It’s ok to be quiet: crisis, silence, and power

CN: mentions hospital, self harm 

On World Suicide Prevention Day, #itsoktotalk trended on twitter. Today is World Mental Health Day, when similar ideas often come to the fore. It is, of course, #oktotalk. It is more than ok – it is lifesaving. Sometimes.


But the theme of this year’s World Mental Health Day is ‘psychological first aid’, and I think that the importance of silence in providing that aid is often underacknowledged. Specifically, in interactions with crisis and emergency services, the pressure to talk can become damaging – the combination of time pressure and a deep power imbalance between the person in crisis and the healthcare professionals involved means that encouragement to speak can feel very much like coercion.


Let me explain. When I am very anxious, I find it physically difficult to speak. In the busy resources-strapped NHS, in the chaos of A&E, this is a challenge for crisis staff who need to figure out how to help me. But the responses I get to my silence are often counter-productive.


Sometimes when I am like this, the person assessing me says, “We can only help you if you talk to us.” This does not feel like encouragement. It feels like an ultimatum: be helped on our terms, or stop wasting our time. They know they are there to help; in that moment, I don’t trust that. Not everybody in my life who has said they were there to help me has really been on my side.


Often in these situations I am trying desperately hard to communicate what I need – sometimes, I turn up in A&E with my name, my details, and details of of my mental health problems and physical injuries on a post-it note. Underneath, I write “Sorry I find it difficult to speak to people I don’t know when I am anxious.” I am trying to give them the information they require to help me. And they reply, “We can only help you if you talk to us.”


A common theme for many people who struggle emotionally as adults is the huge role that powerlessness of one kind or another has played in our lives. Whether through abuse or error or plain bad luck, we were not in control at times when we desperately needed to be. Silence is often the self-protection response we have needed to survive this. 


When I most need to feel control over something, when I have been reduced to exerting power over my body through pain because it is the only thing left, speaking can feel like another loss of control. What will this stranger write down about me? Who will read it? How is this person going to play join-the-dots with a few details of my life, turning it into a picture I do not recognise? How will my story be changed in the series of handovers from triage nurse to A&E doctor to mental health liaison team to crisis team? Who will overhear it as it is passed on again and again?


What I need when I am in crisis is an acknowledgement of how frightening it is to say anything at all in that context, and a willingness to work with what I am able to share. Ask me what would make it easier (even if I don’t know). Tell me I can take my time – go and see another patient then come back if you have to. Ask if I would prefer to speak to a woman. Let me know, somehow, that you can see how difficult this is.


I need to feel that my history and my emotions belong to me. Seeing that my silence angers staff just makes me shut down further; letting me know I am not blamed for it tells me they know I am trying, and is the only way I can feel like it might really be ok to talk to the person in front of me.


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