Hello and welcome, I am Jose Villegas, Clinical Director of Behavioral Health at Erie Family Health Center and Community Care Expert for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar on Engage or Enrage De-escalation Strategies for Mental Health Crisis, Part 1. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinical community, our efforts have been designated to help you get the answers you need for the care of your patient. Today's webinar has been designated for one PRA Category 1 for Credit for Physicians, one Continuing Education Credit for Psychologists, one Social Work Continuing Education Credit, one Nursing Continuing Professional Development Contact Hours. Credit for participating in today's webinar will be available until April 3rd of 2022. Slides from the presentation are available in the handout area, found in the lower portion of the control panel. We will also include a handout with links to helpful videos that will help supplement today's information. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them in the question area, found in the lower portion of your control panel. We'll reserve about 10 to 15 minutes towards the end of the presentation for some questions and answers. Additionally, there are two points in the presentation when the speakers will ask you, the audience, for responses to the discussion questions. Please use the question area to respond. Now I'd like to pass on the presentation to today's faculty, Dr. Mark Fagan and Mr. Brian Bean. All right. Thank you, Jose. Welcome, everybody. We have quite a few in the room and quite a few still getting on board. And so we'll sort of introduce ourselves, give you a little bit of a background, and then dive in from there. So my name is Mark Fagan. I am a clinical psychologist and Senior Vice President of Clinical Operations and Youth and Young Adult Services at Thresholds in Chicago. In that capacity, I oversee a lot of comprehensive programs for youth and young adults in particular that have pretty serious mental health conditions. In regards to our presentation today, talking about crisis and crisis de-escalation, I've been working in that area for over 20 years and been trained in a number of different crisis de-escalation and intervention techniques, including things like CPI and PCI and a number of others. And what we're bringing to you today is kind of a culmination of a lot of that stuff. In our programs, we provide services for youth and young adults that are living residentially, that are living in their own apartments, for young people with early psychosis living in the communities, as well as employment services, other psychiatric-based services, parenting supports, and working with homeless youth as well. And here's my picture. Hey, Brian, you stole my picture. Oh, you're using my picture, Mark. Sorry about that. That's okay. Why don't you show me? That's weird. You stole my picture too. Weird. Hey, y'all. I am Brian Bean. I'm the training coordinator at Thresholds, which Mark described. And I train all of our staff at the Youth and Young Adult Services in various crisis de-escalation techniques and sort of consults on events as well, and also did direct care for over a decade, not just training in how to de-escalate crisis safely, but practicing it and using it. So my experience is both as someone who's been training it for a while and who has been sort of providing and intervening in crisis situations with the youth that we care for. So these are our real pictures. We really like that nice guy with the tie, but this is what we really look like. And so we're going to be taking our culmination of multiple kinds of crisis intervention strategies and intervention strategies along with things that we have learned and experienced and utilized within our own practice over these years to sort of put it together in a small package here, knowing that doing it over webinars is very different than practicing these skills live. But the idea here is that we really want to be able to give you some of these areas to be able to work with. Disclosures-wise, we don't have any relationships or conflicts of interest related to the subject matter of this presentation. And let's jump over to learning objectives. So what we're hoping that you all will get here is, with completion of this, being able to really evaluate the causes, traits, dynamics, and stages of a crisis situation, being able to develop those skills of self-awareness, and we're going to focus a lot on that today, being able to use that as a tool for crisis de-escalation, and then utilizing some new skills of nonverbal communication. We'll get into active listening and some other techniques to get out of power struggles and really work with folks that are in crisis and promote an intervention that deals with that. And so, you know, what we're going to be working on this first one is a lot of sort of early level skills that, you know, might seem basic at first, but to really pay attention to when you're getting into a crisis situation, and then start to build on that with higher levels of crises. And then in part two, which we'll do in two weeks from now, getting into those that are really high level of crises, building on some of the principles that we talked about today. This is stuff that can be used especially in any, really in any kind of setting, whether it's community-based or in-living-based, and especially with 988 legislation coming out, where there will be more and more crisis workers really responding to different levels of mental health crises. These are some of the bases that are going to be important to know and pay attention to as you get into those situations. All right. So today, we're going to be talking about crisis. And so, you know, the normal definition of crisis is any period of intense difficulty or stress. And as it pertains to our work, usually we're talking about when an individual is in crisis, when they are in a period of intense difficulty and stress. And so our understanding of what that is, is something happens. An individual experiences some sort of situation that may be an event that occurs in the world and may be a trauma reminder, reminding them of past trauma. It could be, you know, intrusive voices. Any sort of experience or perception that is perceived as being intolerably difficult is something that they can't handle. Their resources and their coping skills they usually have to deal with stuff doesn't really work. And so we see something happens. They go into crisis. And it's usually characterized as being a point in time in which there's potential danger. It is distressing and difficult and usually, in the situations we intervene in, dangerous and potentially unsafe. Slide. So, Brian, tell us why this is your favorite picture out of the whole slide. So this is, of course, the meme that goes with everything's okay. And a crisis is a period in time in which everything isn't okay. But maybe, you know, if we're effective crisis interveners, we can be as cool, calm, and collected as this little dog with the coffee cup, even with the world being on fire. Ooh, good symbolism. Love it. I won't have that in-depth description of each picture, I promise. So when we talk about crisis situations, I want to get a little interactive. And so people can use the questions tab in the GoToMeeting dashboard that Jose sort of said was a way to interact. And people can just go in and just write, what are some typical crisis situations that you encounter? And, Mark, if you get some good ones or some trends, if you want to just holler them out. But while people are putting those in, I'll just kind of describe some of the stuff that we deal with to kind of paint a picture when we talk about when we talk about crisis. And these are situations where, you know, someone we work with is meeting with their case manager, and they get some sort of bad news, some disappointing news. And the response is, you know, the screaming, the yelling, the trashing the office. This is someone, you know, missing a job interview or going to an appointment and going poorly, and them running away. It can be, you know, property destruction, breaking of glass, screaming, yelling. All these sorts of situations in which sometimes very normal events can set it off if the person can't handle it. Sometimes it can be dramatic and more sort of life-changing events. It can also trigger someone responding with crisis behavior. Did we get anything interesting in the chat, Mark? Yeah, we got a ton. So, you know, a lot of situations where there's suicidal ideation or homicidal ideation, something that we deal with quite a bit. Folks getting aggressive because they feel like others aren't listening. Worries about housing or getting rehoused. Panic attacks. Sometimes illusions of grandeur that's going on. Money problems, not being able to pay bills and really worried about what to deal with there. So quite a bit on here. You know, having folks with medical crises that are going along with their psychiatric crises. You know, wanting to throw themselves in the traffic or jump off top of buildings. Lots of stuff that we've seen and we deal with. And so all of these are going to be situations that are going to be helpful to break down kind of with the dynamics that we're talking about here. Yeah. I think just one trend of that is like, you know, any difficult event, if the person can't handle the associated stress, can go into crisis. And the range of behavior can be quite broad and shocking and frightening sometimes. So you identify a crisis situation. It's apparent. Okay, what do I do? And so we're going to sort of go through today intervening in a crisis situation. And in that decision, like, what do I do? How do I step into this situation that is frightening, that is scary, that is unsafe? We want to keep in mind three kind of following questions we want to ask ourselves. And so the first is, what's going on with me? And so before you step into the crisis situation, before you say your first word or step into the room or whatever, the first thing you want to think of is, what's going on with me? The next one is, what's going on with the person in crisis? And the last one is, what's going on around me? And so these kind of three guiding questions, we're going to go through in the next slides and sort of piece through exactly how we want to go about them. But they're basically quick checks. You're not going to sit down and, you know, ponder deeply what's going on with you or the person in crisis around me. We want to make sure that before you act, before you step in, we want to sort of check in and go through each of these questions internally to help us guide to an effective intervention. So that's part of why what's going on with me is really one of the first places we want to start. Because as we're getting into a crisis situation, whether it's happening on the spot with you present or if you're getting called into a crisis situation, we've got to be in a position where we're mentally prepared to manage what's going on there. And what happens when crisis is going on is that our adrenaline kicks in, right? We know that our natural response to chaotic and dangerous situations are that fight, flight, or freeze reaction. And that's natural, and we have to know that that's going to happen. The idea is, like, what do we do with it when that does go on? And so the most important thing that we can do in that crisis situation is to try to respond rather than react. And so the idea here is that we want to avoid reacting to our instincts that might be around that fight, flight, or freeze, and instead be able to respond to the person in the situation. We've got to be in a mental capacity to be able to handle what's going on there. But to get there is a little bit more tricky than us just talking about it. And so making sure that we respond instead of reacting requires that self-awareness. So if you ever really want to test this, what you want to do is get in a room with somebody to surprise you and just start yelling at the top of their lungs to you. And pay attention to what happens to both your body, your mind, and what you're seeing around you, and then what you can remember from what they're saying. I promise that it makes a difference in terms of how you take your next steps. And so when we think about self-awareness, self-awareness in crisis means sort of actively scanning yourself to really understand how you react in these situations. And you want to think about that in terms of periods before or periods of not involving stress. So these are those times just in general. And you can do this work outside of any kind of crisis work. What are those things outside of work that affect you? What are the things that really kind of get to you? And so this is something else that you can put in the question box right now is, what are your personal triggers? So what are your personal triggers? What's sort of getting you really hot? Like for me, and I can talk about this especially now, coming from Chicago where it's snowing outside, how slow traffic can be sometimes. That gets me hot, right? Brian, do you have anything that's your personal trigger? Well, with working with the youth that I work with, it's like bullying behavior. Like people picking on people who are smaller than them just gets under my skin. Yeah, good. Good example. So keep putting those in the questions, and I'll get to that. So you want to think about what your body's common reactions to stress are. Do your fists tense up? Do you get a hot face? Do you feel pressure in your forehead? Where do you feel that? Because knowing that is going to help you indicate where you are before you get into a crisis situation. But then also, what are the values, beliefs, and worldviews that may affect how you see crisis and how you handle that? Understanding each individual's approach to that makes a big difference. So really taking a look at it from your perspective really matters. And so there's a couple things in the chat about, like, loud noises, people being rude, yelling, disrespect. That's a big one. Noticing the manipulation that's happening. That's another one where people feel like they're either being used or they're being manipulated. Or somebody imposing themselves on somebody else. I got one that's just general, youth and foster care. So, you know, there's some things like that that can really get that going, too. So we got a handful of them, and keep them coming. It's important for us to know that. So if you aren't sure what gets you hot, ask somebody you're closest to. Spend some time figuring it out. It makes a difference in really being aware of that before you get in a crisis situation. But then when we talk about in periods under stress, that's another level. What are the emotions that you're quick to feel? Are you quick to feel fear? Quick to feel anger? Quick to feel panic? What is it that's sort of your go-to that's your fight, flight, or free? So you know to recognize that when you're under stress. And what are your thoughts saying? You know, if you can hear that tape recorder, what are the things that you hear? Do you hear panic? Do you hear negative self-talk? What goes on there? And then are there ethnic or cultural differences that affect your responses under stress, right? So, you know, for instance, I used to work with somebody who would talk quite a bit about, like, you know, this isn't mental illness. I don't really see that mental illness is a big part of this. It's behavior and it's manipulation. And so, like, and so they're talking about their background with mental illness made a difference in how they react under stress. So being aware of that can really matter. And as we think about this a little bit more, you know, the philosopher and poet Ice Cube probably said it best. Brian, do you remember what that quote was? I believe you better check yourself before you wreck yourself. Right. Exactly. And so very similar to somebody who's in crisis, somebody who's in crisis often is not accessing their cognitive abilities at the same level. Think about people you've dealt with when they're really angry. And then later on, they're like, man, I just lost my head. I don't know what I was saying. I didn't really mean that. And a lot of times that's because their emotions are flooded and taking over. Same thing happens with us. We have to know that that parallel takes place and that there's a natural element of it. And we're not going to get into all levels of brain behavior around that. But but, you know, there's brain functions and body and body elements that really play a role here. So these results responded impulsively doing things instead of responding therapeutically and sometimes enraging the person that's in crisis instead of engaging. And so moments of crisis here, we really want to be strategic in our decision making, how we approach that. And in doing so, we want to increase the responding to that person rather than reacting to our internal subjective feelings. So what that means is really managing that internal dialogue, managing those thoughts in our head that are keeping us going. And that subjective feeling that comes with a crisis to be able to recognize that's going on. Do some of your own quick check ins and then be open to responding to the person in front of you in the situation that's going on. And so that emotional competence makes it easier to manage our feelings and reactions and really easier to manage others in crisis. So if we're alive, we could do some practice with this and really kind of diving into this. But I encourage you to do some of this on your own, do a little self reflection and get yourself in a position where you know what your triggers are before you get in a crisis situation so that you know how to kind of pivot when that's going on. So Mark guided us through that first question, like what's going on with me? We've done that self check, you know, how we're feeling, how's our body feeling, evaluating our stress and anger levels. And then we want to move on to thinking about what's going on with the person in crisis. And in doing that, it's important that we start with the thing I mentioned before, which is knowing that the crisis is occurring because the person that you're dealing with encountered some stress or trauma reminder. Difficult to manage emotion, a hard thought that for some reason they weren't able to cope with. And we see that they aren't able to cope with it because we see a change in behavior. They're acting in a different way than they sort of act in a normal, normal day. Slide. And I think through this, it's important to think about the way that crisis is usually related to trauma and what we call the trauma driven perception that occurs in the brain. It's something that is bodily, that is physical in the brain, that sort of switches on and can make it difficult for people to be able to cope. And so we have to understand that advance. That individuals with trauma histories, and I think this is especially the case with folks who have complex trauma histories, have an overactive survival brain. Because of a perception of the world being unsafe that's been shaped by their real lived experience. You see danger where maybe there isn't danger. The metaphor of kind of standing on the balls of your feet, of feeling jumpy is something that's the case. And so what that means is that advance, that potential dangers and difficult emotions may more rapidly trigger these automatic survival functions. And so to something that may not be as dangerous as it may appear to the person because of their real lived experience. Some of that fight or flight freeze responses, advance, will kick in. And so knowing that crisis is something that isn't usually a cognitive choice. It's not, oh, that reminds me of this thing that's difficult and so I'm going to act out. But it's a physical reaction that is sometimes shaped by the way the trauma impacts the brain and the perception of the world of danger, of safety, and the ability to cope. And so with that, I think important kind of trauma driven perception undergirding talking about crisis. Let's advance the slide. We want to understand, okay, so what's going on with the person in crisis? We've got to kind of know what crisis is. So it's important that we understand that it's not like a on off switch. You're not in crisis or not in crisis. And then when you're in crisis, it's all the same. But there's different levels of stress, of arousal and behavior based on things that happen when the young person is in the general category of not acting like they normally are. And if we're able to determine where there are in the level of crisis, that actually helps us determine how we're going to respond. If I'm going in with someone who I see that they're upset and angry and maybe beginning to get really sort of frustrated, then I'm going to intervene. I'm going to pick different tools in my toolbox than someone who is actively breaking a window or something like that. So, us being attuned to the different levels and seeing it not as a static state is really an important tool for us to be able to evaluate, hey, how do I exactly respond at this moment? And the metaphor that we're going to use is that crisis is like a volcano, where there's different degrees of danger, eruption, and thus different things that we can do when we are trying to respond to intervene and deescalate the crisis. Slide. And so, we'll use this metaphor of the volcano to kind of talk about it. Are there words on here, Mark, on the slide? Yeah. And so, we have the dormant phase, the venting phase, the fuming phase, the eruption, and then finally the explosion. And so, we're going to go with the cooling. So, we're going to go through these and talk about what these mean a little bit. And it's a conceptual tool. It's usually not black and white. It's going to differ from person to person. But I think it reflects a continuum of both emotional arousal and behavioral escalation that I think does have some trends. So, let's talk about them sort of piece by piece. Advance to the dormant stage of the crisis volcano. Advance slide. And if any of you guys, if any of you want to invite us out to Hawaii so we can demonstrate some of this in active volcanoes, we're happy to do so. Right, Brian? Yes. Or to correct, I'm sure, our bad seismological science. We're not experts in volcanoes by far. Really? I know. I've been fooling you all these years. So, the dormant is how we describe the person's normal everyday state. And we put normal in quotation marks because that's going to differ from person to person. It's kind of what we would describe as a normal behavior. And there may be a little smoke. I think everyone experiences different stressors that change their emotional arousal without kind of going into crisis normally. And so, there's a little bit of smoke, maybe a little bit of rumbling, even in the dormant volcano stage. But we're going to move on to the venting. So, this is when something happens, something in the world, something internally, a trauma reminder, and they're unable to cope. And then we enter the venting stage. And so, we have used some sort of behavioral descriptors to be able to pick it out. And we have some of them up here that, you know, I'm sure there's many more, but how you're able to identify that someone's in the venting. It's like, you know, they've just been triggered by whatever has made it where they can't cope. And when the lob is kind of bubbling beneath the surface, the volcano is smoking. We're seeing that something is changing with the volcano. And with the individual, you know, we see those tenseness of muscles, the clenching of fists, fidgeting, pacing, kind of that angry affect, maybe being quicker to respond in slightly sort of agitated, angry ways. Or, and I think this is important to note, sometimes it'll be more unresponsiveness. I think some of the people will become more quiet at times when they're venting. And that makes it hard to sort of pick out, but sort of hopefully you'll know the person that you're working with a little bit, and you'll get over time, easier and easier to kind of pick out where they are. So that's kind of the venting stage. Advance. So if the level of emotional arousal increases, then we may get up to where we're seeing kind of an eruption. At this point, you know, in our volcano metaphor, there's lava coming out the top of the volcano. And of course, you know, lava is, I hear, dangerous. And so the degree of stress and risk is increasing, and the potential for danger of getting burnt by that hot thing is increasing. So at this point, we've moved from kind of the pacing, clenched fists, muttering, to out night and verbal aggression, making threats, I'm going to, you know, kick your ass, those sorts of things. Minor property destruction, the individual appears, I think, by some of the common parlance, they appear enraged. And so that's the eruption stage. There's the volcano coming out, and then the behavior has increased. And then we get to the point where we have the explosion. And so at this point, you know, the top of the volcano has popped off, volcano is pouring down. At this point, it's all about safety. The situation is unsafe. There's lava all over the ground. And this is where with the individual, we have the out and out violence. So we've moved from perhaps communicating threats to a violent act being carried out against, you know, other people, fights, attacking, you know, care providers or staff can be directed itself, self harm, of course, is part of that, or severe property destruction. And so by that, we would mean, you know, property destruction, that could cause damage, not like, you know, knocking stuff off desks, but maybe breaking glass or sort of throwing desks or those sorts of things. At this point, we talk about it being explosion. Next slide. And so the idea here, too, is that, as we're going through this, what's the point? And so the point that I think Brian was talking about earlier is that we, knowing what phase a person is in will help you figure out how you're going to intervene. Because people don't just go straight from zero to 60 right away. Typically, there's usually these phases that come in. And so if we can identify these phases, we can intervene a little bit differently. So for example, you know, if somebody is just kind of saying, Oh, man, I forgot something, we're not going to run out of the room and yell for help. So, you know, thinking about what stage a person is in really helps you figure out your interventions. And so as we get through this one, we'll be talking a little bit more about the first two areas for a few clues on intervention. And then when we meet next time, we'll talk about some of the more advanced ones for those higher levels of interventions. And so as we build on what's going on with that person in crisis, sorry, Brian, did you have something else to add? No, go ahead. Okay, cool. You're just agreeing with me. It doesn't happen often. I like it. All right. So as we talk about what's going on with the person in crisis, you know, we're detecting that eruption level, we want to think about a number of different things, want to think about what might the person in crisis be feeling, right? Because we want to get beyond just that they're pissed, or they're angry, or they're mad, what's deeper? Are they disappointed? Are they disrespected? Are they worried? Are they scared? What's really that deeper feeling that might be especially causing some of this crisis behavior, right? What might they be thinking? What's going on in their head? What's happening there, especially for folks that may have disorganized thinking that may be really struggling in that area? It can be harder to detect there. Why is this crisis happening right now? What's unique about what's going on in this situation? And then what's that underlying need that's being expressed? So going beyond the behavior, going beyond even the feeling, what else is that need that's being expressed? And so our natural response is to just jump in and take care of that need, right? But taking care of that need may squash the immediate volcano and bring that lava level back down, but it's not going to address the feelings that are going along with it. And unless we're really addressing both, we're not really taking care of the crisis at the time. So want to think about the lava that's under the surface. That's that feelings and needs. Those are things that really we want to be able to address, even though it's the behavior that's upfront. So these are all kind of areas in which we want to assess what's going on with the person in crisis. Then we move on to kind of our third question, which is a little bit more of what's going on around us, right? So we want to think about maintaining that situational awareness of our surroundings and getting real specific about what's happening in our area. So when you get into a crisis situation, whether you're already there and a crisis starts off, or if you're walking into a crisis situation, where are you in relation to the person in crisis? Are you real close to them? Are you at an arm's length? Are you standing above them and intimidating them? Are they standing above you where you might not be safe? How is the space arranged? Are there things in between you that can really get in the way? Are you in a place that's really tight, really hot, really crammed, that can really kind of set off further escalation? And how much stimulation is affecting the environment? All those sorts of things. Are there loud noises? Are the lights real bright? What kinds of things might be going on that could be affecting that level of crisis too? Then what activities are going on? Are there other people that are sort of encouraging them to continue with their crisis-based behavior? Are they in a position where there's lots of other people around and that may be playing an effect? Is it that they're alone and there's usually somebody else who's there who's really good at comforting them that happens to not be there and present at that particular time? What else might be going on around them? Is the TV really loud at the time? Are things really cluttered where you're walking into? And then are there possible weapons? And this is a hard one to answer because when you think about it, anything can be used as a weapon. Anything from something sharp to a fist to getting spit on to a pencil. And so you want to kind of think strategically about what really is weapon and what isn't. And the more relationship you have with a person in crisis, easier it is to kind of detect that. And then just being able to scan around. And sometimes when you're in a crisis situation, it's helpful to sort of slowly maneuver over to a spot where you might see something that could be used as a weapon. Either shield it or move it or get out of the way of it. Something like that. And same thing with your exits. You want to be able to know where your exits are to both be able to detect if you have to make a quick escape that you're not blocked from doing so. But the other thing you want to think about is not standing straight on and blocking those escapes from the person in crisis. Because the more you do that, the more likely it is that that person is going to feel trapped and then act trapped. And that will amp up the crisis situation too. So standing kind of side to side with somebody or at a 45 degree angle and giving yourself at least some distance for people that are in those higher levels of the volcano of crisis makes a difference. The lower level volcano areas, you're able to use a little bit more closeness with somebody in order to maintain that situation. So that's kind of things to think about in terms of what's going on in the environment. And there's a lot more too. But as you're getting into a situation, that's the other question you want to be asking yourself after. What's going on with me? What's going on with the person in crisis? And what's going on around me? So then we're going to move into sort of de-escalation through active listening. Because as we start to get into that de-escalation piece, we know that we've assessed the situation. We've asked those questions. Now what the heck do we do? And with all of our interventions, how we communicate is really essential. And sometimes it's not about what we say, but how we say it and what we communicate with our body and our voice tone. That's where active listening really comes in. So for y'all, you can go ahead and use that question box and just put a little quick note on how does it feel for you to be listened to when you're in crisis? How does it feel to be understood? How do you know when somebody is listening to you? And I know for me, I can kind of feel my body tenseness go down a little bit. I can hear myself using a little bit more humor. I can feel myself kind of melting into a chair a little bit more. Those are some of the ways that I know I'm being listened to and I'm validated. You know, I'm hearing some feeling words that maybe I didn't hear before, stuff like that. Anything from you, Brian, in terms of how you know that you're being listened to? Yeah, I think to answer that in a different way, I think one of the things that we found is that Mark and I do a lot of like role-playing of techniques in which, you know, one of us is acting irate and the other person's listening. And even though it's pretend, when someone uses kind of good active listening techniques, you still feel physiologically your body calming down. So some of these responses of being listened to are physiological and almost automatic. So that even if you're like pretending to be angry, you just like calm down if someone uses these effectively. Yeah, and I got a couple people in the chat here that are talking about they feel their body kind of reduce tension. They feel, you know, they feel a little bit more validated. They start to instantly feel calmer. They feel heard. Somebody, they can tell that somebody's kind of paraphrasing. Somebody's giving meaningful responses, right? And a lot of times we are busy and we're trying to double, we're trying to take care of a couple of things in our mind. We're trying to do double duty. And when people are in crisis, they pick up on that. So really getting into that active listening mode makes a difference. And sometimes the amount of real attention you give somebody in crisis pays dividends and reducing it a lot quicker. So building upon that, I want to think about active listening as listening to understand, right? And that's different than listening to, listening to craft a response. A lot of times we're in our head trying to think about how to respond, but know that like, if you always default to reflecting a feeling, you don't have to worry about solving the problem. You don't have to worry about crafting a response. Listen to understand and reflect the feeling. Active listening is all about demonstrating that you're paying attention, right? So that builds trust, naturally calming, it reduces that tension. And it's an attempt to facilitate engagement and discovery, helping folks be able to discover what's going on, discover what's going on with them, and really detect the deeper meaning that's getting into those feelings and needs underneath. And active listening uses these areas of nonverbal techniques, questioning and responsive techniques. And Brian will dive into that a little bit more. Yeah, so the first and kind of categories of active listening is that of nonverbal techniques. And these we put first because they're the most important. If you're dealing with someone who is irate, venting or eruption stage, they're not going to hear most of the words that you say. And so really communicating your listening and doing so in a nonjudgmental sort of calming way depends on your nonverbals kind of leading in the forthright. And the first part of that is silence. I think people think of silence as a passive thing. Silence is not talking, but silence is something that you are doing. So I think we want to be able to use it to create that space to facilitate conversation, to have the person in crisis talk out what's going on. And we got to be comfortable with it. I think sometimes if we're not comfortable with sitting in silence, we'll try to sort of fill the gaps in. And that takes up the space that we want to sort of create for the person in crisis to try to vent, to talk out their emotions and to kind of explore what exactly is going on. But we also want to balance with being able to say something sometimes. We don't want to sit completely in silence and basically, you know, be comfortable with silence, use it actively, but don't be weird, so to speak. So the next one we want to sort of talk about is voice tone. I think the guidance here is we want to keep it low and keep it slow. Even if they're yelling, we don't want to mirror their voice tone. We want to be calming and eventually, hopefully, they'll mirror that. They'll sort of talk down. They'll try to listen more intently to figure out what's going on. And it really is effective to try to sort of calm them and get them to mirror it. At the same time, we want to be responsive. You don't want to be the kind of like therapy robot who is impartial entirely. We want to have our responsive. We want to be authentic and genuine with our voice tone. I think that relates also to facial expression, which is the next one. And so similarly, we want to make sure that we're avoiding appearing judgmental, that if we're feeling angry, we ask ourselves that question, you know, what's going on with me? If we're feeling angry, we got to check our face. We want to make sure we're not expressing anger, fear, anything that can be perceived as judgmental. At the same time, we don't want to be, you know, completely deadened, but we want to be responsive. They say something that they're angry or afraid about. We want to have a reflection on our face, the raising of the eyebrows, the changing your facial expressions. We want to be attuned and responsive. At the same time, we're making sure they're not judgmental. Eye contact, you know, some of this differs cross-culturally, but we want to make sure that we have maintained eye, soft eye contact, shows we're listening and connecting, but also not staring. And the last thing is that body language. We want to make sure that we're open, we're not crossing our arms, we have a relaxed posture, particularly if you're taller than the person, that you try to lower your horizon somehow, leaning against a wall, sitting down if appropriate, and then if you're sitting, leaning into the person, sort of showing with your body, I'm focusing on you, not just with my eyes, but with my shoulders, my whole body, I'm trying to listen to you and demonstrating that by how I'm holding myself. So that's your non-verbal active listening techniques. The next kind of category we want to talk about is our questioning techniques. And as Mark alluded to, the whole point of good question techniques isn't that we're just trying to get the information. We don't want to just hear what's going on, but try to sort of promote the person in crisis talking about and their own self-exploration of their situation. If we can get them to kind of be reflective at all in talking about their internal processes and their emotions, that awareness is going to be helpful in calming them down. And so how do we do that? We have a couple of different questioning techniques. The first is our closed questions. So these are the questions, you know, do you like your parents? That typically elicit the one word, yes, no answers. No, I don't. Yes, I do. Sometimes we got to get specific pieces of information. These are useful, but oftentimes we want to be avoiding these. Instead, we want to work towards trying to use open questions as much as possible. So instead of, you know, do you like your parents or your boss? What's the relationship with your boss like? How do you feel about your parents? These sorts of open questions, you can advance the slide, Mark, open questions are going to help the person in crisis to explore their own experience. It promotes their storytelling, getting them to sort of tell the conversation. Again, we don't want to just get them to tell us information. We want to promote them talking out their feelings, exploring their own sort of lived experience in the situation. And that itself is kind of the venting mechanism that will help calm them down. And then the last pro tip that we have is we want to avoid asking why questions. The reason why is that establishes causality. So why did you punch them? The answer would probably be, well, I was mad at them, but that's not what happened. You know, the reason why someone's in crisis is because they were unable to cope with the feeling. We don't want to normalize the fact that the feeling means there's the behavior, but to sort of de-link the causality to the feeling. It's okay to have feelings. We want to figure out is how we can handle them in better ways. And so why establish the causality, I think isn't good for us to sort of work on and try to avoid that and go towards more of the more how questions, but how they make you feel when you open questions is really effective. So we talked about our nonverbal techniques, our questioning techniques, and then we want to get to my personal favorite, which is our responsive techniques. And so these are going to be little kind of short statements. So you're going to pepper in to your intervention with person in crisis. That's going to be super effective at communicating that you're listening and helping with their own self-exploration. So reflective response is you making an educated guess how you think they might be feeling based on what they're saying, based on how their affect is based on what you know of their situation. You're making a guess how they're feeling. Oh, that must've been really embarrassing. Seems like you were pretty disappointed. I get that you were really afraid and we have sort of throw these things in there because it does two things. One, it hopefully helps them identify their emotions. And if you're in crisis, usually we're not really good at being able to identify and articulate our emotions, but that element of exploration by throwing in a reflective response is really key. It also shows you're listening even more than being able to ask, how did that make you feel? What kind of stock response? But you're really engaged with trying to connect with the behavior that they might not even be telling you in words, but they'd be showing you in other ways. So really effective ways of connecting with the feeling that they're showing you, even if they don't say it. I think this is key to say, this is not just parenting. You're not just saying back what they're saying. You're trying to identify the feeling they're feeling and saying, Hey, it seems like you were this. It sounds like, it looks like you are, anything like that. And then empathic statements are again, very short little statements that validate the person's experience. So in different from reflective responses in which you're going to identify the feeling, empathic responses is just saying, Hey, that must be so hard. It sucks to feel disrespected. I get that you have a lot going on. Just noting, Hey, I feel this thing you're feeling, even though we're not naming it. It's just saying, I have a degree of empathy that I think is a very impactful way and making a connection with someone who usually is feeling very alone and conveying a measure of support. And, you know, a couple of words peppered through, use them over and over again while you're intervening with someone in crisis. A little bit on supportive strategies. And these are just a couple pieces that we can try to get into that can help you in these sort of crisis situations. One of which is jumping in and assisting. And so I remember having a roommate that just struggled a ton in getting things started. And doing so, they'd get really frustrated and upset. And so by just kind of stepping in and helping them get started on a task can really help a person get going on what they're trying to do where they may be in that frustrated sort of situation. Sympathetic signals. Something where you're expressing care, concern, or support. Like some descriptive praise. So not just good job, but great job in bringing that file over here for us to look at. A smile or a fist bump. Something to kind of keep them going can really help out. And so keeping that in mind. Remember, we're not dealing with folks that are really close to that eruption phase where you wanna stay as distant as you can. And we'll get into that next time. We're talking about people that are in a little bit of a lower phase where you can do a little bit more of a smile, fist bump, be a little bit closer with them. Distraction. And we get this a lot where we have folks that are really kind of perseverating on a particular problem. And so helping folks be able to move to another activity or even find somewhere else to go and kind of switch it on to something else can make a big difference in just cutting through that stress of something that's continuing to be on their mind and be able to get back to it when they're in a little bit more of a thinking brain mode. Same with steaming off. So using those active listening skills and validating and of course, more validating. Help somebody drain off those feelings. The more that you allow somebody to get all that out, the more likely they are to bring themselves to sort of that cooling phase. And then appealing is somebody's self-interest. So reminding somebody of their goal in this situation. So like accessing their thinking brain and helping them think about like, what is it that they really want? How can we be able to get it in this sort of vein? That would be really helpful. All right, you want me to try the video again or should we just go to sum up? Let's just go to sum up. All right, cool. We'll jump into that for the next one. We'll make sure that we have a video going for you. Okay. All right. So to sum up what we talked about today, I think the first piece is intervening in crisis. We first got to understand what causes it. And I think how it develops. So seeing it not as just crisis as one monolithic block of behavior and feelings, but that it has trends within it. And that can give us clues on figuring out how to select a skill to be able to deescalate and engage the person in crisis as opposed to enraging the situation further. I think through that, the foundation of self-awareness is absolutely essential. So to make sure that we're responding to the individual in crisis and not reacting or reacting to our own feelings. So I think that self-awareness and that being something that's a continual process in our own emotional intelligence and our check-ins in the moment are super key. We talked about active listening, our non-verbals, our questioning techniques and our reflective techniques as being a set of tools that can help us try to engage, demonstrate we're listening, promote conversation and storytelling and trying to get this engagement rather than enraging in a crisis situation. And then we gave a couple of tools that we can use for those lower level crisis stages. So that venting and that lower fuming that can kind of diffuse and build that engagement, those assists, the sympathetics, those distractions to help intervene in crisis. And so join us next time when we'll talk about some other strategies that we can do at those higher level crises, that fuming and that eruption when things are a little more explosive and dangerous, how to avoid power struggles and then how to maneuver and make your cool-off period something that promotes growth and learning. So with that, I think I'll turn it back over to you, Jose. Sounds good. Thank you guys so much for a fantastic presentation. I love your energy, your humor, creativity and how you balance the intensity of this subject with some good jokes and making sure that it's light. I don't think it was intended, but the video only demonstrates how we have to deal with adversity and sometimes we have to go with the flow. Before we move into some question and answers, I wanna take a quick moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, complete mental grading skills and even submit your questions directly to our SMI expert team. Download the app now at smiadvisor.org or slash app. So we have a whole bunch of questions for you both. The first question is a basic one. Someone is asking, how do I deal with my nerves when I'm in the moment of crisis? Yeah, I think it may be self-evident, but the most important thing to first deal with the nerves is to be able to identify and acknowledge that your nerves are going. I think the next thing to do is before I go into any crisis, just to take a really deep breath. And again, it may seem something that's like super obvious, but it'd be really easy to not take that deep breath. We automatically seize up when we're getting into crisis. We automatically seize up when we're getting our nerves and adrenaline. And taking that moment to take that deep breath is real essential. And then I think that paying attention to our nonverbal active listening techniques gives you something to do and has a calming effect on you as well as it does with the person that you're meeting with. So you're thinking, OK, talk low and slow. That is going to be a conscious decision that's going to cut against, I think, a natural process that happens when we're feeling nerves, which is So I think pay attention to your skills. Let your skills guide you. And their effect is also to have a degree of calmness on you and giving you a sense of control and power in the situation and focusing on that. And I think that we'll talk about that a lot more in the next session of the webinar. Another question along the same lines is, does crisis de-escalation become easier with practice? I'm striving to respond appropriately as opposed to just reacting. Yeah, I think definitely. I think crisis de-escalation definitely becomes easy with practice because what you're doing is you're relearning our natural responses to crises. So if you haven't intervened in crisis, or even if you've only done for months or even years, our typical responses are those automatic responses. Fight, flight, freeze. Those kick in. Something is scary. Someone's yelling at you. Your automatic response that we've learned through our own life experiences is get out of here, fight back, or freeze up. And so by doing these skills over and over again, you're actually going to train your body on new responses so that when something pops off, you don't either immediately jump in between people who are fighting or turn and run away, but you're conscientious and specific and strategic by your interventions. And so I can say that from experience for sure. Doing this over and over again, you're relearning a new kind of reaction to a crisis situation. And this question is specifically around the explosion stage. Someone is asking, have you had success calming someone down when they're really at their boiling point? You want me to take this one again, Martin? Yeah, go ahead. I think the answer is yes. And we'll talk about that more again in that second webinar in which some strategies that we've used very effectively to be able to talk someone down when they're in the point in which there's almost violence. I know that Mark and I are both in situations with young people in our care who are actively destroying offices and maybe on the verge of getting in a physical fight and you making sure to keep yourself calm and using de-escalation skills. It's not automatic. It doesn't always work. But it makes it where you're not going to enrage the situation and increases the possibility of engagement. And so if you don't calm them down by doing it effectively, you know for sure you're not going to make it worse. And that's the biggest danger. Thank you for that. We're going to extend the webinar for about 10 more minutes because we have a lot of good questions in the chat box. And I want to make sure that people leave with the answers. So the next question is, I recently had a reaction to a situation and I didn't know if it was worth apologizing to the young person or is that a sign of weakness? Yeah, good question. And we run into this quite a bit. And so I think that there's two elements to this. We'll be talking about some of the higher level crises next time as we talk about. And during those things, there's some strategies around apologizing or saying, man, I'm so sorry that that happened to you. I'm really sorry that you're going through that. So it's one level of apology that we can talk about. I think what you're saying is when you are escalated maybe with somebody at that level. And so when that goes on, when you're in a situation of cooling, which we'll also talk about next time, it definitely is OK to be able to apologize because we are all human. And I think it bonds you with that person in crisis too, that like, hey, I'm sorry I got hyped up also. Or I'm sorry that I didn't respond to you as calmly as maybe I should have. I think it shows both some mutuality as well as some bonding opportunity. And doing that during a cooling phase can really be helpful. Thank you. I have a person here that submitted a question. They are a first responder. And they are saying that after an incident, some people react in an emotional state. And they don't have the time to actually help them de-escalate. They're asking for resources to help the person in the moment. But there's not a lot of time to sit and process the situation. Yeah, and so I think I'm trying to detect the question a little bit clearer. I think what you're saying is that in the situation, you don't have a lot of time to sort of process maybe those three questions that we're talking about in terms of what's going on with me, what's going on with the environment, what's going on with the person in crisis. And I think in terms of that, the idea is that we're asking those things to ourselves very quickly. And the more that we're used to responding quickly, and as a first responder, I imagine this goes on all the time, being able to take that time either walking into the situation or at that situation as quickly as you could is going to help you be able to get to that state to be able to respond. But it oftentimes does have to happen quickly. The other part of maybe what you're getting at is, is this a resource thing, right? Meaning that, like, do you need to be able to get somebody something in the moment rather than processing that through them? And that's a little bit of a different story. And yes, that may be the case. The thing that's important to know is that sometimes the thing that that person needs may be the resource, but sometimes even more, the ability to manage that situation for themselves and learn coping skills to be able to do that. And they're only going to get that by you reflecting the feelings and having that self-awareness to be able to get yourself in a calm place and get them in a calmer place. I hope that sort of answers what you're getting at. Yes, we're addressing the foundational approach to the needs. So a person doesn't necessarily have the time to ask the three questions. They're looking for a response about a healthy person. So it's a perfect response, Mark. I have another one that's going to be down your alley. The person is saying, I work in a residential, and some of the young folks or some of the young patients thrive with physical touch. Should I avoid touching them when they're angry? Brian, you want to take that? Or do you get to that one? Yeah, totally. I think that the answer to that question relies entirely on being able to accurately identify where they are in the kind of levels of crisis. And so particularly if they respond positively to touch and your relationship makes it appropriate for you to do so, if they're in that lower level venting, I think giving a sympathetic statement or sort of a little bit of pat on the back or something like that can be really effective. I would be very hesitant to see that as an intervention when they're at the higher level, the eruption, the higher level fuming, because most often, even if they respond positively to touch generally, that's something that could spark the aggression tipping over into outright violence. You know, that may differ from if it's something for an individual that I think a care team could identify. But I think generally, the answer to the question is you got to know where they are on the kind of levels of crisis and that venting and fuming, that's something that can be really effective, but it's going to be counterproductive and even dangerous if you do it at that higher level fuming and the eruption stages. Thank you, Brian. So we have a few other questions. The next question is, what is a healthy way to process an incident after a strong episode of aggression? And so we'll talk all about that. Yeah, I think that's a good way to put it. We'll be talking quite a bit about that in the next webinar, and there's a lot to it, but just a couple of different pieces around it is making sure that you're also in a place to be able to do that with them. And so making sure that you're regulated and in a position to do that, and they're also in that phase. And then being able to kind of deconstruct what had gone on and kind of access the feelings and needs that were behind it so that you can help them think about strategies for next time, those feelings and needs come up. But we'll talk a little bit more about that next time. And then I think through that cooling off stage is going to help them talk out what's going on and kind of bring them back down to normal. And so I think just focusing on those questioning techniques and just leaning into those kind of reflective responses and empathic statements are going to be a real key too. So active listen, active listen, active listen. Thank you. Thank you for that response. I have another question here. It says, how do you manage a situation when there's multiple people involved? Yeah. So I think that is that third question about kind of what's going on around the situation that's super key. And so what I do if I come into a situation and there's multiple players involved is knowing that one of the easiest things that you can do is to kind of reduce the audience and the amount of people who can get involved. And so it's like, who can I get out of here? And that might not be initially the person who's the most angry. And so I think, you know, do a quick check and be like, is there someone who is calmer and might respond to me asking them to leave or go somewhere else? Is there someone to have the relationship with that could ask them to leave and get somewhere else? And the idea being, you know, who all can we get away as much as possible? And that may be people who are still upset. But if you separate someone who's, you know, pretty upset with someone who's irate, that's gonna decrease the potentiality. They're gonna kind of play off each other and get up to a situation that's really dangerous. So yeah, try to remove as many people as possible. And usually you're gonna wind up moving the people who are more calm in the situation. Yes, it's easier to move the audience than the person that's upset. Absolutely agree. The last question that I'm gonna field here is, one of the listeners is saying, I try to listen to and understand, but I often struggle to identify the need. Do you have any advice? I think that the main thing for that is using those reflective responses can be really helpful. And so, you know, reflecting back how we think they might be feeling, because feelings obviously are evocative and reactive to needs. And so just doing that over and over again is gonna help the person you're talking to explore and you kind of checking in how they're feeling. Because if we get something wrong, if we're like, oh, you know, you're feeling embarrassed, and they'll usually just correct us. No, I wasn't embarrassed. I was, you know, such and such. So I think just using those more often than we do use in, you know, the conversations with our friends and family is gonna be one, I think, of the most important tools to us to kind of dig down beneath the kind of initial affect and get more of the deeper feelings and those needs that are connected to them. And adding to that, you know, it's kind of that question too about where my wife would say, no, I just need to vent right now. I don't need you to solve a problem. A lot of times we're listening to solve the problem. And we wanna be thoughtful about listening for what that need is. And sometimes we can ask. We can ask like, what is it that you think you need right now to be able to get to here? And they may say, I don't know, and that's okay. Other times they're gonna be able to let you know what it is that they need. It might be a need for resources or a need for venting or a need for support or a need for something tangible. And so even if it is that thing that's tangible, accessing them to manage their feelings so that you can hear that a little bit better will make a difference. Sometimes it takes a little while to cut through the real crisis-based loudness and venting to be able to get there. I know I said I was gonna take, that was the last question, but I think I need to present the next question that I think is really instructional. One person is asking, how do I remove a potential weapon that can be used against me without triggering the person that's in crisis? Yeah. That's a good question because I've definitely seen people that I've worked with like lunging for something that's a possible weapon and that draws the attention to the person in crisis. It's quick action that can inflame the situation. And so I think when I think about how to remove like a potential weapon, I think there's a couple of things you can do. One, if there's a way you can discreetly do it, that isn't always something that can be done. I think the other piece is oftentimes if you're intervening with someone, they will kind of remain in a certain kind of proximity to you so you can sort of like kite them away from the weapon. So there's a way you can kind of move yourself, try to bring the conversation of the person away from the area of the room or whatever space you're in where the weapon is. That's really key. And I think all throughout making sure that we have access to an exit is key. And then just keeping a safe distance. So knowing it's there, we can't immediately, you know, discreetly remove it. We've tried to kind of move the conversation to the other side of the room where it's not like immediately in hands breath. I think we just need to keep our space and make sure we keep ourselves safe and keep trying to engage them as much as possible, making sure we don't enrage them. Thank you so much for your response. Go ahead, sorry, Mark. I was gonna say, unless your name is MacGyver, then you can do whatever you want. Otherwise, use Brian's advice. Exactly. So thank you both so much for answering the questions and for staying a little longer. I'm gonna move on now. So for the audience, if you have any follow-up questions about this or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultation. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and completely confidential. SMI Advisor is just one of many SAMHSA initiatives that are designated to help clinicians implement evidence-based care. We encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorder and Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health to the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the required attendance thresholds for your profession. Verification of attendance may take up to five minutes, and you will be able to select Next to advance and complete the program evaluation before claiming your credit. Please join us in two weeks on February 17 of 2022 as both Mark and Brian join us again on presenting on the topic, Engage or Enrage, De-escalation Strategies for Mental Health Crisis Part Two. Again, this free webinar will be February 17, 2022 from 3 to 4 p.m. Eastern Standard Time. Thank you for joining us today, and until next time, take care.

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