examining-the-foreshore

Dealing with distress


From time to time anyone who works with people trying to help them make changes in their lives will encounter someone who is overwhelmed, distressed and generally not willing to (or able to) take even a tiny step forward. It’s hard for us as therapists because, after all, we want to help people – but hey! This person in front of us just isn’t up to it!

I think many of us who weren’t trained in psychology can find it really hard to know what to do, and like all humans, we deal with feeling helpless by hoping to avoid it.

Some of us will tell people what to do – this is the way most of us were trained, so it’s what we do when under threat. We might couch this advice in fancy words, but essentially we try to get the person to make a change on the basis of our expertise and superior position. After all, the person came to us for help, right?

Some of us will feel stuck ourselves. Perhaps we’ll give up, or blame the person we’re sitting in front of. They’re not motivated/willing/ready so we stop trying and back off.

In both of these situations, the person’s actual needs at the time can be inadvertently ignored. They’re distressed and we either ignore and advise, or back off – when perhaps what they’re really wanting is someone to be present with them and offer them time to work together on the next best step they can take.

Here’s one way I’ve used to help people who are stuck, distressed and not certain.

  1. Be fully present and let them express what’s going on. This means listening, perhaps asking “can you tell me more about that?” or “it’s tough but are you willing to talk me through what’s going on for you right now?” or “what’s your theory on why you are feeling what you’re feeling?”
  2. Listen with an open and enquiring mind and heart. That means absorbing what they’re saying without trying to respond to it. At the most, you can reflect what you hear, perhaps saying things like “I think I understand that you’re feeling [sad, afraid, overwhelmed], do I have this right?”, or “From what you’re saying, you’re not sure [what’s going on with your rehab] and this is incredibly hard”, “if I’ve heard what you’re saying… is that what you mean?”
  3. Breathe and be mindful of your own response before charging on with the session. It’s OK to tear up if someone is saying something that would make you feel sad. It’s OK to feel aghast that this terrible thing is happening. It’s OK to notice your own body tighten up, your breathing change, not to know what to say. Just notice this in yourself BEFORE you respond. If you do feel something, respond naturally – normalise the experience described by the person as being something anyone in their shoes would feel, and reflect your own response to it. You can say things like “Oh that sounds like such a tough situation” or “I feel a bit tearful myself when I listen to what you’ve been through”, or “I really don’t know how to respond to what you’ve said, I’m lost for words, it’s really hard”.  The purpose behind doing this is to acknowledge that we’re human too, and get affected by what we hear. To be transparent and real so that the person is aware of your own readiness to “show up” and be fully present alongside them.  If you need a moment to catch your breath after they’ve told you something emotionally charged, say so.
  4. When you do respond, summarise what you’ve heard and ask them if that’s what they intended to mean. In motivational interviewing terms this can be called “giving a bouquet” – collecting together a summary of what the person has said, then offering it back to them to check you’ve understood (and it also shows them you’ve been listening).
  5. Before doing anything else, ask them “where does this leave you?” or “what do you think you should do right now?” or “what’s the next step for you now?” People have ideas about what to do next, most times, and we work more effectively with those ideas than if we try to bolt on some piece of advice without recognising their thoughts.

A couple of nice tools to use at this point are the choice point  , and the matrix by Dr Kevin Polk.

The hardest part of responding this way is often our own response. Because we feel uncomfortable, and we’re aware of timeframes, expectations, and because we probably don’t enjoy people crying or being angry in our sessions, we often don’t want to take the few moments needed to be present with someone who is in the middle of it all. Being present is about being there and not trying to change the situation, or rush away from it, or fix the problem – it’s about being willing to bear witness and honour the vulnerability that person has shown us. What a privilege!

It can be emotionally tough after a day of seeing people who are feeling distressed. I think this is where using mindfulness as I’ve described above can be really worthwhile. Noticing what our body is doing when someone is distressed can help us notice the work we do (and help explain why some of us don’t want to talk to anyone at the end of a hard day!). The odd thing is, that when we honour someone by being present and not trying to change their situation at the time, we often find the person is ready to move on and engage in therapy far more quickly than if we’d tried to “make” it happen. At least, that’s my experience!

A good clinician once told me “never be afraid of allowing someone to have a crisis, because after a crisis, shift happens”. I’ve found that to be true.

I’d love to know your thoughts on this post – I don’t have loads of references for it, but a couple that come to mind are:

Beach, Mary Catherine, Roter, Debra, Korthuis, P. Todd, Epstein, Ronald M., Sharp, Victoria, Ratanawongsa, Neda, . . . Saha, Somnath. (2013). A Multicenter Study of Physician Mindfulness and Health Care Quality. The Annals of Family Medicine, 11(5), 421-428. doi: 10.1370/afm.1507

Goubert, Liesbet, Craig, K., Vervoort, Tine, Morley, S., Sullivan, M., Williams, A., . . . Crombez, G. (2005). Facing others in pain: The effects of empathy. Pain, 118(3), 285-288. doi: dx.doi.org/10.1016/j.pain.2005.10.025

7 comments

  1. I agree shifts do happen after these points of crisis. Patients do want you to listen. Often it is a way to talk out loud to help them open a door forward. I deal with a lot of patients with persistent pain with significant distress. What we need to be aware is sometimes the shift can be a decision for suicide as well. This is not common but it does occur. I listen but also listen for this risk at the same time.

  2. blockquote, div.yahoo_quoted { margin-left: 0 !important; border-left:1px #715FFA solid !important; padding-left:1ex !important; background-color:white !important; } Brilliant. I’m a psychotherapist and even for me, this is a really good summary and reminder. To take a step further with it, check out NVC, Nonviolent communication process online.

    Sent from Yahoo Mail for iPhone

  3. Nice post B…
    I think the paraphrasing/bouquet giving is especially essential…
    We can’t accurately or effectively react (or not) if we are making decisions based on misunderstood, incorrect, suboptimal or incomplete information…
    Just because a patient thinks they’ve conveyed a story in a language that the therapist understands and can appreciate, and that the therapist has intently, openly and wholeheartedly listened, doesn’t necessarily mean they’re on the same page – at least at that point…
    The other thing I’d add, is that the above process doesn’t ALWAYS occur over one session…
    It can take time (amongst other variables) for a patient and a therapist to ultimately connect and move forwards on the same wavelength…
    And for crises? Well, they are entirely normal and potent potentiators of change…not that I try to facilitate an increased frequency of them…
    No references to add sorry🙂

  4. Great post Bronnie
    I watched many of the videos and it makes such good sense. i enjoyed being in the moment and thinking about my answers and what i could do about the feelings i had and i could see myself wanting to fix things for patients with advice when maybe they only needed to be understood about where they were at the time.
    really great info recommend going through the activities in the videos

  5. Congratulations on writing such a thought-provoking essay, Bronnie.
    The “Choice Point” is in parallel with our behavior as clinicians to either:
    1. Move towards the person we are with; seeing, listening, feeling, then comprehending. Which leads to acting effectively, with integrity through our values, strengths and skills, “doing the right thing,” or
    2. Move away; look away, hear what is needed to write a Subjective, callous our hearts, avoid knowing their difficulties. Which leads to inaction, ineffective treatment, blame, a festering problem for this person who has come to us for help. (and burnout, I suppose)

    “The odd thing is, that when we honour someone by being present and not trying to change their situation at the time, we often find the person is ready to move on and engage in therapy far more quickly than if we’d tried to “make” it happen.”

    I recently worked with a person who exemplifies this statement. He came for chronic pain treatment, loved to talk but didn’t seem to be very interested in the “treatment” I offered. But, getting better, he says “I think it’s the car rides making me feel better.” This guy was driving 2 hours one way to see me! It was the SOCIAL interaction that he needed, not physical therapy or TNE.

    People are amazing in their individuality!

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