BY, BSN, RN-BC, CCM
As a telephonic case manager for an insurance company, there are inevitably times when I have to speak with an angry or upset client. One of the best ways I have found to be able to compassionately and effectively calm down a client over the phone has been to rely on the nonviolent verbal de-escalation training I received many years ago as a residential counselor in a group home setting. The techniques come from a program called “Therapeutic Crisis Intervention” (TCI) developed by Cornell University, and are still widely used today in residential settings (https://rccp.cornell.edu/).1 Here, I will organize some of the interventions into what can be used before, during and after an interaction with an upset client. These techniques can empower us to be compassionate listeners while also maintaining our own sanity and keeping our boundaries intact.
Preparation: (before or at the beginning of speaking with an upset client)
- Tone. Tone is everything. According to TCI training, when we communicate in times of crisis, we rely mostly on facial expressions (55%) for understanding what the other person is saying. The remaining meaning is transmitted through tone of voice (38%) and the words we use (7%).2 Clearly we can’t rely on facial expressions during telephonic case management, which means tone of voice is really our most important tool. In order to keep my tone calming, I focus on my breathing and make my voice slightly lower and quieter than usual. I try to speak with confidence (and if I am not confident, I confidently state that I am unsure of what the best answer to their question is but will work on finding them a solution).
- Grounding. One of the first steps in TCI training is to always make sure I am aware of how I am feeling before I engage the upset client, as my emotional state can subconsciously affect my tone and conversational approach if I am not aware of how I am feeling. Am I tired, overwhelmed, worried, happy, distracted, etc.? Am I aware of my triggers? Am I focusing on being aware of cultural or ethnic differences that may impact the effectiveness or our communication? And what self-regulation skills do I want to use today? My usual go-tos are taking slow, quiet, deeper breaths mostly through my nose; walking slowly around my office or apartment (using a wireless headset); or doodling small circles or squares on a Post-it. Whatever you choose to do, the goal is to do an activity that calms your nervous system so that you are able to think more clearly (which can be particularly hard to do when someone is yelling at you).
During: (interventions that can help during a difficult exchange with a client)
- Managing the environment: In a residential setting, this usually refers to getting furniture out of the way while a resident is having physically aggressive behaviors so that people are less likely to get injured. Over the phone, managing the environment can be as simple as taking time to clarify exactly what the main complaint is so that there aren’t too many complaints circling around the conversation leading to further confusion and overwhelm. This allows you both time and space to manage each complaint, one at a time.
- Example: “I want to make sure I understand exactly what your concerns are so that I can best address them and try to get some good answers for you. I hear that you want the prior authorization to get approved, that you want to see a provider who is currently out of network without paying an additional cost, and you want to get timely care for your daughter at a facility near your home. Did I understand all that correctly? OK, so of those three things, which one is the most important that we address first? After we address the first one, we can go on to the next two.”
- Caring gesture: A caring gesture over the phone can be statements of empathy or condolences in the face of upset or tragedy. Sometimes it can be very tempting to just want to address the task at hand and problem-solve as quickly as possible. But when we take time to address the emotional toll that a situation is having on an upset person, this can help calm the situation quite a bit.
- Example 1: “I am so sorry to hear your husband passed away last year. I can see how that would make taking care of your healthcare needs on your own really overwhelming. This stuff can be really hard when we lose support like that.”
- Example 2: “Yes, I would be really upset and frustrated too if I had asked to speak with a manager two days ago, and still no one had gotten back to me. I would have a hard time trusting them as well. It makes total sense to be feeling this way.”
- Redirection and distractions: This is a TCI technique generally used as an attempt to dial down the intensity of a situation by getting the resident to focus on something more calming or neutral. This allows for some mental space to be created so that problem-solving can start to occur. For case management purposes, I would say that redirection can come in handy when a client is yelling about how no one is helping them, and that everything is just going to get worse no matter what we do at this point.
- Example: “I hear that you really want to find a drug and alcohol treatment facility for your daughter that can best address her needs, and that you have had bad experiences finding one in the past. I also remember you saying that she has found support groups in the area that have been helpful in the past. Can you tell me more about those? What did you or she like about them? What improvements did you see her make while she was attending support groups regularly? Did any of the other people in the support group have a rehab experience in a facility they found helpful that your daughter might be willing to consider exploring? Sometimes word of mouth can be a great way to get started in finding the best match for what you are looking for.”
- Time away (or giving space): Sometimes people just need some time away or space from the conversation to help diffuse the intensity of the situation. This is a technique that should be used carefully, especially if the client is triggered by people pulling away from them, or they struggle with boundaries. Other times, space is something that people welcome in order to reduce too much stimuli. It can be almost impossible to problem-solve while anyone is actively experiencing a lot of anger. For case management purposes, I don’t necessarily suggest taking space, but I recommend activities that would inherently create enough space to calm down.
- Example: “I hear that you are really upset about not hearing back from a manager right away. I want to make sure I get the right person for you who can best address this problem. I could find someone now who would be able to talk to you, but they may not be able to do much to help you if they don’t have the authority to do it. But since I’m new to the situation, if you could give me a little bit of time to find the right person for you, I will give you a call back in 1-2 hours to connect you to the help that you need. I know you have already waited for 24 hours to get a call-back, so I appreciate your patience as I work to figure this out. I can also give you my direct number just in case if for any reason I’m not able to get through to you. Is this the best number to reach you?”
After: (the follow-up call)
When I call a previously upset client back with an update, many times I am concerned it could become another long, charged conversation. If that is the case, I make time to state clear, compassionate boundaries before beginning the conversation. An example of this could be: “Hello, ___! I’m glad I was able to reach you. I set aside 20 minutes just to talk with you today and then I have another meeting I need to get to directly after. But I wanted to be sure to connect with you today. Here is the information I found for you, and the plan moving forward. We can connect more in the next couple of weeks if there are still more questions or concerns.”
In summary, there are a lot of excellent communication techniques that can be used to help calm down angry clients, but I am I most grateful for the verbal de-escalation training I received while working in residential care. It has shown itself to be invaluable in many settings, including telephonic case management work. There are several other TCI techniques that can be useful in de-escalating difficult situations, but I hope this initial information will be helpful to others as we all navigate difficult terrain with our clients together.