Conflict Resolution Training

1. Conflict Resolution Training

2. Aims and Objectives • Describe common causes of conflict • Describe two forms of communication • Give examples of communication breakdown • Explain 3 examples of communication models that can assist in conflict resolution • Describe patterns of behaviour they may encounter during different interactions • Explain the different warning and danger signs • Give examples of impact factors • Describe the use of distance when dealing with conflict • Explain the use of “reasonable force” • Describe different methods for dealing with possible conflict situations

3. Background to the training • Violence in mental health/learning disability settings is not new. • Reliable data problematic, but there are concerns that problem is getting worse in some areas. • Increasing demands from staff, unions and service users for safe and therapeutic services. Although the focus of this initiative is on violence by people with mental disorders directed towards staff, service users can also be victims. Violence by staff towards staff is also a serious problem.

4. Policy background • NHS Security Management Service measures (2003) • Zero Tolerance (1999) • National Audit Office report (2003) • Blofeld inquiry into the death of David Bennett (2004) • Delivering race equality in mental health care: An action plan for reform inside and outside services and the Government's response to the Independent inquiry into the death of David Bennett (2005) • National Institute of Mental Health England (2004) • National Institute of Clinical Excellence (2005) • MHAC 11th Biennial report “In place of fear” (2003-2005)

5. NHS Protect (Security Management Service) http://www.nhsbsa.nhs.uk/Protect.aspx Government body which has policy and operational responsibility for tackling violence across the NHS. Within SHFT Security Management Director – Huw Stone Non-exec SMD – Pam Charlwood Security Management Specialist – Dave White (Risk Team) Legal Protection Unit (LPU) Memorandum of understanding Supporting staff in pursuing sanctions for those service users who police can’t or won’t prosecute

6. What is Conflict & What Causes it? In Groups discuss and write down what conflict means to you? What different types of conflict are there? What does it look like sound like etc?

7. What are the causes of violence and aggression?

8. Communication Breakdown • Below is a simple communication model. What things could stop the correct message getting across Transmitter Receiver Message Message

9. COMMUNICATION NON-VERBAL VERBAL Body Language …..% of meaning is facial expression and body language Tone …..% of meaning is in the way the words are said Words …..% of meaning is the words that are spoken How do we communicate?

10. Cultural awareness • People have different expectations of the services we provide. • There are many factors that affect these expectations – language barriers, differing gestures, body language, modesty, religion, fear, anxiety and a lack of knowledge and understanding. • Not all cultures have the same body language. Some people will not make eye contact when talking and some people will not shake hands as touching is not accepted. Invading personal space is accepted and common practice is some cultures. Some females may not even communicate without a chaperone or a husband present…

11. Transactional Analysis In the 1950,s a Psychoanalyst, Eric Berne developed a theory which claimed we all have 3 basic ego states, which make up our personality. The model is useful for explaining why and how • People think like they do • People act like they do • People interact / communicate with others.

12. 3 EGO STATES PARENT ADULT CHILD Nurturing Critical Adapted Free Transactional Analysis

13. 3 EGO STATES PARENT ADULT: You are right, I was wrong I think it might work what do you think? CHILD Nurturing: Don’t worry we can work it out Let me help you with that Come with me let's have a cup of tea Critical: Don’t do that again How many times do I have to tell you? Don’t slouch… Adapted: Why me? It’s not fair! If you loved me you would do it I’ll throw it away if you don’t want it Free: Yahoo! I’ve won BRILLIANT Just what I wanted Let’s Party Transactional Analysis

14. Critical Parents display disciplinarian behaviour and make statements that are critical of others, “How many more times do I have to tell you”, “Sit up straight and look at me when I speak” • Nurturing Parents display teaching, caring, supportive, loving and praising behaviour. “Don’t worry, we will sort it out” “Let me help you with that” “Come on, let’s go and have a cup of tea”

15. The adult ego state is characterised by mature, factual, logical and rational behaviour. It is the state that offers the least, or no conflict. Adults treat people with respect, the are approachable, reasonable, adaptable, rational and non-judgemental. “You were right to point the incorrect figure in my report, thank you” “ I think this could help us, what do you think?” “Can we try and avoid any misunderstanding?”

16. The adapted child may display behaviours that they have learned and can be manipulative and play on a persons emotions. “why me, its always me, never anyone else” If you loved me, you would do it for me” The Free child is characterised by behaviour that is instinctive, spontaneous, carefree and without boundaries. “Oh Brilliant! That’s fantastic, I can’t wait” “Let’s do it differently now, I’m a bit bored of this way!”

17. Lines of communication

18. Transactional analysis

20. Transactional analysis. STATEMENT EGO STATE Look, I’ve shown you this over and over again. Now you go and do it! Critical parent How do you think the first presentation went? Adult I love it when the boss is on holiday, work is so much more fun, I’m going shopping! Free child Do you realise that I called you over an hour ago? Where have you been all this time? Critical parent I know I made a mess of that report. Please give me a chance to do it again- I know I can do it better. Please! Please! Adapted child I’m not sure I understand. Would you explain it to me again, please? Adult Don’t worry, never mind. It wasn’t really that bad. Nurturing parent Why aren’t you working? It looks bad if you’re just sitting around. Haven’t you got anything better to do? Critical parent You’re right. I have written it down incorrectly. Thanks for pointing it out Adult

21. Communication Models The C.U.D.S.A. Model • C – Confront the situation • U – Understand each others situation • D – Define the problems • S – Search for and evaluate solutions • A – Agree upon and implement the best solution

22. Communication Models The LEAPS Model: • L – Listen; Listen actively • E – Empathise; Show understanding • A – Ask; If you need more information • P – Paraphrase; Put the facts into your own words • S – Sum up; Condense the facts • Useful in interviews and crisis resolution

23. Communication Models This 5 STEP APPEAL model is used to de-escalate conflict. It is useful when resolving a difficult situation or where a person refuses to comply with a request. • SIMPLE APPEAL. To make a reasonable request of somebody. 2. REASONED APPEAL. The reason / understanding as to why you are making the request. • PERSONAL APPEAL. Appeal to their better nature, why do YOU want them to do it? • FINAL APPEAL. The last chance to get the person to stop what they are doing. Offer alternatives / options / consequences. • ACTION. Make sure you do what you said you are going to do, don’t make threats!

24. My Behaviour My attitude Your attitude Your Behaviour Attitude and Behavioural Cycle Sometimes known as Betaris Box

25. Attitude and behaviour cycles “ The way you see them is the way you treat them and the way you treat them is the way they often become” Zig Ziglar

26. Serious or aggravated resistance Aggressive resistance Active resistance Passive resistance Verbal Resistance Compliance Patterns of Behaviour

27. Patterns of behaviour. Trigger Phase • An event or situation triggers an aggressive response within the individual • Early warning signs can be easily missed • The trigger may not be obvious and the persons response may seem to ‘come from nowhere’.

28. The Escalation Phase • Anger and aggression begins to escalate. • Stress and frustration increases. • Person becomes overly focussed on the issue and less likely to respond to any rational intervention. The persons feelings need to be acknowledged

29. The Crisis Phase. • As the person becomes increasingly physically, emotionally and psychologically aroused, control over aggressive impulses lessen and direct violence becomes likely. • It is important to focus on the safety of yourself, the aggressor and anyone else who may be affected.

30. The Recovery Phase. • Agitation decreases, anxiety lessens, communication becomes possible. BEWARE! IT IS AT THIS POINT THAT MOST INTERVENTION ERRORS OCCUR. • Adrenalin can remain effective for up to 90 minutes, causing heightened states of physical and emotional arousal, you may be at risk if you expect the person to be able to discuss the incident at this time.

31. Post Crisis Depression Phase. • The persons behaviour will usually regress below their baseline behaviour. • Mental and physical exhaustion is common and the persons behaviour will ‘dip’ below their normal base line behaviour. They may become tearful and withdrawn or ashamed.

32. Danger Signs Fists may clench and unclench Facial colour may become paler Lips tighten over teeth Head drops to protect throat Eyebrows droop to protect the eyes Hands raise above the waist Shoulders tense Stance moves from square to sideways Stare is now at intended target Lowering of body to launch forward Warning and Danger Signs Warning signs Direct, prolonged eye contact Facial colour may darken Head is back Subject stands tall Subject kicks the ground Large movements close to people Breathing rate accelerates Behaviour may stop/start abruptly

33. Impact factors

34. Distances

35. 90º The Fighting Arc The “Fighting Arc” is the area in which people can fight successfully. It covers a 90º degree angle in front of the body. Offside Positioning By positioning yourself in the “offside position” you will make it more difficult for him / her to attack you

36. What is Assault? Physical assault • The intentional application of force by one person to another, without lawful justification, resulting in physical injury or personal discomfort Eisener v. Maxwell 1951, Kaye v. Robinson 1991 Non-Physical Assault • The use of inappropriate words or behaviour causing distress and/or constituting harassment Physical and non-physical assaults should be documented in the service users notes and on an incident form and physical assaults referred to the police.

37. What to do when it doesn’t work? Flight This is always your preferred option, and it is safer. Never stay in a situation in which you feel uncomfortable; remember, even if your job role means that you work with a duty of care that duty starts with you! Unfortunately fight may be you only option. If it is, you should be aware of the limitations and legal requirements; the following laws are relevant if you have to protect yourself legally

38. The Criminal Justice and Immigration Act 2008provides a statutory defence: ‘A person may use such force as is reasonable in the circumstances in the prevention of a crime… Any force must be absolutely necessary and proportionate to that which it seeks to prevent. Reasonable force

39. The law states that any use of force must be : Necessary Was there any need to use force at all? In proportion to that which it seeks to prevent Was the level of harm suffered reasonable compared to what would have happened if no forcible intervention had been made? Carried out because of an “honestly held belief” ‘The test to be applied for self defence is that a person may use such force as is reasonable in the circumstances as he honestly believed them to be in the defence of himself or another.’ Reasonable Discussed on next slide Using Reasonable Force

40. In all cases, surrounding circumstances will aid the decision with regard to pursuit of criminal proceedings. The assailant’s height, build, gender, level of threat, use of weapon, intent to harm. The victim’s height, build, gender, alternative courses of action available, location circumstances, e.g. action deemed suitable in response to a threat in a pub may not be considered appropriate in a care home. Additionally, the interpretation of reasonable force depends on several further factors which are decided upon in the courts – The gravity of the crime you were trying to prevent whether it was possible to prevent it by non-violent means whether you were ready to try those means first Assessing reasonableness

41. A note about weapons • If anyone is armed with a weapon DO NOT approach them • Instead secure the area, removing any other service users and staff members and call the police • only staff with proper training and protective equipment should approach armed assailant

42. A member of the public strikes a man who attempts to steal her bag. The thief tells the police that he was assaulted….Was the action taken “reasonable”? Assessing reasonableness

43. Any thoughts? • A CPN who has recently been appointed is alone with a male service user in his home. He threatens to kill her but as he is between her and the door she cannot escape. He grabs her hair and attempts to force her to the floor. She strikes him in his ribs and kicks his shins while shouting for him to stop. • Are her actions acceptable?

44. P.L.A.N. P = Proportionate – am I using the right level of force? (don’t use a sledgehammer to crack a nut) L = Legal – Am I covered by law? A= Accountable – Am I accountable for my actions? Yes you are! N = Necessary – Was the action taken necessary?

45. With this? Think people… Key messages: how would you rather manage violence and aggression? • Or this? • Think problems… Empathy Listening Restrain Prosecute Patience Understanding Compassion Helping Section Medicate Seclude Caring Talking Empowering Hearing Sharing Inject Contain Paterson and Miller 2005

46. Challenge the language… Tormented • Change the culture… She went crazy Frightened It is just behavioural She is acting up Distressed Agitated It is just attention- seeking He is playing up Unwell She is a typical P.D. Angry Upset He is bad not mad He kicked off

47. Thank you for participating… Any Questions?