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, 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’s 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’s 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’re 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, “You’re right, we are holding you against your will and you have every right to be angry,” 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, “I think you’re really upset because we’re keeping you against your will.”
The patient shouted “Yes!”
Then I said, “And you’re telling us that you do have a place to go to if we let you out.”
The patient said, “yes,” 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’t have much time to think and have to respond quickly, including these:
For the Disarming Technique: “You’re right,” followed by a statement affirming the truth in what the patient just said.
Thought Empathy: “What you’re telling me is” 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: “Given what you just told me, I can imagine you might be feeling X, Y, and Z” where X, Y and Z are feeling words, like “upset,” “anxious,” or “angry,” and so forth.
Inquiry: Heather emphasizes two productive lines of Inquiry:
“Am I getting it right?”
“Can you tell me more about how you’re feeling?”
“I Feel” Statements: “I’m feeling X, Y, and Z right now,” 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 “I feel like you . . . ” since this ends up not as a statement of your own feelings, but a criticism of the other person. “I feel that . . . “ has the same problem.
Stroking: This conveys caring, liking and respect, but cannot be done in a formulaic way. You might say things like “I care about you and I’m really concerned that you’re struggling right now,” or ‘What you are saying is very important, and I want to understand more.”
For example, you might say this to an angry patient being held against his or her will:
“You’re right, I am holding you against your will, and insisting that you stay, and I don’t like it either. But I’m 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’t think I could forgive myself if I did that.”
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’d 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, “Boy, are you ugly!”
On another occasion, she walked into the room of a male patient, introduced herself, and asked if they could talk. He replied provocatively, “Sure, if you get into bed with me, baby.”
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
You can reach Heather at the Feeling Great Therapy Center.
Dr. Rhonda Barovsky practices in Walnut Creek, California, seeing people in person and via Zoom, and can be reached at email@example.com. She is a Level 5 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. Check out her new website: www.feelinggreattherapycenter.com.
You can reach Dr. Burns at firstname.lastname@example.org.
This is the cover of my new book, Feeling Great.
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Really love your simple brief and effective responses. You are a very beautiful person. You speak very graceful. Also loved the stories of the hospital where you work. I am not a therapist but I would love to see you working with your patients! In my opinion those brief answers as listed above in the ‘show notes’ should be learned by all trying to master the 5 secrets. Thanks. I’ll propose them for a practice in our Thursday evening 5 secrets group!
Thanks, sent it on to Heather and Rhonda. David
What a great interview. I found myself practicing along side of you all!
Thanks Heather David and Rhonda! In addition to my small private practice, I also do this work in Washington state just outside of Seattle. Here people are involuntarily held (“5150”) by MHP’s designated by the state to do so. We see people in the community, private homes, ER’s and psych wards. I have found my TEAM training including 5 secrets, positive reframe, paradoxical agenda setting and even challenging distortions to be invaluable in building rapport with some really challenging folks (could certainly ID with Heather’s vignettes!) and often, as Heather says, finding positive solutions that decrease the need for hospitalizations and other extreme interventions.
Thank you for bringing this use of TEAM in crisis situations to light. I’ve passed it along to my colleagues!
Fabulous, thanks! I’m forwarding to Rhonda and Heather! Warmly, david