First response for extreme distress

Emotional distress can cause abrupt thinking and behavior changes, hallucinations, or severe confusion. These distress responses may frighten the person experiencing them and people around him. They may last only a moment or for a longer period of time.

If someone in emotional distress wants to hurt herself or others, or caused or escaped violence, it is an emergency. Provide calm, focused attention. Check breathing, stop any bleeding, and check for physical injuries. Then establish emotional connection, problem-solve, look around, and follow-up.

1. Connect with the person

Connect emotionally.

When a person experiences severe emotional distress, he may feel alone or afraid. He may have trouble understanding the world around him or feel others cannot understand him. Emotional connection is necessary to communicate and problem-solve.

Some ways to establish emotional connection:

  • Be patient, kind, and attentive.
  • Engage your empathy. Try to feel what he is feeling with him.
  • Match his tone of voice, and make your voice slightly more gentle.
  • Repeat his words to him. Mirror motions and body language as you try to understand.
  • Sit or squat on his level. Try to make eye contact.
  • Listen calmly. Ask gentle questions to show you care and be sure you understand.
  • Life experiences and neurodiversity change how people connect. Find a way that works for the person.

It can damage your connection to think displays of severe distress are symptoms of illness. Severe distress is a response to something that happened and felt threatening. The distressed person made sense of what happened and responded in a way that helped them survive.

Recognize your limits. Offer connection, not therapy. If a distressed person wants to tell traumatic stories, consider redirecting him to basic needs or helping him call a hotline with trained operators.

Connect about the situation.

If someone says he was raped, abused, or is in danger, let him know you believe him:

  • I believe you.
  • It’s not your fault.
  • You have options.

If someone says he wants to hurt himself or others, believe him. Limit questions, but ask directly about intent, plan, and means. For example:

  • Do you want to kill yourself? (intent)
  • How? (plan)
  • (If he says “with a gun”) Do you have a gun? Where is it? (means)

If someone tells you she hurt someone, pause. Decide how much you need to know. Say what kind of details you will and won't listen to. Tell her if you will report anything she might say.

If someone's level of responsiveness is lowered or he reports poisoning himself, he may need emergency interventions such as recovery position, rescue breathing, naloxone, and hospital care. If he is very drunk or high, the possibility for connection may be delayed.

2. Problem solve

Basic needs.

People in severe emotional distress have at least one unmet basic need. Prolonged lack of sleep is the most common cause of psychosis and suicidality. HALT is a basic needs check-in. When someone is very distressed, Alcoholics Anonymous members found four problems they can fix that help prevent relapse. Are you too:

Hungry

Angry

Lonely

Tired

Each can be excessive or deficient. “Lonely for others” is the need for empathy and human connection. What about “lonely for self” – inability to get personal space for too long? On a picket line or if someone lost housing, “too cold” or “too wet” belongs on the list – hypothermia makes you tired.

If someone is fleeing abuse or getting out of jail, when did she last eat? How will she get her next meal? Where will she sleep tonight? If she hasn’t been able to sleep, what activities or meds help her sleep? Who does she want get in touch with? How will she express anger?

Safety, healthcare, and morale.

Problem solving may involve getting permission to take someone’s gun to a friend’s house. She may want to have someone stay with her for the night, or go to a hospital, peer respite, or domestic violence shelter.

If she hurt someone, help her contact someone qualified to hear the story and help her make amends. If the person is currently dangerous to others, it is often easier to move other people away than to move her. You may need help to make the area around her safe. Look out for your own safety as well.

Sickness can change medication blood levels, cause financial or other problems, and directly cause emotional distress.

3. Recognize and respond to other distressed people

Extreme distress is contagious. Recognize witnesses, family members, friends, people who have been harmed, or responders who are distressed.

The basic recipe for crisis survival is have a buddy, ground, and do something. Sugar’s check-in can take care of all three basic solutions at once.

  • What did you do for yourself today?
  • What do you need to do?

Consider using Sugar’s check-in, HALTS, or a rapid group low point/high point debrief to recognize and engage good coping among people distressed by the extremely distressed person.

4. Follow up and plan how to respond to future severe distress

Check back in a day or two after severe distress, if possible. Express care and find out if longer-term planning is needed. This is a great time to help someone make a plan to prevent and care for severe distress in the future.

A good plan might include:

  • What I do to stay well.
  • How to tell I’m getting worse.
  • What I should do if I’m getting worse.
  • How to tell I’m in crisis.
  • What to do when I’m in crisis.
  • How to know I’m getting better.
  • What I should do while I’m getting better.
  • Who I want and don’t want involved.
  • Medications, medical facilities, and providers that help or don’t help.

Respect confidentiality. If you want to process the crisis with someone or involve someone in a person’s care, let him know who and what you will tell. It may be helpful to seek the help of spiritual or community leaders the person respects. Following up to see that he continues to get help, and to show that you care about him, is important.

Resources

Hotlines are staffed 24 hours a day unless otherwise noted. We tried to exclude hotlines that nonconsensually involve police from this list. Ask before putting someone in crisis on the phone if the operator is ever required to involve police.

Call the hotline and put the distressed person on the phone with the trained operator. She may want privacy during the conversation. Afterward, ask about her plan and if she needs help carrying it out.

  • National Domestic Violence Hotline (fine to call in rape crisis, too): 1-800-799-7233 (SAFE)
  • Poison Control Centers (can identify poisons and talk you through overdose response): 1-800-222-1222
  • Veterans Crisis Line: 1-800-273-8255
  • Suicide hotline (connects you to local options): 1-800-784-2433
  • Trans Lifeline (9am-3am central time): 877-565-8860 and Trevor Lifeline (for LGBTQ youth): 1-866-488-7386

Warmlines are usually staffed by people with lived experience – who personally understand what you’re going through. They know about local options, including places that could board your pet for a few days or peer-run respites where you could stay with trained people with lived experience. They are happy to just listen. Most of them are not staffed 24 hours a day. Some have chat or email options.

Info lines (like 311) just answer questions.

  • warmline.org is a national directory of peer-run warmlines. Save the number for your state in your phone. If you don't like the warmline in your state, call another state.
    • A Kentucky warm line is run by Participation Station: 859-252-0058 or 877-840-5167
  • Alcoholics Anonymous local info and online meetings at aa.org.
    • Lexington Kentucky Bluegrass Intergroup hotline: 859-225-1212
  • Veteran Peer Support Warmline: 1-877-927-8387
  • StrongHearts Native Helpline (domestic/dating violence helpline for Native Americans): 1-844-762-8483.
  • Backline pregnancy options line (pregnancy options counseling and assistance accessing abortion care): 1-888-493-0092
  • Non-emergency services (food pantries, shelters, etc.): 311
  • SGR Hotline (sex, gender, and relationship questions, including about pleasure, dysphoria, STIs, or abuse): 415-989-7374
  • National LGBT Hotline (for local resources): 1-888-843-4564

There are currently no hotlines or warmlines specifically for black people experiencing severe distress, but there should be. See warmline.org for information about how to start a warmline.