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“She won't tell me what's wrong, but she's been crying for hours and she can't catch a breath,” said Lisa, the mom of one of my adolescent clients. The client, Anne, lived out of town and was unable to attend an emergency office visit, so a phone session was the only option.
I asked if Anne was suicidal or if she had tried to hurt herself. “No,” Lisa said, “but she won't calm down. She's hyperventilating. She refuses to talk to me. She won't talk to anyone. I don't think she'll talk to you,” Lisa said tearfully.
“It's OK. Put the phone on speaker and place it by her door,” I instructed.
My first intervention was to empathize. In a gentle, slow, and compassionate voice I said, “You are hurting. You are hurting a lot. It feels really bad. I can tell.” Anne’s crying softened. “I bet you feel helpless and hopeless. I get it. I'm here,” I said softly. Her sobs slowed down. “I bet you are scared, huh?” Anne muffled, “yes.” “I know. It's hard right now,” I said empathically.
Deep breathing was the next step. I gently asked Anne to take a breath with me. “On the count of three, we are going to inhale,” I said. As exaggerated as possible, I inhaled so she could hear over the phone. “Exhale,” I said as I let my breath go. After a few minutes of the slow and synced breaths, Anna's breathing returned to a normal rhythm.
Tensing and relaxing was the third step. I asked Anne to squish up her toes with me and then relax them. Next, I invited her to flex her ankles tightly then relax. From the waist down I instructed Anne to tighten up her legs, then relax. Finally, I asked her to give herself a hug by putting her hands across her chest like a mummy and tighten, then relax. After several rounds of tensing and relaxing, Anne stopped crying.
Yet, I sensed she was still resistant to talking, so I asked her if she could answer a few questions with yes or no. She agreed. I asked:
Has anything happened with your friends? Anne said no.
Did something happen at school? No.
Is everything alright with your parents? Anne said yes.
Did something disappointing happen? No.
Do you feel like hurting yourself? No.
My assumption was correct, she was not ready to talk, but I had enough information to formulate an idea about what happened. A few months prior, Anne experienced a traumatic event. During her last session, she seemed indifferent and unemotional about it. At the time, I surmised she was possibly mildly disassociated or detached from the event in order to get through it. She appeared to need more time before tackling it in session. Forcing a client to process a traumatic event before they are ready often re-traumatizes them, so respecting Anne’s pace was critical.
Yet, trauma is tricky and often the emotions from the event are fragmented and split off from the actual memory of the event. Occasionally, the terror and pain experienced during the trauma bubble up to conscious awareness without warning, unattached to the concrete memory of the experience. Thus, the fear and hurt are confusing and crazy-making because they come out of nowhere and don't make sense.
Assisting Anne in understanding this was the next intervention. “I bet you are confused and scared,” I said. She said yes softly. “I bet,” I said. I continued, “sometimes when a person experiences a traumatic event, they detach or disassociate from the event so it doesn't feel so bad. It's self-preservation. Yet, often the hurt, pain, and fear that has been repressed floats up to the surface without warning and overwhelms the person later on. This may be what you are experiencing. Anne agreed. I reassured her that this was a common experience and that it was understandable and made sense. Anne said she felt better knowing that.
The final step was to help Anne identify several coping mechanisms she could implement if she became upset again. I recommended Anne snuggle with her dogs, listen to soothing music, and do some yoga when she felt up to it. Anne agreed. We also scheduled an appointment for the following week.
Later, Lisa told me that after the call Anne sat on the couch with her dogs and fell asleep for a couple of hours. When she awoke, she felt a great deal better. Lisa thanked me and wanted to review how I helped Anne. She cited breathing and tensing and relaxing as the interventions. I agreed they were important, but I reminded her of the very first thing I did with Anne. Empathy.
In essence, fact-finding, pressuring a child to talk, and instructing them to breathe are interventions that may not be helpful to the child. Calming the child down by empathizing with how they feel and honoring their pain is the most important intervention. Breathing and tensing and relaxing with the child helps the child feel less alone. Above all else, empathy should come first.
The science behind empathy is important. The vagus nerve originates in the medulla which helps regulate the central nervous system. When there is good vagal tone in the vagus nerve, the central nervous system is soothed. Empathy is what creates good vagal tone in the vagus nerve.
Empathy is an immediate way to comfort a child. When a child feels empathy they feel understood. A child that believes their parent understands them feels connected to their parent and is willing to share how they feel. Empathy is a parent’s most important tool.
