As a helping professional, you have a special power that can be harnessed when a patient goes into fight-or-flight mode: co-regulation. When you’re working with a patient who is feeling triggered, you can help them de-escalate through co-regulation—often without even using words.
In this Q&A, PrairieCare’s Nathan Grumdahl, DNP, APRN, PHN, PMHNP-BC, breaks down how co-regulation works and why it can be an integral aspect of your practice. Plus, learn steps clinicians can take to fill their cup, access support after a difficult appointment, and ensure they’re taking care of themselves as much as their patients.
What does it mean to co-regulate with a patient?
Co-regulation is when a clinician practices an intentionally calming and supportive approach with a patient to help them regulate their nervous system activation. This approach utilizes the clinician’s own regulated nervous system to help the other person feel safe, heard, and calm. It can help to move the patient out of a reactive, fight-or-flight, or trauma-activated nervous system state.
It’s a meaningful approach we can use to support patients who are dysregulated or activated due to trauma, anxiety, autism, distress, family conflict, or other challenges. However, it requires us to be mindful of our level of activation to ensure it translates successfully to the patient. That means we need to bring forward a calm, peaceful, and affirming presence, which requires self-awareness, practice, and intention.
Versions of this approach exist in many practices, including mindfulness work, CBT, ACT, EMFT, DBT, and others. Co-regulation is also discussed in Carl Rogers’ “growth-promoting climate” concept and other earlier forms of psychotherapy. You’ll also see similar approaches cultivated in nursing, education, daycare, and long-term care settings, as well as in disaster relief and crisis response. One example may look like a hospital nurse spends time with a patient before a procedure to answer all their questions and in the process nonverbally soothe their fear. Another example could be an aide in a memory care unit who offers a calming reassurance when a patient is confused or agitated due to dementia.
What are the signs that you and/or your patient need to pause and redirect?
The signs that we may need to help patients “pendulate,” or move out of states of activation, can vary significantly. Generally, when someone is in a fight-or-flight state, we can see it in their body and behaviors: Their rate of breathing or rate of speech might increase, they might begin to grimace or tense up in their body, or they may become tearful or clench their fists. The way they’re speaking could also change—they might begin to make shorter, more intense, and less descriptive statements. All of this indicates that they may be moving outside the window of what they’re able to tolerate.
Some people enter a freeze state when they have moved outside their window of tolerance. It can be harder to identify when a patient is dissociating, masking, or shutting down, but often people seem to respond more slowly, or not at all. They may speak in hushed tones or broken sentences, look away, close their eyes, or cover their face. This could also be the patient communicating with you that they’re feeling overwhelmed, which is always something we must listen to and support.
Can you provide examples of how this can be done in practice?
Co-regulation can include verbal communication, but is most notable for its nonverbal methods. As clinicians, we can modulate a patient’s energy and activation by intentionally lowering our own energy and level of activation.
The ways we can do this include relaxing the body, shifting our posture to be more open, and sometimes turning our gaze so it’s not directly on the patient at all times. We can take long, deep breaths and, over time, invite our patients to join us in this practice. While speaking, we should lower our tone, reduce our volume, and slow the rate of our speech. We should also consider using shorter sentences and leaving more space between statements.
While it’s important to still offer validation and affirmation, sometimes it’s beneficial to speak less and focus more on active listening. Nursing has a concept in these spaces called “therapeutic silence,” which I often use. At other times, it helps to slowly restate what the patient is saying to confirm for them that they have been heard. By using these approaches, we can increase the person’s sense of safety and generally slow down the energy in the room, creating a more regulated space.
Can you explain how co-regulating helps patients build self-regulation skills?
Part of helping patients build these skills is demonstrating and teaching them in a way that feels approachable and attainable for them to use outside of therapy. However, if we try to introduce skills when a patient is too far outside their window of emotional or nervous system tolerance, they may struggle to engage in the learning, resist that skill, and even encode the experience in a negative way. Which makes sense, as when someone is in a state of fight-or-flight, their cognition has moved away from the areas of the brain that control the executive functioning that’s needed to learn new skills.
Co-regulation can help build trust and is a vital part of a trauma-informed approach for many patients. Especially as you’re building rapport with a new patient, it gives you a means to connect with them right away and create a safe, calm space for them to have hard discussions and do the work they came to you to do in the first place.
What about when providers get triggered and experience an emotional/physical response when working with a patient?
To be very frank, every clinician brings their history into their practice. To do the work we may need to do with our patient, we first need to do it ourselves. This means being aware of our traumas, anxieties, insecurities, and triggers, and working with these in spaces outside of our work with patients.
I could not do my job without being in therapy myself. Getting support is a tool all mental health professionals should fundamentally consider. It is an important part of cultivating self-awareness about our own triggers. While we may not be able to perfectly anticipate when we’ll react, recognizing and considering the edges of our window of tolerance can help us back off the intensity or shift strategies in a way that supports our work with patients—without compromising our well-being in the process.
To this end, it is essential to consider the benefits of clinical supervision to provide support when we’re experiencing our reactions, activation of trauma, and countertransference with patients. We need to unpack our experiences in a supportive way, apart from patient time. This encourages our growth and well-being, and can also help prevent harm to the patient.
When is it appropriate to share with a patient that you relate to their experience?
Everyone has their own boundaries around self-disclosure in this space. A golden rule for me (and many other talented clinicians I’ve talked to, from whom I got this advice) is to limit my impulse to share these things unless it’s beneficial to the patient. It can be helpful to very minimally disclose as a clinician, to help patients feel a sense of connection and safety, or to build a commonality that encourages trust. But sharing too much can end up inserting our needs or experiences into the therapeutic dynamic in a way that is not helpful.
If we do share, we should do so sparingly, with consideration of its purpose, and with the patient’s pre-approval. This might look like, “I have had similar experiences as you describe. Would it be helpful to hear about that for you?” Remember that they may say no, and that is ok! This is quite a tightrope to walk at times, and supervision can be very beneficial to help you review the boundaries of that self-disclosure.
How can you care for yourself after an intense appointment and manage your mental well-being?
Having good boundaries outside of work and engaging in regular self-care practices can increase our resilience at these times. As I’ve said, I’m a big believer in doing our own therapy outside of work. Like the old saying goes, we cannot pour from an empty cup.
One skill I often use is taking a walk or two during my day, usually in the middle of paperwork time, rather than prioritizing getting through my notes or emails. Stepping away, even for 15 minutes, can be transformative. Raising my gaze to the sky and taking in nature, connecting with my senses, and focusing my attention on the present moment pay a lot of dividends in this space. Especially after a hard session, taking a break is crucial, even if it’s a stroll across a busy parking lot.
Also, it’s important to ask: Who can we turn to during our workday to process, get advice, or decompress when we have a lot on our minds? If you read any biography of a successful CEO, politician, or changemaker, a fundamental skill they have is recognizing when they need support. Seeking support is a very healthy habit in this field.
I have also benefited from reaching out to colleagues, other NPs and MDs, and seeking direct clinical supervision from our Regional Operations Director for the Twin Cities. When complex patient dynamics or activating situations have come up for me, it has been a lifesaver. I hope that everyone has an experienced and thoughtful confidante that they can go to when more challenging situations arise!
About Nathan Grumdahl, DNP, APRN, PHN, PMHNP-BC
Nathan specializes in treatment for mood, anxiety, gender, and trauma concerns for adolescents, adults, and their families at our outpatient location in Edina. In his practice, he takes pride in working with LGBTQ+ patients and their families to provide support and informed care on their journey exploring issues related to gender or sexuality. He has extensive knowledge at all levels of mental healthcare, including emergency medicine, and is passionate about supporting underserved communities.
Mental Health Services for All Ages
At PrairieCare, we offer a full continuum of mental health support throughout Minnesota. With services for all ages and a no-cost mental health screening to determine appropriate care, there’s no reason to wait to access the support they need. We help patients develop management skills and self-confidence, so they can focus on what matters most to them.
Referring professionals can call us anytime at 952-826-8475 to talk with our team. We can answer your questions, find the appropriate care for your patient, and help you make a referral. You can also explore our resources for professionals that include specific admissions processes and free tools that make your job easier to find the proper support. We look forward to working with you!
