TASK 6: THE VOICES
- What was your internal dialogue like?
- What were the voices in your head saying?
- Were they mean? Were they positive or negative?
- Describe what you noticed.
Supporting someone through a difficult time can stir up many emotions. We can feel sad, worried, helpless, frustrated, awkward or even angry. This is normal.
As compassionate and caring humans, our natural tendency is to jump in and try to “fix” the problem. We will do everything we can to relieve the suffering of those we care about. But sometimes the way we offer support has more to do with relieving our own discomfort and distress and this is where things get tricky.
It becomes even more difficult if the one you’re supporting lacks insight into the problem or refuses to accept that a problem exists.
When we know someone really well, it is tempting to assume we know what they need at all times. But we don’t. Each of us responds differently to different situations even if the situation is similar to previous ones. Just because someone needed “X” in the past does not mean we should assume “X” is still relevant.
If you’ve ever traveled by airplane, you are probably familiar with the oxygen masks. Flight attendants tell us to put on our oxygen masks first before helping others. If you’re feeling exhausted, angry, sad, overwhelmed or frustrated, take a moment or two for yourself. Close your eyes and take a few deep breaths focusing on your breathing. We can’t help others if we aren’t taking care of ourselves.
Many of us might feel an urge to offer reassurance or advice if silence sets in. Resist this urge. Sitting with someone in silence can send the powerful message that you are there to listen whenever they are ready. Offering advice or quick reassurance can be perceived as dismissive. Have you ever cried in front of someone else? What would feel more reassuring, response number 1 or response number 2?
1) “Oh no, don’t cry, it will be okay.”
2) A silent hug or gentle back rub.
Nonverbal communication is very important. Position yourself so your entire body is facing toward the person you are consoling. Lean forward slightly without violating personal space and make eye contact. But don’t stare if they aren’t looking at you.
Sometimes we need a hug, other times we need space. Or maybe we don’t know what we need. Regardless, if you aren’t sure what someone needs, simply ask in a compassionate, supportive, and curious way. Example:
“What can I do to support you during this really difficult time?”
Reassurance is okay, but validation is better. Being honest and genuine is of upmost importance. Making promises we can’t keep or offering a false sense of hope can be more hurtful than helpful. You will never go wrong with validating someone’s feelings, even if you disagree or believe they are overreacting. “It’s going to be okay” isn’t as supportive and nurturing as “I can tell this is really upsetting you.”
Using a technique called reflection can help you become a better listener. When reflecting, you will repeat back what someone has just said to you, but in your own words. This shows that you didn’t just hear the other person, but you are trying to understand them.
When used correctly, reflections receive a positive reaction and drive a conversation forward. The tone of voice you use for reflections is important. Use a tone that comes across as a statement, with a bit of uncertainty. Your goal should be to express: “I think this is what you’re telling me but correct me if I’m wrong.”
Your reflections don’t have to be perfect. If the other person corrects you, that’s a good thing! Now you have a better understanding of what they are trying to say. Try to reflect emotions, even if the person you’re listening to didn’t clearly describe them. You may be able to pick up on how they feel by their tone of voice or body language.
Focus on reflecting the main point. Don’t worry too much about all the little details, especially if the person has a lot to say.
Supporting someone who is acutely agitated, manic (i.e., impulsive, irritable, grandiose, distracted) and/or psychotic (e.g., delusional, responding to internal stimuli) can invoke a number of emotions and reactions in both parties. It becomes even more difficult if the individual you’re supporting lacks insight into the problem or refuses to accept that a problem exists. Supporting someone in a heightened state can be a bit trickier and requires a slightly different approach. Again, one size doesn’t fit all but here are a few tips.
When supporting someone in an excited state (i.e., impulsive, irritable, agitated, psychotic) remember that they are in a state of heightened arousal and are easily triggered. Surrounding them or crowding them both physically and emotionally can induce panic and a sense of being trapped. Always maintain your distance and give them both physical and emotional space. Demanding or commanding someone to seek help is not helpful. Allow them to vent but place a limit on it. For example, allow the person to vent for two minutes uninterrupted before intervening.
When assessing safety, share your concerns in a genuine and heartfelt way.
“John, I am feeling worried and concerned about the way you’re behaving and the things you’re saying. I really care about you and I’m wondering whether you might be thinking of hurting yourself or hurting someone else. What do you think about these concerns?”
Although this sounds trivial, it is actually important. You don’t know what an agitated person is really thinking. Perhaps they are paranoid and think you are trying to hurt them. Placing your hands in your pocket or behind your back is not good practice. Always show your hands. This way the individual doesn’t mistake your hands in your pockets for your hands reaching for something hurtful.
While some would not agree with this, using the defeated wolf approach by slouching your shoulders and looking down can clearly convey you aren’t a threat. Puffing your chest out, raising your voice, assuming a threatening stance, or staring the person down signals dominance and aggression which may worsen the situation for all involved.
Use an empathetic tone at a normal volume and show genuine concern. Letting the individual know how their behavior is affecting others is a very useful tool. For example:
“Mr. Thomas, I can see you are speaking quite rapidly and seem very irritable and impulsive. This really concerns me and is making me uncomfortable.”
One of the most useful strategies in de-escalating an acutely heightened individual is to offer safe choices. A major reason people become agitated or aggressive is because they feel a loss of control. By offering choices it can provide comfort in knowing that autonomy is being respected. In these situations, asking someone what he or she needs is rarely helpful as they often don’t know what they need. By offering choices, you maintain some control over the situation while also giving some control to the person you’re supporting.
Loud voices, noisy surroundings, yelling, and crowded spaces are not helpful in de-escalating an agitated person. The intensity of external stimuli can make or break a situation. Try to remain calm, speak in a normal tone and volume, and keep external noise to a minimum. Providing a quiet space can be soothing for an agitated person.
Remember not to take anything personally. People can be heightened for many reasons, but it is unlikely that you are the primary reason. Being authoritative is not helpful. Make an effort to establish a collaborative relationship. Let the individual know you are on their team and there to help.
Blaming doesn’t work. In fact, it is hurtful and could escalate agitation and aggression. Be sure to share how the individual’s heightened state isn’t necessarily their fault.
This is very important for someone in an acute manic or psychotic state. If the person sees a psychiatrist or mental health professional, suggest they reach out to them. Offer to sit with them while they do so. If they don’t see a mental health professional, encourage them to seek help and/or offer to reach out on their behalf. But don’t do this in a threatening manner. Do not say, “if you don’t do X, then I’m going to do Y.” Consider this alternative:
“I’m so worried about you and I care about you so much. What do you think about us calling a professional who can better help you? What do you think about us going to the hospital together to see if there is medication or other professional help that might make your situation a little easier? It hurts me to see you this way.”
This discussion wouldn’t be complete without mentioning empathy. Empathy is the capacity to share and understand others (i.e., the ability to place oneself in another’s shoes). Empathy can be divided into two types, cognitive empathy and emotional empathy.
Cognitive Empathy: Understanding another’s position from an intellectual perspective.
Emotional Empathy: Understanding another’s position by sharing similar emotions.
We can appreciate the difference with the following example:
Your best friend Sally recently found out her spouse, Dave, has been texting another woman. Sally comes over to your place in tears.
“I am so mad! I can’t believe he would do this to me! I hate him!”
While you might understand why Sally would be angry and upset, you might not actually feel angry and upset as well. Sally reveals that she doesn’t actually know if Dave is texting someone else but suspects he is based on his recent behaviors. Sally also reveals that she didn’t receive a promotion at work recently.
Cognitive empathy is your understanding of Sally’s reaction. It makes sense. But there are still many unanswered questions. Perhaps Sally is feeling unwanted and rejected because she didn’t receive the promotion and is now feeling insecure about her relationship with Dave. The best support for Sally is a healthy balance of both cognitive and emotional empathy, what I call Goldilocks Empathy.
Too much cognitive empathy and you might come across as “too cold” and dismissive. Too much emotional empathy and you might come across as “too hot” and potentially reinforce a negative pattern of behavior. The goal is to share understanding on both emotional and cognitive levels as we strive for Goldilocks Empathy.
Many of us are more prone to one type of empathy over another (i.e., some of us tend to be more emotionally empathetic and some of us tend to be more cognitively empathetic). Achieving Goldilocks Empathy takes practice and doesn’t come naturally for most people so don’t get discouraged!
Learn about the bipolar disorder spectrum, manic episodes, and depressed episodes.