safety and crisis intervention. I put the hyperlink in here and you can look at this book online in previews of it. And if it's something that you think is useful, you can always purchase that book or even get it at your local library. This book is at a lot of local libraries. In summary, change causes crisis. Crisis is an extreme state of anxiety. Something's got to happen. It's important that we hear the client, not just listen and go, yeah, yeah, yeah, yeah, yeah, yeah, yeah, okay, you need to do this. We hear them, we understand from their perspective what's going on. But that requires them to educate us. And sometimes we will never understand. Like I said earlier, people in crisis tend to be very attuned to when you're lying or when you are trying to hide something. If you don't get it, don't say you get it. Try not to tell them, I understand this. I would like to understand. Or what I'm hearing is people in crisis. One of the things we talked about before with isolation is they don't believe anybody understands. They feel isolated. So if you can develop that rapport where they feel like you at least sort of get it, you're going to have gone a long way. Help the client re establish equilibrium. Identify environmental and social supports. Social supports are people, obviously. Environmental supports are things in the environment that can help keep them safe or help them reach their goals. Whether it be if they're feeling bad, they need to go to their church and pray, or if they're feeling like they're going to use, they need to go to a meeting. These are roadblocks, if you will, to the suicidal or homicidal or crisis oriented behaviors. Develop a plan. Write it down. I didn't put write it down on here, but it's important to write it down. In crisis, nobody remembers anything. You need to write down point by point what they need to do. And keep it simple. Keep it very, very simple. Like I said, don't say, okay, tomorrow morning when you get up, you need to call these 14 people. No, tomorrow morning when you get up, you need to come to my office. And then we will talk about making these contacts and we will do it together then. The client's not fretting about it all night long. Take action. Take the next reasonable step, whether that be committing the person to a facility, putting them on suicide watch, having somebody call them every four hours, whatever the action is, in order to guarantee the person's safety or at least try and to ensure that the person has future plans and is willing to receive a phone call from you. When in crisis, clients may act out against themselves or others. Just remember that a cat backed into a corner is going to lash out. That cat may normally be the sweetest thing in the world. It's scared. And people in crisis are reaching back into that primitive part of their brain that goes, I can't do this. You need to get away. Danger. Ensure your office and common areas are free from potential weapons. Develop a safety plan for your exit, removing bystanders and other staff and aiding other clients who may have already been injured or be involved in the situation. Never make promises you can't keep. When you work with people in crisis, it's important to remember that they're doing the best they can with the tools they have. And acting out, which is typically what we're calling it, either against themselves or against others, is the only way they know at this point. They've tried every other thing in their arsenal that they can think of to get attention to help them. They're saying, help me, help me, help me, help me. Nobody's listening. So then when it gets bad enough, the behaviors ramp up. If they're asking for help, if they're even willing to talk to you, they don't want to die. They don't want to kill somebody. They want the pain to stop. And that's our job.