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Aug 21

Pay Attention

attentionWe need to be noticed and attended to. It is one of the most important psychological needs we have.

For several years, I have been lecturing residents in psychiatry at UCSF on the management of people in crisis. One of the topics, is how to work with people who are potentially violent.

On an inpatient psychiatric unit there are, from time to time, people who repeatedly act in a way  that seems designed to create fights, with staff, with other patients, or with anybody in general. In preparing my lectures, I spent some time reading about people with recurrent violence and trying to understand why anyone would do this. Were they just bad people?

There are many reasons for this kind of behavior, but the one that seems most often relevant is that people who do this tend to have very few social connections and a history of terrible childhoods. For them, getting hostile attention is better than being ignored. If you fight me, at least I matter.

In New York state they set up a special unit to work with people with this pattern of behavior. What they found worked to change the behavior of the most intractably violent patients was not to give them lots of medications, but rather to systematically recognize and reward positive behavior and to try to deal with violence in as neutral a manner as possible. In essence, to withdraw when the person was violent and to do a better job of engaging when they weren’t.

Easier said than done.

How to decline the opportunity for a fight and, at the same time, see that what the person really wants is some positive attention?

A very wise psychiatrist, Bob Okin, told me once that the hardest thing as a parent was to recognize that the angry, shouting, young child sometimes just wants to be hugged.

It gets harder when the child grows up. He or she might think they are small and helpless, while others see someone large and scary.

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