209 Appendix F—Engagement Handout ABCD Specific Engagement Techniques: Affect modulation, Body language, Cultural cues, and Delivery/diction Affect modulation If the provider rejects or is defensive or annoyed by the parent’s/child’s anger, the child (or parent) will get more angry and more dysregulated. The physician can match the affective expression of a parent’s/child’s anger without being angry themselves. The parent/child will experience this as empathy for their anger and experience it as “They get it” and “They understand how angry I am about this!” The physician matches the affective state but remains regulated, which helps the parent/child be more regulated. Affect is the facial and body expression of our emotional state. Emotions, such as anger, sadness, fear, joy, and excitement, are expressed in our body language and facial expressions and can be interpreted by others without words. Some emotions are difficult to hide: anger, in particular, is so powerful of an emotion that it is almost impossible to prevent it from becoming evident in our facial expressions and vocal tone. Emotions as expressed through our facial affect and body language evoke a similar reaction in those who perceive them. Description Using in engagement: unhelpful provider response Using in engagement: helpful provider response Technique Body language Glance at watch or computer often. Become defensive, angry, or impatient. People feeling highly defensive or rejection sensitive can disengage or even dissociate in response to just a change in tone of voice or subtle shift in eye movements. Maintain defensive posture (eg, arms crossed, withdrawn). Remain calm. Project an open demeanor. Listen attentively. “Lean in” (with body posture). Maintain eye contact. Nonverbal communication The fastest way to send safety messages to another’s person’s brain is through nonverbal communication. Nonverbal signals stimulate the emotion-generating right-side limbic system of the brain and then quickly transmit to the amygdala for assessing safety or threat. Nonverbal communication is perceived by the brain at a rate 6 times faster than voice. Thus, nonverbal communication trumps verbal communication in projecting safety to a parent/child. Cultural cues Assuming that you understand the meaning of what has happened in the culture Leaping to conclusions and to treatment recommendations Failing to use interpreters Engage in attuned, attentive listening. Reflect back what you’ve heard. Ask for the meaning of what has happened or of the illness or behavior in the culture. Begin by following the parent’s/ patient’s lead at first. Ask least intrusive question(s) first. Use interpreters if necessary avoid using family members. Cultural sensitivity and humility Use encounter as an opportunity to learn more about the family’s culture. Building rapport is critical. Approach the patient with as few assumptions as possible. Be aware of the stigma associated with trauma and emotional issues. Use collateral sources of data. Be aware of disagreements in explanatory models between family members. Use cultural consultants when appropriate. Be aware of cultures in which prolonged eye contact is considered rude or an affront. Delivery/ diction Use of low tones or a shift to low tones in conversation may send a child or parent who has experienced trauma into self-defense mode. Approach children and families with higher-pitched sounds, stimulating the release of oxytocin in the amygdala, to calm this threat-sensitive region. Empathic words of comfort may be a bridge to safety, especially if expressed with a gentle rhythm and light intensity. How tone of voice is interpreted by others There are specific safety sounds: the inner ear interprets higher-pitched, musical sounds such as “parent-ese” or child-directed speech as being safe. There are specific danger sounds: the inner ear interprets lower- frequency sounds as being more predatory or threatening, and they are likely to be heard as anger flat sounds may signal depression. By focusing middle ear muscles on the intensity of sounds, the ear can detect these lower-pitched sounds as speech shifts to anger. The brains of children living with threat have auditory systems tuned to hear the low-pitched sounds of threat and ignore or suppress the higher, more musical sounds of safety. Relearning to hear safety sounds can be like learning a second language. CTAR BOOK.indb 209 5/16/21 2:54 PM
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