A New Approach to Cooling Things Down
How can we help an agitated person to cool down enough to let us help them? What skills does it take to achieve that goal? How can frontline worker be taught to remember and use those skills?
We Learned How From the Experts:
EMTs, Paramedics and Their Patients.
Starting in 2011 and over the next six years, Christine Alvarez and I co-led a project sponsored by New York City’s LaGuardia Community College’s pre-hospital training program (Directed by Christine) and my home organization, the Trauma Studies Division of the Institute for Contemporary Psychotherapy, also based in New York City.
The project had two complementary objectives. We wanted to find out how seasoned emergency medical workers calm panicked, humiliated and/or enraged patients, their families, and bystanders in emergency medical situations. Equally important, we needed to figure out how these skills can be effectively taught to emergency workers who are at the beginning of their training.
eSCAPe was a team project
The project team, made up of both EMT instructors and trauma informed psychotherapists, interviewed seasoned EMT’s and paramedics who had decades of field experience. The team asked them, “When you are trying to calm people who are really upset, what works and what doesn’t work?” The team posed similar questions to individuals who had been treated by first responders. “What were you feeling? What helped, what didn’t help you with those feelings?” The team observed instructors teaching in the classroom and talked to students about what it was like for them to interact with patients and families who seem terrified, humiliated or furious.
Calming people down takes remembering what to say
What We Learned
It turned out that reducing the agitation of terrified or angry people is not all that complicated, but, what’s really hard is remembering to use those skills while carrying out their job’s primary goals. Efforts to address these twin challenges led the team to the formulate the eSCAPe Protocol.
An unexpected bonus of the Project was our realization that the skills of the eSCAPe protocol could be used in virtually any work setting where frontline workers must interact with people too upset to explain, listen or wait for what they need.
What is the eSCAPe Protocol and Why Does it Work?
When our brains perceive a situation as life-endangering we can lose the capacity to reason, think and talk. Instead, our brains focus on raw survival. It doesn’t matter if, in reality, nothing terrible is going on right now. Folks whose brains are operating in survival mode are too distracted by the search for danger to find the words for what they need. These are the folks who shout demands and insults, who storm out the door and won’t wait for an explanation. These are the folks who call an organization and complain about bad service. Frontline workers get worn out trying to placate relentless, unpleasable people and demoralized by their own ineffectiveness.
The science of neuropsychology tells us that to calm an angry or panicked person we must speak to the parts of that person’s brain that perceives and reacts to danger. Logic doesn’t work. Sympathy alone isn’t enough. Reacting with irritation or contempt will blow the lid off someone who is already agitated. Instead, we must let the parts of a frightened person’s brain know that things are safe enough to turn control back to the reasoning, thinking parts of the brain. It is only then that our efforts to help a person use our help will help.
Frontline workers get worn out and demoralized.
A lot of our contemporary unrest, unreason and overall incivility has come about because our brains are misreading the world. Yes, things are uncertain, even potentially dangerous, but in the moment we are OK. The sales clerk who can’t give us what we need may be disappointing us but they are not about to kill us.
With modern neuroscience in mind, what should frontline workers say to calm the agitated brains of the volatile people they are required to help? What skills does it take to defuse that agitation? How do we teach these skills to frontline workers so they learn and remember to use those skills? LaGuardia’s EMTs and paramedics with years of experience calming frightened people taught us that the cumulative result of the repeated use of four simple interventions communicates to the brain of a distraught person that things are safe enough to switch into a calmer, problem solving part of their brain.
What are these interventions and why do these interventions work? The why has to do with evolution. When it comes to danger, we humans have a deep ancestral memory of what to do and how to react to a perceived life threatening danger and instinctively we become less agitated in the presence of a compassionate, informed person who themselves stays steady and calm despite whatever stressful events are going on. When a compassionate informed person says and does the things that communicate to us that things are safe enough to stop fighting, running or hiding, we can begin to think, react and talk logically about our situation.
Our Project’s EMT and paramedic colleagues taught us that if we want to help an agitated person, we need to understand that an angry person, a demanding person, an illogical person, a mute withdrawn person is, at heart, a very frightened person and their fear has has four fundamental features.
These four features are what mental health experts mean when we say a person is experiencing traumatic stress.
1. Isolation
They experience themselves as isolated and alone, especially if the people who are around them don’t notice they are scared.
2. Trapped
They experience themselves as trapped and helpless.
3. Can't Anticipate
They have no idea what will happen next.
4. Can't Plan
They can’t react to logical explanations because they are too focused on escaping something they cannot find.
The eSCAPe Protocol is an antidote to traumatic stress. It’s designed to neutralize the four features of traumatic stress.
The Four eSCAPe Interventions
1. Social Connection
Instead of isolation, let an agitated person know you are here to listen and help.
Ask the agitated what they are upset about. As best you can tell the agitated person what you think their problem is and ask if you have really understood them. Acknowledge that their situation is upsetting/infuriating/confusing/ frightening. Don’t give way to your own feelings of shame when the upset person tells you are incompetent and stupid. Keep telling them that you want to help and will do what you can to be helpful.
2. Choice and Control
Let a person who is feeling helpless know they are not totally without choices.
Give the agitated person some experience of personal agency: Something as simple asking where they would like to sit is enough. It helps some people if we offer the opportunity to talk now or later, if they want a drink of water or a cup of coffee. A little bit of choice goes a long way to give someone a sense of control.
3. Anticipation
A person experiencing traumatic stress thinks the world is totally unpredictable and chaotic. A frontline worker should tell a traumatically stressed that even though not everything is predictable some things are predictable. It is actually calming to say to someone what is going to happen next happen next, even if what is going to happen next is unpleasant. “When you go to the motor vehicles office, it’s going to be crowded.”
4. Planning
A panicked, traumatically stressed person does not have access to the parts of the brain that can think, plan and decide, but once the person calms down, it means that the parts of the brain that can look ahead and decide what to do next can come back on line. The frontline worker can encourage that renewed sense of logic and say, “Let’s make a list of the documents you need to take with you to the social security office.” It is important not to ask for planning too soon. Wait until the person’s level of activation had decreased enough. The helping person will know that when the traumatically stressed person can answer questions that require thinking; for example, “Are there any documents in your car that you want to take with you before your car is towed away?.”
The Power of eSCAPe Training
An essential feature of eSCAPe Protocol Training is that it is designed to empower frontline workers to navigate complex situations. Remember that on the one hand, frontline workers must perform their assigned responsibilities. For example, a sales associate needs to fill out the paperwork that permits an irate customer to get credit for an unsatisfactory purchase. Simultaneously, the frontline worker must interact with the upset person in a way that helps calm them down and articulate their concern.
Think about the challenge frontline workers face every day. They are expected to defuse emotionally volatile situations while carrying out their assigned task. Imagine yourself saying to a loud, angry person (while your supervisor is looking at you wondering why you are still with this one customer,) “Mrs. Smith, I know you are in a hurry. This process is really frustrating. I will do everything I can to finish the process so you can leave.”
In an eSCAPe training, frontline workers start by understanding and memorizing the four interventions. The odd spelling of eSCAPe is intentional. The word is a mnemonic. A mnemonic is a mental device for remembering a string of ideas or tasks that are all necessary but whose individual components are easy to lose track of. The capital letters in eSCAPe, S, C, A and P, stand for the four interventions: Social Connection, Choice and Control, Anticipation and Planning, the two lowercase e’s stand for every activated person and every time we have the opportunity to make an intervention.
eSCAPe is based on four interventions.
Role-play is at the core of eSCAPe Training.
Participants in an eSCAPe training role-play their own workplace challenges and observe others role-playing theirs. Participants are coached to use eSCAPe as a check-list which they should refer back to from time to time. They are told if social connection doesn’t work, try giving your “customer” a choice. If that doesn’t work go back to social connection and let them know you know that they have a reason to be upset:. “It’s really hard to keep your cool when there are so many forms to fill out.” Participants are encouraged to be persistent.
An essential part of eSCAPe training is self reflection and self awareness. Participants are encouraged to notice their reactions to difficult people. For some it is a tight neck and shoulders. For others it is a dry mouth or sense of confusion. I encourage people in my trainings to use eSCAPe for themselves. Maybe they are starting to get overwhelmed and need encouragement or advice from a helpful co-worker (social connection). Maybe they anticipate that if this interaction continues the supervisor will indeed be angry. At that point it is important for the Frontline worker to give themselves choice and control. “Mrs. Smith, I can’t finish our work today. I can see you next week on Monday or Tuesday.”
eSCAPe Protocol Training is uniquely grounded in an understanding of how everyone’s brains react to perceived danger. It embodies in its four interventions the capacity our brains have to return to reason and civility when we receive clear information that another person is concerned for us, that we are not helpless, that we have some sense of what will happen next and that is possible to think through what we need to do next. As frontline workers, we can use eSCAPe’s four interventions with other people, but we can also use eSCAPe for ourselves.
The Big Picture
Everyone Benefits When People use eSCAPe.
eSCAPe training is a positive response to our deeply polarized society. It can help bring about a shift away from the attitude so prevalent today of “It’s us versus them.” “We’re right. You’re not just wrong; you are bad and stupid.” Instead, eSCAPe training fosters a sense of respect and compassion for our common humanity.
