Q & A: “Beyond the Ability to be Soothed”

QUESTION:

At times I feel as though when a patient or family member expresses anger it is often too late to soothe the situation. Listening can often help, but it’s not always enough. What would a therapeutic relationship even look like when one person is angry beyond the ability to be soothed?

ANSWER:

Michael-Trout-150x150We’ve talked about anger often in this column, and in the book, so I won’t rehash all the principles. Besides, you seem to be saying there are situations when things have escalated so far that it would seem ludicrous to use Wondering, Following or Holding. In fact, it might seem laughable to you, at the moment, for someone to suggest that you pause to wonder in the face of a patient or family member who is threatening or who has resisted all other efforts at calming.

So I’ll just mention one little trick that is sometimes useful when things have gotten quite out of control: affect-matching. We don’t do it as a replacement for wondering, following or holding. It is not an excuse to fail to be present, and it is not an invitation to fail at attunement. Indeed, it may be that this little trick amounts to all of these principles, on steroids!

What is it?

We would all know better than to approach a calm, serene patient going into surgery, and shout instructions to him: “YOU’RE GOING TO BE FINE! JUST LIE THERE QUIETLY AND THE DOCTOR WILL BE HERE SOON, AND THEN WE’LL BEGIN THE CUTTING PART!”

We would all know better than to enter a patient’s room—let’s say there are also four or five family members visiting, all looking somber—with a tutu on, happily dancing and careening around the room. Even when we feel like dancing—even when we think the patient would feel better if he could just rise up out of that bed and do a jig or two—our cute little outfit and truly great moves, don’t quite match the tone of the room.

Ditto when we enter a space with a seriously angry patient or family member. Calmness, sometimes, is as much a mismatch with the tone of the room as a tutu. When we decide to match the affect of the other, we simply decide that the best acknowledgement of their state of mind, at the moment—and, as far as they’re concerned, the best acknowledgement of their problem—is expressed when we match the affect of the loudest person present. “OH MY GOODNESS! I CAN SEE THAT THINGS HAVEN’T BEEN GOING WELL HERE!” may, oddly enough, feel comforting to the angry patient or family member. Somebody gets it. No one is trying that “Calm down” routine on me. This clinician really cares! (And please note, the clinician has consciously followed, rather than contradicting the patient or family member.)

If all the remarkable literature on co-regulation (see See Me as a Person, especially pp. 62-73) is right, then such affect-matching creates the potential for us to eventually turn down the volume and intensity of the other’s anger much more easily. We begin right with them—not trying to get them to calm, but actually matching their state, while remaining in control of both our own emotions and the situation—and then we slowly turn down our own volume and intensity. If we’re lucky, the patient or family member follows.

A caution: We must be in control. We don’t run into the room shouting because we’re triggered. We don’t give anger for anger; we’re matching the person’s affect, not his or her emotional state. We simply respond with empathy and understanding spoken in a way that matches the voice tone and affective intensity of the angry patient or family member. Then we begin turning it down. It’s not done much in polite society. Hospitals, of course, are not “polite society.” People there are in a world of fear and hurt.

~ Michael Trout