Where you are right now
45 sec[Speak in short sentences, slightly louder and flatter than your usual therapy voice. At high arousal a soft voice does not register as information. This is instruction, not induction — do not soothe, and do not ask questions you will have to wait for.]
Something in your body has already decided this is an emergency. Your heart is fast, your thinking has gone narrow, and anything anyone says to you right now is going to sound like nothing. That is the state we are working with. We are not going to talk about it. [pause for 10 seconds]
We are going to change what your body is doing first, and let your mind catch up afterwards. Four things, in order. You do not have to want to do them and you do not have to believe they will work. [pause for 5 seconds]
Temperature
1 min 45[Before you read this segment, check what you know about this client's cardiac history, eating disorder history, and current medication. Cold water on the face slows the heart through the diving reflex, so any heart condition, low resting heart rate, anorexia or bulimia, or beta blockers and similar cardiac medication means you skip this segment and go straight to intense exercise without commenting on why. If you do not know, skip it and ask afterwards — never test it in the room.]
Fill the bowl with cold water. Straight from the tap is enough. You do not need ice in it, and if you use ice, use a little. [pause for 30 seconds]
Take a breath and hold it. Bend forward from the waist and put your face into the water so it covers the area around your eyes and the tops of your cheeks. Stay there while I count. If you need to come up before I finish, come up. [pause for 30 seconds — count aloud to thirty]
Come up. Sit back. Leave your face wet for now. Let your breathing do whatever it wants to do. [pause for 20 seconds]
Notice your heart. It is slower than it was a minute ago. Nothing about your situation has changed. Your body has changed. [pause for 10 seconds]
Intense exercise
1 min[Check for injury, pregnancy and anything cardiac before this one too, and take the answer at face value — where there is any doubt, a minute of fast marching on the spot does most of the work. Stand up and do it alongside them; nobody sprints on the spot while a clinician watches from a chair.]
Stand up. For the next sixty seconds you are going to move as hard as you safely can. Run on the spot, jump, push against the wall, take the stairs — whatever this room allows. Hard enough that you could not hold a conversation while you did it. Start now. [pause for 60 seconds]
Stop. Stand still. Let yourself breathe hard. Do not try to control it yet. [pause for 20 seconds]
Paced breathing
1 min 30[Count aloud in a steady, boring voice and let your own breathing be audible so they have something to lock onto. Do not stretch the counts to be impressive — four and six is enough, and it is a length clients can hold on their own later.]
Sit down. We are going to slow your breathing, and the part that does the work is the out-breath. Out longer than in. That is the whole instruction. [pause for 10 seconds]
In through your nose while I count four. Out through your mouth while I count six. Keep going while I count, and if you lose it, pick it up again on the next one. [pause for 60 seconds — count the four and the six aloud, about five breaths]
Let the counting stop. Keep the shape of it on your own. Long out-breath. [pause for 20 seconds]
Paired muscle relaxation
1 min[Say the word 'relax' on the client's out-breath, not on yours — watch their shoulders and time the word to the fall. That pairing is what makes the word usable on its own outside the room, and it is the only reason this step is last.]
Now we pair letting go with the breath out. Breathe in and tense your hands into fists. Hold it. Then breathe out, let them go completely, and say the word 'relax' in your head as they open. [pause for 20 seconds]
Again with your shoulders. In, and lift them towards your ears. Out, drop them, and 'relax'. [pause for 20 seconds]
Now everything at once. In, and tense every part of you that you can find. Hold it. Out, and let all of it go. [pause for 25 seconds]
Sit there for a moment. Your body is in a different state from the one it was in six minutes ago. Nothing has been solved, and nothing needed to be. This is the point where you can think again — so tell me the next small thing you are going to do.