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293: The Five Secrets with

Violent and Angry Individuals,

Featuring Heather Clague, MD

Heather Clague MD is a Level 5 TEAM therapist and trainer with a practice in Oakland, California and consult-liaison psychiatrist at Highland Hospital in Oakland. In addition to running an online consultation group for TEAM therapists, she is faculty for All Things CBT,\\xa0 teaches for the Feeling Good Institute, and has taught the Five Secrets of Effective Communication to medical staff. Her writing can be found at psychotherapy.net.

With Dr. Brandon Vance, Heather co-leads the Feeling Great Book Club, a book club for everyone, everywhere who wants to learn the magic of TEAM.

In today\\u2019s podcast, Rhonda and David speak with Dr. Heather Clague who describes her working in the psychiatric emergency room at Highland Hospital in Oakland, California, and other emergency facilities including Fairmont Hospital in San Leandro, California, interacting with hostile and psychotic individuals who often have to be held against their will because they are a danger to themselves or others, or unable to care for themselves.

Although today\\u2019s podcast will be of special interest to mental health professionals, it will also be of great interest to anyone having to interact with strangers, friends or family members who are angry and abusive.

She explained that

In these types of settings, we often have to give patients the opposite of what they want. For example, if they\\u2019re involuntarily hospitalized for dangerous behavior, we have to restrain them, or keep them in the hospital, when they desperately want out. Or, if they want to stay in the hospital, we may have to discharge them. Many of these patients are psychotic and lack judgment, so they may shout and act out in anger and frustration.

The Five Secrets (LINK) have been a godsend, and when it works, the results are amazing. For example, if a patient is screaming for us to release them, the natural instinct to get defensive just agitates them more and is rarely or never effective. If in contrast, you say, \\u201cYou\\u2019re right, we are holding you against your will and you have every right to be angry,\\u201d they usually feel heard and calm right down.

In one recent case, an agitated and confused homeless woman needing dialysis was near death because she was refusing treatment and refusing to take her medications. She was manic, agitated, and talking rapidly, non-stop.

I said, \\u201cI think you\\u2019re really upset because we\\u2019re keeping you against your will.\\u201d

The patient shouted \\u201cYes!\\u201d

Then I said, \\u201cAnd you\\u2019re telling us that you do have a place to go to if we let you out.\\u201d

The patient said, \\u201cyes,\\u201d in a softer voice, and let the nurse come in and give her her medications, which she took.

Heather described phrases she uses to get into each of the Five Secrets in high-secrets situations when you don\\u2019t have much time to think and have to respond quickly, including these:

For the Disarming Technique: \\u201cYou\\u2019re right,\\u201d followed by a statement affirming the truth in what the patient just said.

Thought Empathy: \\u201cWhat you\\u2019re telling me is\\u201d followed by repeating what the patient just said. This is helped greatly by writing down what the patient said.

Without writing things down, this technique tends to be impossible for mental health professionals OR the general public. In spite of this, most people refuse this advice!

Feeling Empathy: \\u201cGiven what you just told me, I can imagine you might be feeling X, Y, and Z\\u201d where X, Y and Z are feeling words, like \\u201cupset,\\u201d \\u201canxious,\\u201d or \\u201cangry,\\u201d and so forth.

Inquiry: Heather emphasizes two productive lines of Inquiry:

\\u201cAm I getting it right?\\u201d

\\u201cCan you tell me more about how you\\u2019re feeling?\\u201d

\\u201cI Feel\\u201d Statements: \\u201cI\\u2019m feeling X, Y, and Z right now,\\u201d where X, Y, and Z are feeling words like sad, concerned, awkward, and so forth. When done skillfully, this technique adds warmth and genuineness, and facilitates the human connection.

Heather cautions against saying \\u201cI feel like you . . . \\u201d since this ends up not as a statement of your own feelings, but a criticism of the other person. \\u201cI feel that . . . \\u201c has the same problem.

Stroking: This conveys caring, liking and respect, but cannot be done in a formulaic way. You might say things like \\u201cI care about you and I\\u2019m really concerned that you\\u2019re struggling right now,\\u201d or \\u2018What you are saying is very important, and I want to understand more.\\u201d

For example, you might say this to an angry patient being held against his or her will:

\\u201cYou\\u2019re right, I am holding you against your will, and insisting that you stay, and I don\\u2019t like it either. But I\\u2019m very concerned that if I let you out now, you might get hurt, or do something to hurt yourself, and your life is precious. I don\\u2019t think I could forgive myself if I did that.\\u201d

Of course, all of this has to come from the heart and has to be done skillfully, or it will not work.

Heather described other inspiring stories of challenging patients she\\u2019d worked with, and we took turns modeling Five Secrets responses to ultra-challenging patients, including one who was brought into the ER by police on a gurney in leather restraints who took one look at her doctor and said, \\u201cBoy, are you ugly!\\u201d

On another occasion, she walked into the room of a male patient, introduced herself, and asked if they could talk.\\xa0 He replied provocatively, \\u201cSure, if you get into bed with me, baby.\\u201d

Rhonda and Heather reminisced about their meeting at one of my four day intensives for mental health professionals several years ago at the South San Francisco Conference Center, and became best of friends. They have traveled together to India and Mexico teaching TEAM-CBT and spreading the gospel according to Burns!

I also reflected on my two years of internship and residency training at Highland Hospital, and my profound gratitude and admiration for that hospital and the many dedicated and talented health professionals who serve there.

Thanks for tuning in today!

Heather, Rhonda, and David