After another day of training people around how to work with people who hurt themselves and find it hard to trust others (often diagnosed with Borderline Personality Disorder) I was left thinking about how eager staff are for ways to be helpful. The generic ward and community staff often have a sense that they can offer nothing and that all the skills for working with this client group lie either with psychologists or mystic practitioners of 3 letter therapies. One of the exercises we do on the day looks at how to take the heat out of situations so that people can talk to each other. We normally identify it as ‘validation’ and in all my years of working with people labelled with personality disorder, I think its the most useful thing I’ve picked up.
In the spirit of trying to be helpful to the Keir Harding who struggled to work with traumatised people 15 years ago, I’m going to go through the 6 levels of validation as outlined in DBT. While DBT is a therapy specifically aimed at those with a diagnosis of borderline personality disorder, this way of relating to people is useful for everyone. I even used this to get £300 worth of free mechanical work so this is literally a valuable tool to have in your arsenal.
Level 1 – Being present
I think in the old days we would call this active listening. Eye contact, nodding, smiling in the right places. Budding Elvis impersonators might like to throw in an ‘uh huh’. While this seems like the most obvious thing in the world to do I think back to my early career when I was doing assessments with people. The session tended to move away from a place where we could learn something and instead turned into an exercise in getting a form filled in. I’m pretty sure I’d ask closed questions so as to fill a particular box and then stop listening once said box had been ticked or crossed.
So without being too creepy, look at people with rapt attention, as if in this moment what they are saying (or not saying) is the most important thing.
Level 2 – Accurate reflection
This is where you move on from showing people you are listening to showing them that you have heard them. This can be a simple “So you’ve told me you’re upset” a more hypothetical “It sounds like you’re really sad” or “When you came in you said you wanted x”. All we are doing here is repeating back what people have said in different (but not always) words. Again, when I think of myself doing this badly, I’d get to the end of the form and say “Right then, I’ll write this up and send you a copy. See you next week” which would pretty much give the impression I hadn’t heard anything they said. It was as if the priority was getting the form filled in, rather than tryin to understand something about the person in front of me.
Level 3 Reading
This is where validation gets more interesting as we get to use our brains a bit more. Here we are taking what someone is telling us and offering something new. “When they walked out and the house was silent, I wonder if you felt utterly alone?” or “When your friend said she didn’t like her present, I wonder if that hurt?”. Again this lets people know that you’re not only listening but thinking about them. Try to avoid telling them what they should have felt.
I think my best (worst?) examples of doing this wrong is similar to the above, where I’ve written down responses verbatim or, where I’ve told people what they should feel.
“So he ran away with my bag”
“You must have been angry”
“I was too frightened”
“You weren’t angry that he took your bag?”
Telling people they should see and feel things your way never tends to work out too well…
Level 4 – Normalising based on past experience
This is one I use a lot and probably the one I’ve done most badly in the past. This is where we show that we are not only listening and thinking about someone, but we know them too. With this we try to show people that what they have felt/thought/done is entirely understandable given their background. It’s something I like to use when people say “I was so BPD”. For example…
“I get so worried about saying the wrong thing I just don’t say anything …it’s just my BPD”
“Well you could think of it as BPD, but you said that when you were younger you used to be severely punished for saying something that your parents disagreed with. I wonder if you learned that saying the wrong thing can be dangerous so it makes sense that you’re frightened.”
Here we are trying to show that their feelings are perfectly understandable, based on what has happened to them in the past. If we don’t know their past we can be curious – “So you say that you feel worried about speaking. Worry makes me think of fear and that makes me think of something threatening or dangerous. I wonder if something has happened that has taught you speaking can be dangerous to you?”. You might get a few “don’t knows” but I’m betting you will build a better relationship with one “I expect there’s a really good reason you feel this way” than you will from a hundred “There’s nothing to be afraid of”s.
Level 5 – Normalising based on it being normal
It’s this one where we help the person who feels freakish and different to see that they’re like everyone else in the world. We take the bizarre, baffling and unfathomable and turn it into pure reason. I often find this is what many staff struggle with and when they can’t understand, they make their own interpretations as to why people do what they do. To use a real life example …
“I want to go on leave”
“We’ve sent you on leave a few times but you just sabotage it” – might possibly be better framed as:
“when you’re home by yourself you get frightened and desperate, so you cope by doing what you normally do when you’re scared. Everyone does what they can to cope when they are desperate.”
“I get scared that I’ll be on my own forever”
“I think everyone would find the idea of being alone forever fairly scary”
It is in this area that I excelled in invalidating people. I’d learned some CBT on my travels through mental health and I had an obsession with challenging ‘thinking errors’ and ‘negative thoughts’. I would have seized the above statement and tried to convince them that they were wrong to feel what they felt. I’d ask what there was to be afraid of, I’d ask what was so bad about being on their own. I think I would tend to keep going until they felt stupid and ashamed for thinking what they did. I’m not proud…but (sadly) I am certainly not alone in making this mistake. One of the interactions I regularly see in services is someone saying “My life is so shit” and the other person leaps in to tell them they’re wrong.
“I want to die, I’ve got no money, everybody hates me and I’m never going to go out on my own”
“But Rachel, yesterday you were laughing at Simons joke, and this morning you made a cake and said you’d enjoyed it”.
This rarely makes people suddenly believe that their life is worth living and it certainly convinces them you don’t understand.
“I want to die, I’ve got no money everybody hates me and I’m never going to go out on my own”
“I can hear how much you want things to be different. Most people would despair at the idea of being hated and dependent on people”
The other common one I used to do a lot was “I’m never going to get better” at which point I’d leap in with gusto (because remember, my patient not getting better is an explicit criticism of me) ranting “But you’re doing so well!!!” To make me feel better the college lecturer would nod and agree when I told him he’d caught a bus by himself and stayed in the busy shop for a whole hour. In reality I had totally dismissed what he was feeling and instead put some work in to make myself feel better.
It is useful to challenge people but for most, and certainly the group I work with, people hear you louder if you can validate what they’re saying first.
Level 6 – Radical Genuineness
This is the master level of validation that only the true mental health ninjas can achieve, although in essence it’s not that hard. Once we have shown people that we are listening, hearing them, thinking about them, shown it makes sense given their experience, shown it makes sense given the rest of the world would feel like that too, – then we can take the final step, “I would probably feel like that!” or even “I have felt like that”. This can be as simple as:
“When they said I couldn’t get any leave I was fuming and just trashed my room”
“If I’d been planning something all week and someone told me it couldn’t happen I’d be pretty angry too”
Or it can be a bit more personal…
“Its so unfair, I just want to go home and they said they’ll section me if I try to leave”
“My daughter was in hospital once and the consultant said we could take her home. He went off shift and the physio said we couldn’t take her until the Dr said it was OK. Knowing it had been agreed I wanted to discharge her ‘against medical advice’ and the ward staff told me they’d call social services if I tried to take her. I know it’s not the same but I understand some of that feeling of being trapped, threatened and it being unfair.”
It’s possibly my own reading of radical genuineness, but i think there is a value in being, well, genuine with people. I think back to the times when someone has told me of some weekend that Stephen King and HP Lovecraft couldn’t have imagined if they’d had a month together. I’ve nodded along as if tales like this are all in a days work for a consummate professional like me when inside I felt like a cartoon of a shocked man. It might well have been more useful to convey the horror of what they had told me. When it seems helpful I now tend to drop in the odd “If that happened to me I think I’d be terrified”, “I can feel myself filling up as you’re describing that” “I’m trying to listen to you but I’m so worried about what you’ve told me I think I’m going to be useless to you until you get medical attention and my anxiety comes down”. Non verbally I might wince when someone describes something painful.
The other obvious element of GR is that if you can do something to make the situation better then you do it or at least be really explicit about why you’re not. I’ve known people who were desperate to be admitted to hospital be told that they won’t be admitted because it’s not in their best interest. End of explanation. Either acting, or giving a detailed pros and cons of why you are not acting is a lot more validating than giving the message that they are wrong to want the things they want.
So those are the 6 levels of validation. I find myself using them most when meeting people for the first time and when the situation is becoming heated. Very often I’ve seen someone go up to a member of staff and shout at them. The staff member shouts back. They shout louder and a few minutes later there’s a wrestling match going on for which the staff have a numerical advantage. I’ve seen people shout at staff and the immediate response is that “You can’t talk to me like that”, which is a valid point, although a debate on the niceties of social etiquette is not something anyone whose emotions are dialled up to 11 is ready for.
“Youre a F***ing C*** you are!!!”
“You seem REALLY angry, can you help me understand what’s going on for you”
“You seem really angry at the moment but when you shout at me my anxiety goes through the roof and I can’t think. Can we both take a breath and think together about what’s going on ?”
And you can wrap up with “If that happened to me I think the other person was a bit C***y too”.
In other blogs I’ve talked about wanting to ‘win’ interactions with people. Validation is not about ‘winning’, but giving the people we are talking to the clearest picture possible that we are there for them. When I’m doing training, at some point someone says that we can’t just validate everything. There are limits. Lines have to be drawn. And this is true, there are behaviours that can get people in trouble with the police, hurt people and destroy relationships. We do not validate the behaviour we find unacceptable, but we do validate the motivation. We don’t validate the assault but the anger. We don’t validate the overdose but the hopelessness.
The other question that comes up is whether or not we can challenge people. Of course we can. Most of the people I work with have been repeatedly abandoned so theyre always on the lookout for signs its about to happen again even when the staff are really invested. While being told how much I hate the person I work with, I’ve found a Monty Python style “Oh no I don’t” usually isn’t going to cut it.
“To be honest, I do get a bit frustrated when you interrupt me, but I wonder if I can be slightly irritated sometimes and enjoy working with you as well”
“I can hear you think I hate you. I wonder what I’ve done to make you think that?”
“You seem upset and angry with me. I expect I’ve done something that’s led you to feel that way. Can you help me understand what it might be”
The consistent thing with all those examples is to validate first. Once they know we’re listening we can offer something else. That might be a direct contradiction or it could be a synthesis of ideas:
“I’ve got nowhere”
“I know you feel stuck and that nothings good enough, but I wonder if two things are true, that your standards of success are really high and you haven’t changed as quickly as you wanted”.
So there is validation in a nutshell. It is not rocket science. It is barely paper aeroplane science but it is something that can easily slip when we’re tired and the work is hard. I forget a lot but I tend to be at my most effective when I’m using this a lot. I think this would have been useful to me when i was first starting out in the NHS. I hope it’s useful to you.
Keir is an Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk