What to do if your client reaches breaking point
Gripping the sheared shard of glass in her dripping hand, she suddenly thrust the sharp end toward my face.
Serrated shadows from the fading light of her bedsit seemed to take on a life of their own, stabbing at me from all angles.
This wasn’t the sickening thrill of a slow-mo nightmare – this was reality. Never in my wildest dreams had I imagined psychotherapy could be this dangerous.
But, of course, this wasn’t psychotherapy. Maybe psychotherapy could have helped Emma as the stresses and strains built up before she tipped into psychosis.
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But it was too late for that now. Now was the time for pure practical crisis management and, more immediately, for survival.
As Emma screamed of the murderous ghosts tormenting her, myself seemingly included, my inner portfolio of solution-focused questions didn’t quite seem to fit the situation.
As fear tightened its grip, I felt immobilized. Keep calm, I told myself. And above all, keep thinking!
Getting in too deep
Not long after qualifying as a therapist I’d been asked by an ex-psychiatric nurse colleague to make a house call to a patient who “could use some help relaxing”.
I’d never met this patient and knew almost nothing about her but, keen to prove myself, I took on the task and headed around to her house.
Not five minutes later, I was trapped.
Before I knew it, Emma had closed the door behind me without so much as a hello, sat me down, punched a window as if immune to pain, scooped up a dagger-like shard and began bellowing of her immediate need to “kill those f***ing ghosts!”
My first thought was, of course, “How can I escape this?” But given my line of work, it wasn’t long before I also wondered, “How can she get what she needs in this emergency?” What I was doing here wasn’t psychotherapy or crisis management.
So what was it? Well, at least in the short term, it was survival.
There must be some way out of here
There was no sense in trying to stop her from reaching breaking point – she’d long since passed it. I entered the situation ill prepared and too late.
And I couldn’t blame my ex-colleague – it was my own heedless desperation to get my psychotherapy practice off the ground that got me into this mess.
Of course, crises aren’t always that dramatic – or dangerous. Most personal crisis points don’t manifest in a way that is as disconnected from reality as what I saw with Emma.
But I do believe there is always some kind of reality disconnect during times of crisis, and I’ll talk more about that soon.
Interestingly enough it was psychology that got me out of that situation and helped Emma to get what she needed. But more of that in a moment.
First, I want to talk about helping people out of crisis before it gets to such an explosive point.
What happens to people when they reach crisis point? Why do some people start to act alarmingly out of character? And what can we do to prevent it?
The best crisis is the one averted because we saw it coming and did something about it.
Averting a crisis
I don’t mean to glorify the past, but I do think it’s possible that emotional crisis is more widespread now because of less cohesive communities, increased social isolation, job insecurity, and more fluid relationships.
Many people these days do feel isolated and the old safety nets of strong community may be much weaker than they once were.
We psychotherapists and coaches are lucky in that often we won’t be the ones on ‘the front line’ of client crisis.
Social workers, doctors, nurses, even the police may all be called upon to help before a psychotherapist is needed. Or I should say after a psychotherapist was needed.
There are different kinds of crisis. Crisis brought on by widespread disaster, warfare, earthquake or famine isn’t what this piece is about.
No, I’m talking about the personal emotional crisis. Of course, personal life crisis can be connected to wider societal events, but it needn’t be.
So what exactly is an emotional crisis?
Two signs of crisis
We recognise there are two broad types of crisis: energized and de-energized.
The former is characterized by agitation, sometimes to the point where a person becomes destructive to themselves or others.
An ‘energized’ crisis can involve extreme restlessness, inability to concentrate, pacing up and down, wringing of hands, constant adjusting of clothing, sleeplessness, obsessionality, incessant talking, sleep loss, impulsivity, and out-of-character risk taking. This general and uncontrolled agitation has been associated with increased suicide risk (1).
The second type of crisis occurs when a person feels so trapped and helpless, or sometimes exhausted from an energized crisis, that they can’t bring themselves to do anything at all. Their life grinds to a halt. They may stop eating, washing and even talking.
We often refer to this type of crisis as ‘de-energized’. In this state people feel sapped of energy, almost paralysed. They lose all motivation, self-confidence and interest as feelings of powerlessness and hopelessness take over.
It’s important to note that some medication side effects may precipitate either kinds of crisis. But there is something else that is really important to understand about any kind, or phase, of a crisis.
Disconnecting from reality
For friends, partners or relatives of someone entering an emotional crisis, what can be really scary is how the person’s personality seems to change.
A normally humorous, bubbly person may become deadly serious and withdrawn, and start to see their reality in hopeless terms that don’t seem to reflect their true situation. The usually sensible friend may start spouting wild ideas and suggestions with no regard for common sense or the way reality actually works.
For the 1% of the population prone to psychosis, a buildup of stress may result in an almost complete disconnect with reality as the person’s internal thoughts and imagination become their new reality and the real world falls away.
I saw one man who took to lying in the garden for hours, sometimes in the pouring rain, after his girlfriend had left him. Needless to say, his family was distressed.
There will be some reality disconnect in all emotional crisis, but not often to the extent of total reality disconnect.
The common element to both kinds of crisis symptomatology is stress buildup. So what might cause feelings of unbearable overwhelm?
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Causes: Where does the crisis originate?
Stress happens when we are not meeting our basic primal emotional needs, and it builds more and more as we worry about not meeting those needs. Stress is merely a signal of ‘thirst’ or ‘hunger’ on the emotional level.
Relationship breakups, job loss, illness, bereavement, poverty, being bullied or threatened, the residual effects of unresolved trauma and any other stressors all have the potential to precipitate a crisis. Even boredom is a type of stress, signalling that our innate needs for challenge or excitement are not being met.
But other stress signals include fear, depression and anger. Strong unremitting emotion leads to an overactive imagination that can conjure very real fears or ideas about the self – ideas that can start to feel more real than life itself.
This happens partly through disrupted sleep and partly through stress’s effects on how the brain normally works to question and modify the imagination.
When someone is in crisis they will invariably have come to believe stuff that may seem bizarre, even to their normal self. This is called ‘trance logic’ and can happen to many people in crisis, not just those prone to psychosis. This explains the scary changes in character of those in crisis.
Often a person veering toward crisis will not have strong enough self-objectivity (because of the distorting effects of high emotion) to realize they need a break, to make the effort to talk to someone about what they’re going through, or to identify what needs to happen to help them out of the crisis.
And unless someone in their community sees the warning signs and takes steps to help, that person may tumble into crisis after crisis.
Frightening changes: The mystery of ‘trance logic’
Have you ever noticed that when you are dreaming, stuff that would usually seem bizarre – like talking animals – you just accept as ‘normal’?
In a dream state, you are processing reality purely through your imagination: the normal rules of logic don’t apply.
The way we interpret events in this type of state is sometimes called ‘trance logic’ because during hypnosis it seems the ‘dream machinery’ of the brain that is normally activated during REM sleep is able to be accessed.
In hypnotic trance the contents and processes of the imagination tend to remain unquestioned by the conscious or analytical mind.
People that are experiencing stress buildup may have stopped sleeping, meaning REM states may start to break out during wakefulness. This, coupled with overactivation of the stress-fuelled imagination, can inhibit the prefrontal lobes in the brain, which are normally responsible for reality checking.
So how does this relate to emotional crisis?
Processing life through an agitated mind
Trance logic is what makes people act so ‘out of character’ when approaching an emotional crisis.
Just as we believe and think things in a dream we would never normally think and believe, so do people acting under trance logic.
The important thing here is to understand that the REM state (so-called ‘paradoxical sleep‘) normally associated with dreaming isn’t a state just confined to sleep. Here are some examples:
- A friend of mine began to believe the man upstairs was targeting him through microwave bombardment. Even during his crisis he questioned whether he was “just imagining” it, but he kept coming back to the idea. After the crisis passed he couldn’t believe he’d ever entertained such an idea, let alone become fixated by it.
- One client convinced himself he was about to lose his house even though he had no real financial problems.
- A woman imagined all her friends had come to hate her and that she was in love with her friend’s 16-year-old son. She started imagining that he was hinting that they should run away together even though he had no idea of her infatuation. After the crisis she had no such feelings and felt acutely embarrassed by her, as she put it, “crazy ideas”.
These are not full-blown psychotic delusions; they are just the result of a stress-fuelled imagination that has failed to perform the proper ‘reality checks’.
In fact, trance logic probably affects all of us sometimes – when we are extremely angry or jealous, for example – and it certainly explains the phenomenon of so-called ‘brainwashing’, in which intelligent people can come to believe all kinds of strange things through emotional conditioning, as occurs in a cult.
It’s a cliché to assume bizarre actions and beliefs are a ‘cry for help’ as people often like to suggest when they just can’t understand why someone would do or think such a thing. And of course, on some level the person is crying out for help.
But it’s important to understand the point of view of the client, who may be perceiving reality through their own temporary trance logic. Trying to argue logically with someone experiencing reality through trance logic may just produce a ‘rubber band effect‘.
Emotions fuel beliefs, and until the emotions are dealt with, the beliefs or delusions will tend to remain fixed.
Okay, so let’s get more practical. What can we actually do when someone is approaching a crisis?
How to help heal or prevent a crisis
1. Ascertain safety
Before you do anything, know the answers to the following questions:
- Has the person started to use maladaptive coping strategies, attempts at escapism that are exacerbating the problem?
- Do they need physical medical help before any psychological intervention?
- Is there someone they have access to 24/7? Someone they can call if they need to or someone who can check on them?
- Are they engaging in self-harm? This might be alcohol or drug use, out-of-character promiscuity or refusal to get out of bed or leave the safety of one room.
- Are they a threat to someone else? Have they threatened suicide?
If the answer to any of these questions is yes, then you may need to enlist the help of other professionals. It’s handy to have a list of numbers and contacts – a community of professionals that you can call on if need be.
We’ve all heard the proverb that it takes a ‘village’ to raise a child – and sometimes it can take that whole village to help one community member in crisis.
2. Calm your client
The common element to all personal and psychological crises is stress.
Reassure your client that the myriad of worries, fears or obsessions bombarding them can take a back seat for a while as they rest and recoup healthy energy again.
If you are trained in ways to relax your client, and most therapists and coaches are now, then teach them to rest and relax regularly.
Help them meet their immediate needs for attention and connection through reality rather than imagination. This might be as simple as getting them to go for a walk and look around them every day for a while to reconnect to ‘out there’.
If they are suffering from post-traumatic stress disorders or debilitating phobias, de-traumatize your client using an ethical (non-invasive and comfortable) method such as the Rewind Technique.
Just as fire needs oxygen to burn, a crisis needs strong emotion to fuel it. Once the mind calms and energy returns, the crisis has essentially passed even if external problems remain. Once calm is restored, we can go onto the next step.
3. Engage resources
Ascertain your client’s awareness of their resources: social, professional, and personal.
The more embedded someone is in a community and the more friends and family they have access to, the more resilient they tend to be. This even seems to extend to physical resiliency, such as pain thresholds (2).
Social isolation and loneliness (3) doesn’t just mean a crisis is less likely to be picked up but also that it might be harder for the person to re-emerge from it.
Encourage and help the person to access their social support network, but respect their decision if they want to keep their crisis private.
You could also gently talk to them about the kind of person they are ‘underneath’ all this: what they’ve done in the past, times when they have pulled through. Basically you want to reconnect them with the personal qualities and sense of self they have had in the past.
I worked with a man who had threatened suicide and was refusing to leave his room. As I coaxed him into talking about the things he had achieved in his life ten years before, he eventually started to feel that he did have the personal resources to pull through the hard time he was going through.
This is a kind of remembered wellness that can help get a sense of wellness back in the present.
Personal resources can come from the most surprising of situations. If you watch my therapy session videos online inside UPTV you’ll see that there is an example in my second session with Tansy (who needs help with overcoming fear and increasing self-confidence).
During the session, I locate a resource from the past of a time when she kept calm while her daughter self-harmed through cutting and had to be taken to hospital. On the face of it that might not seem like a resourceful time, but for Tansy you’ll see that it is. So resources can come in surprising forms.
Also, it might be an idea to have a list of professional agencies to call upon if your client needs additional support or help.
4. Ascertain their beliefs during the crisis
Beliefs will be skewed during a personal crisis. Terror, depression, and helplessness are all feelings that warp thoughts and beliefs.
Ascertain what the ‘trance logic’ of strong, exhausting emotion has them believing. This can be done through listening to what they say about themselves and the world.
Do they blame themselves excessively? Do they have unrealistically bleak beliefs about their situation? Do they approach their reality in unrealistic black-and-white ways?
Once you have helped calm your client on a day-to-day basis, then you are better placed to help reframe anymore destructive beliefs. Only when your client has become less stressed will they regain access to their prefrontal lobes and start to be able to see logic again.
This is the time to intervene – not before. Trying to do cognitive therapy when someone is still flooded with stress is like trying to light a candle in a hurricane.
Eventually – once energy is restored (or balanced if they had been full of nervous energy) – you can do the following:
5. Help them find hope through an action plan
During a crisis life may seem overwhelmingly chaotic. An unfathomable mess.
Once the initial emergency has passed, we want to depotentiate any re-escalation of stressful feelings by helping make the mess of life feel negotiable again. A useful way to do that is to make an action plan with steps towards feeling better again.
Even if the first step is just to withdraw and rest for a little longer, knowing there are steps to follow helps in itself by rebuilding that all-important sense of control.
We all need a sense of autonomy, a belief that we can influence our own lives. And we all need a meaning and a purpose, even if it’s as simple as getting back to full health.
An action plan should include ways to work towards meeting the client’s primal emotional needs, and can also include usable strategies to head off any future crisis episodes well before they get so bad again.
This can be deeply reassuring, as many people fear – sometimes to an almost phobic degree – ever ‘going off the rails’ again. Part of our job is to show them that they needn’t harbour that fear anymore.
Anyway, all this is a far cry from my nerve-frazzling experience 23 years ago!
First let’s survive
As I cowered in Emma’s darkened bedsit, as she manically waved razor-sharp glass before my eyes and screamed about needing to “kill those f***king ghosts”, I thought fast and asked myself: “What is a basic universal psychological principle I can use to help calm this situation?”
I thought of Milton Erickson’s principle of utilization, of building profound rapport with the client by inhabiting their reality before trying to lead them anywhere else.
I didn’t shout, but I raised my voice loud enough that I knew she’d hear. “I’m going to kill those f***king ghosts!” She looked startled, and I could tell the trance was broken just a little.
Knowing I was making progress, I shouted it louder and said I knew a way to kill them. And then I asked her if she wanted to know how.
She nodded uncertainly, and I told her I needed to get outside because they were out there and I needed to stop them coming in. I worked within her trance logic. I stood up. She let me pass, momentarily forgetting about the glass dagger in her bleeding hand.
The moment I got outside her door, I told her to wait in her home, not to answer the door or leave. That I would deal with these “f***king ghosts!”
I went to her neighbour’s house and asked to use their phone (this was BC – before cell phone) and called the police. They then contacted her social worker and an ambulance. She was admitted under Section 1 – that is, forcibly – and I learned a massive lesson.
No thanks to me, but I heard through my old colleague that Emma did eventually come through her crisis. She left the hospital, things calmed down, and her life started providing her with meaning and satisfaction.
As one final thought, I think it’s always worth bearing in mind that sometimes a person can come through a crisis and end up feeling better than they did before. Sometimes, when change has been needing to happen for a while, it isn’t until things get really bad – until change becomes a necessity – that a person finally seeks the help they need.
Remember, a crisis can be a doorway to something better. And in this way, a crisis point can turn into a turning point. Hope and calm are not drug prescriptions, but they are powerful, and we can help our clients rediscover them.
In the words of Emily Dickinson,
“Hope is the thing with feathers
That perches in the soul
And sings the tune without the words
And never stops at all.”
- See the research summary here: https://www.ecnp.eu/~/media/Files/ecnp/About%20ECNP/Press/AMS2015/Popovic%20PR%20FINAL.pdf
- https://www.theguardian.com/science/2016/apr/28/people-with-more-friends-have-higher-pain-thresholds-study-suggests
- http://www.theguardian.com/society/2016/apr/26/co-op-members-vote-war-on-loneliness-british-red-cross
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About Mark Tyrrell
Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.
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