One Word Every Mental Health Worker Should Know
Mastering crisis with SAFER-R
Recently, I have received many calls from mental health workers who struggle to calm their patients when they are in crisis. As a social worker at a crisis and suicide hotline, I always give the same advice.
However, my advice was vague and people seemed to forget it all the time. Instead of getting frustrated with others, I looked at myself and asked a few questions:
- Why do people seem to forget my advice?
- How can I make it more relatable?
My girlfriend and I work at the same hotline, and we decided to create a training program to help other mental health workers who are not specialized in mental health crisis management. To keep it simple, mental health workers should only remember one word:
SAFER-R
Stabilize
First of all, you will not succeed in overcoming a crisis if the situation is not safe and stabilized. My girlfriend and I have a routine we follow when we go to someone’s house. We first saw this routine at an amusement park.
We saw the staff, before starting the roller coaster, give a thumbs-up, perform a full visual scan, and, if all was clear, they all said “dispatch” at the same time.
So, when we enter someone’s house and feel any threat, we always do this visual scan and say “dispatch” if everything seems safe. This moment is quick but crucial. When our brain doesn’t feel safe, it enters alert mode. In this mode, it’s impossible to calm someone else because you’re too alert. Humans often mimic others’ emotions. If I’m not calm, then my girlfriend isn’t calm, and the patient will not resolve their crisis.
First and foremost, ensure that you and your partner are safe. Any needed first aid should be administered at this point. Stabilize the basic needs of the patient and yourself. In, these are the first two layers: physiological needs and safety and security.
Acknowledge the crisis
When everything is under control and safe, the next step is to acknowledge the crisis. This usually happens in the first five minutes of the intervention. At this point, it should be a monologue, either from the patient or the mental health worker.
If the patient is having a panic attack in the first minute, we encourage the patient to breathe slowly and be present in the moment. If the patient is aggressive and full of rage, this is usually the moment to take a step back.
In this scenario, it’s important not to confront the patient. As a reflex and in order to establish authority, mental health workers often try to raise their voice by asking the patient to calm down.
Although this is a normal reflex, it’s not the best approach. The patient should be allowed to express their emotions. If they don’t, they will bottle them up and it will explode later. When a mental health worker is present to ensure safety, it’s the best moment to let it all out — as long as it is safe.
I have yet to master this, so I often let my girlfriend handle this part. When I try, my brain goes into protective mode and I try too hard to assure everyone’s physical safety. She beautifully acknowledges that the patient is in crisis by saying:
“I understand that you’re upset and you have the right to be so. Take your time. I will stay here with you. It’s okay to feel anger and rage.”
At this moment, it’s also important to set boundaries. If the patient was hitting the wall or throwing stuff, it’s important to gently remind them of the rules and offer alternatives.
My girlfriend often invites patients to hit their bed or scream into a pillow. She does it so masterfully that the patient often calms down even before screaming.
The best way to calm someone is to make them feel heard and to legitimize their emotions.
Facilitate understanding
When everyone is safe, the patient has expressed their emotions and is calmer. It’s the perfect time to make sense of what happened.
It’s very important to do this as quickly as possible. Our memory is not perfect and if we delay this step too much, it’s possible to forget the intensity of the moment and why the patient got so upset or overwhelmed.
This step usually is the longest. The job of the mental health worker is to go through what happened while normalizing the patient’s emotions. It’s a mix between the psychological and the cognitive aspects.
The patient should be able to recall what happened, what went wrong, and if the way they acted was appropriate.
Often, patients will doubt themselves and be hard on themselves. As a mental health worker in a suicide hotline, I often hear dysfunctional thinking, such as black and white thinking, selective abstraction, minimization, etc.
These thoughts can sound like this: “I’m useless. Others are perfect. I’m a complete mess. I need to be perfect. I’m a lost cause. The only solution is suicide. My family would be better off without me.”
When this happens, the mental health worker should acknowledge the way the patient feels. The mistake I often hear from new mental health workers is to invalidate their feelings. They often say, “No, I’m sure your family loves you.”
The patient has the right to feel that way. Even if our job is to make them believe otherwise, it’s not by opposing what they’re saying that it’s going to work.
Encourage effective coping
That’s usually the part that most people are comfortable doing. This is a highly cognitive step. The mental health worker should assess how the patient usually deals with stress and why it hasn’t worked out.
The most common mistake I see in mental health crisis counselling is going too fast to this step. I often hear people right away try to find solutions for someone in crisis. Spoiler alert: it will not work.
However, when all the other steps are done correctly, this step is quite fun to do. This is a brainstorm while the mental stress should be at the lowest.
Again, another common mistake I see is for the mental health worker to find 10,000 solutions while the patient denies everything. In this step, the patient should talk 80% of the time. They should find themselves other coping mechanisms while getting encouragement from the worker.
Good suggestions if done correctly include meditation, journaling, walking, , gardening, seeing friends, playing music, etc.
This is a double-edged sword. If the patient commits to one or more coping mechanisms and fails to do it, they will feel worse than before and probably have another crisis. The mental health worker should carefully assess what’s possible and what steps the patient can take, given their reality.
Recovery or referral
The last step requires a lot of clinical judgment. If all the steps are done correctly and the patient didn’t give too much pushback, the mental health worker should give themselves a pat on the shoulder and invite the patient to call again if needed.
When a lot of time has been devoted to the intervention and the patient still seems very fragile, it’s important to refer them to a follow-up.
If the patient has mentioned suicidal thoughts, the mental health worker should evaluate the risk of suicidal behaviour. If the worker is not trained in risk assessment, they should contact a suicide hotline to assist them.
When everything goes according to plan, all steps take place one after the other. However, if you struggle to complete a step, there are two possibilities. First, maybe you went too fast and skipped some steps. It’s not possible to encourage effective coping mechanisms if the person is not calm and does not feel that we understand their situation. The second possibility is that the patient needs to be hospitalized.
As mental health workers, we don’t want that to happen. Unfortunately, it’s sometimes the best thing we can do.
But the best way to avoid hospitalization is to correctly assess SAFER-R every time a mental health worker encounters a crisis.
The SAFER-R model has been invented by and adapted by my girlfriend and I.
