Creating calm in the clinic

Most affected by the HIV epidemic face many stressors such as racism, homophobia, financial constraints, and stigma around drug use—all of which can lead to distress. Understanding that someone is distressed, rather than labeling them as “difficult,” is essential, says Mathew R. Roosa, LCSW-R. A negative label distracts from working well together to resolve challenges to a person’s health care.

“You’re trying to figure out how to continue providing care while managing a person’s distress within a limited amount of time and resources,” says Roosa. “How can we pivot to address the distress so we can get back to providing the care that is our primary goal?”

Roosa has worked on a number of research projects designed to enhance mental health support in HIV care settings. His clinical work includes serving as a mental health and substance use therapist, agency administrator, and government planner for mental health and substance use services. Now working as a consultant, Roosa helped put together a presentation, Creating Calm: Engaging People Who are Distressed, for the Mental Health Technology Transfer Center (MHTTC). He speaks here to key points for creating calm, why we need to avoid language such as “acting out,” and to the magic of empathy.

Mental health first aid for everyone

“We find that there is a lot of good training for clinical staff—social workers, psychologists, counselors, marriage and family therapists—for effective response to people who are having a lot of strong emotional dysregulation. By that we mean stressors that are creating intense emotional reactions that might be getting in the way of their functioning, causing them to struggle or not be able to think clearly or solve problems in the moment. There isn’t, however, so much stuff out there for individuals who are not working as a mental health clinician, such as people sitting at the front desk or coming in to do research surveys.

“There’s now this field of mental health first aid, which lets us know that there are core things that all of us can do to help someone who’s having a crisis or a strong emotional challenge. It’s like regular first aid. We can all apply some physical first aid now. We don’t need to be a nurse or a doctor.”


“We know what it’s like when someone’s really upset and we’re trying to just push them through the service. And they’re reluctant to do that because they’re upset. If we can just take a minute to do something else, we may be able to re-establish our connection and de-escalate their level of distress, and then we can more efficiently move back into that care.

“Rather than leaning in, try to lean back. Rather than asserting, try to ask questions. Try to provide an opportunity for the person to communicate with you, rather than you trying to dictate to the person. That’s hard when things are stressful, because we all want for things to get less stressful quickly. So we often engage in behaviors that inadvertently create more stress. Avoid that quick reaction and create some space for that person. They might be yelling or wagging their finger at us, but in fact what’s happening is that they’re worried. So much of a person’s distress can be managed if you’re sharing empathy and building trust.”

Don’t worry about opening a can of worms

“I’ve talked to a lot of providers and some very skilled, excellent ones who will say, ‘Gosh, I really don’t want to ask those questions because I don’t feel like I have the time, the staff, or the resources to respond.’ No one feels good about that. The challenge is to come up with some clear, simple strategies to respond effectively.” (See How to create calm while engaging with distressed people.) (insert link)

Speaking up

“I’ve seen it over and over that when someone becomes very upset, either because they’re angry, frustrated, worried, or concerned, there is a frequent tendency to ease that burden by telling the person what they should do, giving them specific directions, or telling them that they should try to calm down. It’s almost always well intentioned. And it almost never works, because we all know what it’s like when someone tells us to calm down when we’re feeling upset. We generally feel like our experience is being discredited, disrespected, or ignored, and we usually get more upset. It’s like, I’m being loud so that you can hear me. You’re telling me to calm down, which means you’re not hearing me, which means I need to get louder in order for you to hear me.”

Words matter

“Using the words ‘acting out’—that’s a tremendous judgment. I put you in a one down [lower] position, and I put myself in a position of judgment, power, and control. That is the opposite of what we want to do when we’re trying to help someone feel more in control and more able to make decisions. My belief about your behavior might determine how we understand and address the situation. ‘Acting out’ is terrible language and is also infantilizing because it is language that’s associated with children. And so when we use it in reference to adults, that’s another way that it’s stigmatizing and disrespectful.

‘Rather than leaning in, try to lean back. Rather than asserting, try to ask questions. Try to provide an opportunity for the person to communicate with you.’

“The language that we’re using here, in terms of creating calm for people who are distressed, is what I like to think of as a much more empathic and person-centered language. We see a lot of language related to ‘difficult’ or ‘challenging’ people. And those are versions of judgmental language which tend to distance us from empathy toward that individual. We are all difficult at times.”


“We traditionally used to think about trauma as a ‘yes or no’ question. You either experienced these things that were very difficult, which have resulted in some challenges for you currently, or you were able to resolve that trauma and so you’re not struggling with it currently. But we didn’t think of it as a universal phenomenon.

“The reality is that it’s more of a spectrum. Most everyone has some experiences from their earlier years that caused pain. They have a legacy in their current life that might impact how they see the world or how they react to stressful situations. So, rather than yes or no, it’s what is my history of trauma? How much did I experience? And how is it impacting me now?”

Cultural divide

“I had one training with several people where a trainer responded to two African American women sharing ideas with each other by saying, ‘Well, there’s no reason to get angry about it.’ The whole room fell apart. The women just had a slight disagreement with each other and were a little bit animated in their expression of their ideas. He was a white man who saw the discussion as a fight. We had to do all this damage control discussing this harsh judgment and this cross-cultural barrier. That’s a good example of a lack of empathy. He did not understand what they were thinking or feeling and he didn’t have a cultural lens that allowed him to understand them.”

Empathy is not tolerance

“There are times when people need to get kicked out. Someone comes in and tries to punch someone at the front desk, they should get arrested. We can’t tolerate that. At the end of the day, we have to keep people safe and healthy and able to deliver care and support. And if there’s exposure to that kind of hurt, they won’t be able to do it.

“I think it’s actually lacking in empathy when you tolerate problematic behaviors because then you allow that person to get further away from healthy behaviors. It allows them to get closer to high risk for themselves and for others. That’s not an empathic and compassionate response. We’re not expecting much of them. We’re not appreciating their humanity and their capacity to improve and move towards healthier behaviors. Healthy boundaries are part of an empathic compassionate response. ‘We want to have you aspire to healthy behavior and that is not what this is.’

“Concerns include anger and rage. Second-most common is anxiety and panic. Distrust and paranoia feed on each other. Distrust-related paranoia often can result in risks to safety because people feel like they’re being mistreated or that they’re at risk, or that someone’s trying to harm them. And so they might feel a need to protect themselves. That can create some pretty serious risks.

“Calling the cops, however, can cause great harm. We need to find alternatives to calling the police in some types of situations. Involving emergency services like the police is a last resort.”

Empathy, not sympathy

“Understanding empathy is maybe the most important part of all of this because most people don’t appreciate empathy for what it is. It is not sympathy. It is not a warm, fuzzy feeling sorry for someone.

“Empathy is more head than it is heart. Empathy is more about understanding what the person is experiencing, trying to put yourself in their shoes and appreciate what they’re thinking and feeling, and how that relates to what they’re doing. ‘Understanding’ is a better word to use when defining empathy.” 

Also go to For copies of the Creating Calm for People Who are Distressed PowerPoint presentation, email MHTTC supports resource development and dissemination along with training and technical assistance for the mental health field. In addition to regional centers, the network includes a center for American Indians and Alaskan Natives and another for Latinx people. Creating Calm was produced with funding from the Health Resources and Services Administration (HRSA) under a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA).