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
As our work as an interdisclipinary team progressed, we started to recognize that 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.
It turned out that reducing the agitation of terrified or angry people is not all that complicated. What’s really hard for frontline workders is to remember what to say while they simultaneously carry out the tasks their job requires. It was our recognition of the dual challenges frontline workers face that led the team to create the eSCAPe Protocol.
An unexpected bonus of the Project was our realization that the the eSCAPe Protocol could be used in virtually any work setting where frontline workers interact with people too upset to explain, listen or wait for what they need.
What is the eSCAPe Protocol and Why Does it Work?
Neuroscientists employ the term traumatic stress to describe a situation that is life-endangering. Most of us if we experience a severe traumatic stress will lose the capacity to reason, think and communicate. Instead, specific neural networks take charge and get us to execute behaviors designed to help us survive. We will fight, flee or freeze. It doesn’t matter if, in reality, nothing terrible is going on. What matters is that folks whose brains are under control of their survival neural networks do not calm down just because we tell them to.
Neuroscientist Stephen Porge tells us that in responding to tramatic stress, an important nerve, the ventral vegas nerve, starts to shut down. When that happens, a stressed person loses the capacity to calmly discuss problems or notice their impact on others. 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 telephone or email an organization and complain about bad service. Frontline workers get worn out trying to placate relentless, unpleasable people and demoralized by their own ineffectiveness.
Frontline workers get worn out and demoralized.
The science of neuropsychology tells us that to calm an angry or panicked person we must consciously and deliberately try to activate the parts of an upset person’s nervous system that evaluate and react to danger. Telling someone to be reasonable doesn’t work. Sympathy alone isn’t enough. Reacting with irritation or contempt will blow the lid off someone who is already agitated.
Frontline workers have immense influence as to whether someone’s survival neural network is revved up or switched off. Irritated, disdainful or indifferent frontline workers accelerate our survival behaviors. In contrast, most of us become less agitated in the presence of a compassionate, informed person who stays steady and calm despite whatever stressful events are going on.
As they execute their jobs, seasoned frontline workers can shift into a state of mind that is somewhat detached. They stay calm enough to sympathize with but not be activated by the intense emotional aura of an upset person. In a respectful, calm state of mind, the frontline worker speaks to the parts of an upset person’s brain. that are on the lookout for danger. Using the right words, spoken in the right tone, frontline workers can convince the nervous systems of agitated people that things are safe enough to turn control back to the reasoning, thinking, socially connected neural networks..
What exactly do frontline workers say and do to calm the agitated nervous systems of volatile people? How do we teach these skills to frontline workers so they learn and remember to use them? LaGuardia’s EMTs and paramedics with decades of experience gave us numerous examples of the kinds of things they say to help distraught people calm down. The team’s trauma therapists pointed out that the verbal interventions of first responders can be conceptualized as neutralizing or defusing the four essential features of traumatic stress. In other words, despite their differing behaviors, an angry person, a demanding person, an illogical person, a panicked person, even a mute withdrawn person are essentialy the same. They all suffer from traumatic stress. They need help turning off their survival neural networks and turning on the complex neural networks that facilitate thinking, planning and social engagement.
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 feel in danger but don’t know what the danger is or what to do about it.
The eSCAPe Protocol is an antidote to traumatic stress.
It’s designed to neutralize and defuse 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 person what they are upset about. 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 have what it takes 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 somone would like to sit is enough. It can help some people if we offer the opportunity to talk now or later or if they want a drink of water. A little bit of choice goes a long way to give someone enough control so that they can start to relax.
3. Anticipation
A person experiencing traumatic stress is panicked because to them it seems that the world is totally unpredictable and chaotic. A frontline worker should tell a traumatically stressed person that even though not everything is predictable some things are predictable. It is calming to tell someone what is going to happen next even if what is going to happen next is somewhat unpleasant. “When you go to the motor vehicles office, it’s going to be crowded.”
4. Planning
A traumatically stressed person does not have access to the parts of the brain that think, plan and decide. Once the person calms down. the parts of the brain that 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. We must wait until the person’s level of activation has decreased enough. When the traumatically stressed person is somewhat calm, then the frontline worker can ask questions that stimulate thinking, for example, ““Are there any documents in your car that you want to take with you before your car is towed away? The ability to plan and decide again is in itself calming.
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 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
A unique and important outcome of eSCAPe Protocol Training is that it empowers frontline workers to navigate complex situations. Remember that frontline workers must perform their assigned responsibilities — for example, helping someone fill out a form, . Simultaneously, the frontline worker must interact wiith upset people in a way that defuses the intensity of the upset person’s agitation. Learning to execute these dual tasks takes more than listening to a lecuture, or memorizing words, It requires practice and coaching by trainers who understand the neuropsychological forces that are operating.
At the start of eSCAPe Protocol training, participants learn the four features of traumatic stress and memorize the four interventions. The peculiar fonts 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.
Once the ideas behind the eSCAPe Protocol are absorbed, participants role-play their own workplace challenges and observe others role-playing theirs. Participants are coached to use eSCAPe as a check-list which they can refer back to from time to time. If efforts at social connection don’t result in calming someone down, participants practice switching to another type of intervention; for example they can offer a choice and control option such as “Would you like to talk here or in my office where its more private?” If choice and control doesn’t work the participant learns to go back to social connection and let the agitated person know that 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 awareness. Participants are encouraged to notice their reactions to angry expressions or raised voices.. We invite participants to become curious about how their bodies respond to difficult people. For some it is a tight neck and shoulders. For others it is a dry mouth or sense of confusion. Participants give each other feed back about their expresson, tone of voice and body language. We ask them to notice what happens in their bodies when they take a deep breath, look away, look down orchange their posture.
Integrating eSCAPe skills takes time. In the beginning most people experience their performance as awkward, even artificial. It’s a bit like learning to ride a bike or play a musical instrument. It takes time for everything to come together.
I encourage people in my trainings to use eSCAPe on themselves. Maybe they are starting to get overwhelmed and need encouragement or advice from a helpful co-worker (social connection). Maybe they notice that they are on the edge of losing patience, that their own survival neural networks are about to take over and scream “Shut the F…. up” at some relentless, demeaning person. At such times, frontline workers should give themselves choice and control. They can ask themselves if they should continuing dealing with a difficult person or turn the situation over to a supervisor.
The eSCAPe Protocol is uniquely grounded in an understanding of how everyone’s brain reacts to perceived danger. In dealing with people who are illogical rageful, panicked or demanding, we can decide to employ eSCAPe’s four interventions, For starters, we can give clear signals that we are concerned and that we understand why they are upset. We can tell them what skills and authority we have and the extent to which we can help them. We can give an agitated person an experience that lets them know that they are not totally helpless. We can give them some sense of what will happen next. We can let them know that when they are ready, we will help them think through what they need to do next. We can even use the eSCAPe Protocol to calm 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.
