Working with complexity: managing challenging conversations in practice

1. Working with complexity: managing challenging conversations in practice n.lambert@mdx.ac.uk

2. Why this session! • Health and social care settings can be places where emotions run high. • Our work often involves working with people who are frightened, disappointed and in pain. • People experiencing these emotions can become distressed, confused and angry which can makes interpersonal work more challenging. It’s important to remember that poor outcomes are not inevitable and that we can to develop skills to proactively support better experiences for the people we work with and for ourselves.

3. What we will cover today • Supporting people who are experiencing anger. • We will briefly touch on: • Responding to personal or sexualised questions &comments. • Broaching sensitive issues. • Breaking bad news And we will finish with a note on self-care

4. ‘Mind Awareness’ All interactions can have value in supporting someone to thrive. They don’t need to be about care issues or problems: even casual conversations about the weather can help by supporting the ‘therapeutic alliance’. You have to be a bit ‘human’, to help humans.

5. Personal review

6. Supporting people who are experiencing anger What is Anger? Anger is linked to a perception of damage loss or hurt and to a belief that expectations have been violated. Notice the emphasis on fairness, reasonableness andexpectation. It is not just the hurt or damage that make us angry, but the violation of rules and expectations. It manifests physically and emotionally. How to deal with anger https://www.mind.org.uk/media/4032145/how-to-deal-with-anger-2016.pdf https://www.mentalhealth.org.uk/sites/default/files/boilingpoint.pdf

7. Beliefs about Anger • Anger is inherited. • Anger automatically leads to aggression. • People must be aggressive to get what they want. • Venting anger is always desirable. • Anger serves several defensive purposes: • It works as a shield that deflects uncomfortable feelings so they can be avoided or kept at a distance. • It provides a sense of power or control. • It directs focus outward to individuals, groups, or institutions (it’s easier and more comfortable to focus on the actions of others than it is to focus on oneself).

10. Skills for defusing anger. • Stay calm, communicate simply and clearly. • Allow the person space and time. • Be kind - show concern and understanding. • Help the aggressor to save face. • Help: convey a desire to reduce stress and make the situation better. • Balance power: make a concession or a deliberate friendly gesture. • Be nice: Avoid provocative phrases and confrontation (no sarcasm /paternalism). • Depersonalise issues. • Using Shouldn’t or mustn’t statements. • Being ‘told’ how to think and feel. • Failure to listen. • Taking things personally/acting defensively. • Rigidly defending your position. • Assuming you are always right. The overlooked skill that can change your life!

11. Apologising • I’m really sorry. That came out all wrong • I’m sorry. That was an inappropriate thing to say. • I’m sorry. We seem to be misunderstanding each other. Let’s try that bit of the conversation again. • I’m sorry. I put that badly. What I should have said is... • Oops. That was a stupid thing to say! I’m sorry about that. • I’m sorry. I put that so badly that you’re probably feeling... / I’m sorry. • I’m sorry. That was a clumsy thing to say. Are you ok? • Aarrgghhh! I’d be really annoyed if someone said something like that to me. I’m sorry. • I was wrong to say….I’m sorry. Think about a time when you probably should have said sorry, but couldn’t manage to: • Why do you think this was? • How might things have turned out differently if you had said sorry? • Do you think you were being mind-aware, in particular about what the other person was thinking and feeling? What might stop us? • We don’t want to admit we were wrong. • We don’t want to look, or feel, ‘weak’ (esp. if we feel it’s important to be in a strong position of authority in relation to the other person). • We might worry that the other person will ‘take advantage’ of the situation. • Apologising may mean valuing a relationship more than your ego!

12. Responding to personal or sexualised questions and comments… aggression can take many forms some physical, some are verbal. • I can see why you’re asking this, but my focus needs to be on helping you at the moment. (The classic therapists’ answer!) • I’m afraid I can’t really talk about that at work, this is your time. • Thanks for being interested, but I don’t think that knowing about my experience will be any help to you. • I’m sorry, but that’s a bit too personal for me to talk about. I don’t feel comfortable. • Is there a particular reason why you’ve asked that? ‘Hmm. I’ll need to think about how best to answer that. Can I get back to you on that one?’ This gives you time to think about how to respond, and also to consult you or another colleague. It respects people who are genuinely curious and allow you to regroup with someone who is ‘pushing buttons’.

13. Broaching sensitive issues • Pick your moment! • If you find a subject sensitive - think about why the subject is difficult for you. • Take a universal approach: “Many people in your situation experience … is that true for you?" or "Some people taking this medication have trouble with...“

14. Recognise and empathise with them Set out a plan of action Provide info in small chunks, check understanding Mentally rehearse & sort privacy Get the person’s perspective Ask them what they want to know http://www.cetl.org.uk/learning/feedback_opportunities/data/downloads/breaking_bad_news.pdf

15. Getting started ... • Planwhat will be discussed with the team. • Confirm thefacts. • If this is an unfamiliar task, rehearse what you will say. • Don’t delegate the task. • Create an environment conducive to effective communication. • Allowtime. • Safety / Accompaniment – for you and the client/carer.

16. What does the person want to know? Guidelines for informed consent indicate information which patients need to make informed decisions. Equally respecting a person’s autonomy also means that patients have a right not to know or want to hear information. In any conversations about bad news the issue is often “do you want to know?” but “at what level do you want to know?” • Would you like me to go into details at the moment ?If not, is there somebody else you would like me to talk to?Who would you prefer? (carer/advocate etc.). • “Would you like me to tell you the details of your case?” “If this turns out to be a problem are you the kind of person who likes to know exactly what’s going on” If someone won’t hear what you have to say or can’t understand it - record it and talk it over with the team.

17. Sit down privately - don’t get stampeded into giving bad news in a public place, such as in the hallway. Avoid interruptions and communicating news over the telephone unless the person is prepared ahead of time (they may be driving or alone). Use a “warning shot;” that is, say something to prepare them such as, “It’s not good news.” Say it, then stop and listen. It’s common to talk too much when nervous, uncomfortable - so stop yourself. Havetissues handy. Deliver the information in a sensitive but straightforward manner. Say it, then stop!

18. Responding to feelings • People respond to bad news in a variety of ways. Some respond emotionally with tears, anger, sadness, love, anxiety, relief, or other strong emotions. • Others experience denial, blame, guilt, disbelief, fear, or a sense of loss or shame, or may even try to rationalise why the situation is happening. • A few may demonstrate reflexive responses such as “fight or flight” and may even try to bolt from the room or totally withdraw into themselves. Remind them that their responses are normal. Make a box of facial tissue available. • Nonverbal communication may also be very helpful. Consider appropriate touch. Offer a drink of water, a cup of tea, this is where rapport and relationship are vital..

20. Plan – timelines. • Keep people informed, arrange ongoing support and contact. • Keep a clear record of what’s said and agreed (share it!). • Get supervision and work with your colleagues – you part of a team and should be role modelling adaptive coping strategies. • Make sure you record everything! Planning and follow-up When the person has left: Check your own feelings Deal with the next person sensitively, as they may have been neglected.

22. Treat yourself well! - Exercise/eat/sleep properly! • Address stress. • Be powerful - Saying no to what you don’t want, is saying yes to yourself. • Don't postpone joy!