Responding to Angry Patients and Upset Family Members

1. Guiding your responses and controlling your reactions in tense situations. Responding to Angry Patients and Upset Family Members

2. Program Overview We will discuss and share examples of: • The advantages and limitations of this training. • The definitions and outcomes of anger; • Our reactions, both positive and negative, to anger and strong emotions and how to encourage our positive responses;

3. Program Overview • The stages of crisis development, what to look for and how to respond; • The verbal escalation continuum, what to look for and what to say; • Nonverbal communication and how to present ourselves in a way that will reduce emotion and encourage reasoning; and • Engaging in joint problem solving with the concerned parties.

4. Advantages & Disadvantages What this training will and won’t provide

5. Advantages of this Training • It promotes consistency and uniformity when working with people. This will help us be more predictable and thoughtful. • It will give us some ideas and insights into why things may be happening. This will help us to prevent some problems before they occur and others from getting worse. It will also help us to feel and show empathy for the other person.

6. Advantages of this Training • It will help us to communicate more effectively and consistently, especially during emotionally charged events. If we do this we may be able to stop a small problem from escalating into a larger one. • It can enhance the delivery of services to our patients and their families. It helps us to better identify and meet their needs. • It provides a structured approach to problem solving.

7. Limitations of this Training • It will not prevent/stop all incidents; • It will not provide all of the answers; • It will not change the people we interact with; and • It will not make us experts. REMEMBER: Unfortunately, there are no guarantees when working with people.

8. Understanding Anger Why? Because empathy comes easier with understanding

9. A General Definition of Anger • According to the Random House Dictionary of the English Language (Unabridged Edition) Anger is . . . a strong feeling of displeasure and belligerence aroused by real or supposed wrong.

10. A Clinical Definition of Anger • The clinical description of anger is much broader. It is described as a state of heightened activation or arousal of the autonomic nervous system that is fueled by our cognitive interpretations (Conscious and subconscious).

11. What Causes Anger in You? • We all have different things that push our buttons. What triggers your anger response? • What has or would trigger your response in situations like our patients and their families face?

12. What Typically Causes Anger In Our Patients? • The Angry I’s from Mark Gorkin’s The Four Faces of Anger: • You have a palpable sense of: • Injustice • Injury • Invasion • Intention

13. The Angry I’s INJUSTICE: • A rule of conduct, a cherished belief or instrumental goal is being threatened or abused; you see yourself (also others with whom you are psychologically dependent or connected) as a victim of an injustice, unfairness or disloyalty.

14. The Angry I’s INJURY: • You feel disrespected, discarded or ignored; there's a sense of insult and humiliation along with injury - often psychological, at times also physical.

15. The Angry I’s INVASION: • Your freedom, autonomy, boundary and personal space are perceived to be constricted, disrupted or violated; your identity and bodily and/or psychological integrity are being threatened or attacked.

16. The Last Angry I INTENTION: • There is an energy and determination to do something about the aforementioned injustices, injuries and invasions; you are ready - reflexively and/or purposefully - to challenge the status quo. When it goes from internal to external.

17. Is Anger Always a Bad Thing? No, but it certainly can be. So let’s set some criteria so we can better describe it and categorize it. Mark Gorkin, in Anger or Aggression: Confronting the Passionate Edge (1986) identified these four: • Purposeful • Spontaneous • Constructive • Destructive

18. Anger Criteria Definitions • Purposeful - When anger expression is intentional, with a significant degree of consideration or calculation; there is also a significant degree of self-control. • Spontaneous - When anger expression is immediate with little contemplation or planning; there is little to moderate self-control.

19. Anger Criteria Definitions • Constructive - When anger expression affirms and acknowledges one's integrity and boundary without objectively intending to threaten or violate another's integrity or appropriate boundary. • Destructive - When the expression of anger defensively projects and rigidly fortifies one's identity and boundary by threatening or violating another's integrity and appropriate boundary (Whether the intention is conscious or not).

20. The Four “Boxes of Anger” What do these criteria produce when combined? Destructive Constructive Assertion Purposeful Hostility Spontaneous Passion Rage

21. If anger can be positive, what is the critical variable? THE LEVEL OF EMOTION • As the level of emotion goes up; reasoning ability goes down and when that happens communication breaks down too.

22. So, if we help reduce emotion we can restore reason? Yes • But first we need to be calm and reasonable ourselves. And that’s not always easy, given our natural reactions to the strong emotions of others. So what do we do?

23. Our Reactions to Strong Emotions You can’t help others if you can’t control yourself

24. The Reciprocal Reaction • As we have already discussed when emotions are high, reasoning suffers and also, what we do can affect how it will proceed for us. Our reactions matter! This is referred to as the Reciprocal Reaction. Emotions Low High Low Reasoning High

25. The Reciprocal Reaction • It is based on the simple concept of action  reaction. What you say and do affects the behavior of others and vice versa. In this application it involves consciously monitoring yourself and getting involved in order to defuse an emotional situation.

26. How Do You Experience Anger? • How was anger expressed in your family growing up? • How do you express it now? • How does your experience affect how you respond to anger now?

27. Your Reaction to Stressful Situations • The Fight or Flight Response • What is it? First described by Walter Bradford Cannon- The theory states that we react to threats with a general discharge of the sympathetic nervous system, priming us for fighting or fleeing.

28. Unmanaged Reactions to Stressful Situations • Freeze • Inaction, inability to react to a situation. Example: Stage fright • Overreact • Rationally – Misperceive situation, make it worse than it really is. • Sensorimotor – Motor skills don’t function normally.

29. Unmanaged Reactions to Stressful Situations • Inappropriate Response • Verbally – Saying things that are not pertinent to the circumstances, not helpful, or even damaging to the situation. • Physically – Slamming, shoving, throwing something intentionally or unintentionally.

30. Managed Reactions to Stressful Situations • Increase in Sensory Acuity • Special alertness or sharpening of your senses takes place. • Decrease in Reaction Time • We respond more quickly to circumstances than normally. • Increase in Speed and Strength • Hormones released into our bloodstream increase these abilities.

31. How Can We Help Ensure Managed Reactions? • Understand what about these situations makes us fearful or anxious. • Learn what to do when such situations arise. • Use a team approach. Not being the only one in the situation helps. • Know what to do in case of an emergency.

32. How Do You Stay Calm & Objective? • Staying cool and calm is important and we need to find techniques that work for us. Some of these techniques are: • Count to ten; • Don’t personalize the person’s reaction; • Controlled breathing; • Positive self-talk (I am O.K., I can do this); • Empathize – Walk in their shoes; • Here them out, really listen; or • Realize that the only person you can truly control is you.

33. The Stages of Crisis Development What to look for and how to respond to them 2 1 3

34. Why This Knowledge Matters • Due to the nature of these situations, it is vital that you stay calm and proceed with a plan. This information will help you to respond appropriately to the individual given their current emotional state. • Even more important is the fact that crisis moments don’t just sprout into being; there are almost always warning signs that let you know an individual’s behavior is escalating. The earlier you intervene the better.

35. The Stages of Crisis Development

36. Crisis Stage #1 – Anxiety • Anxiety: An observable and unusual change in behavior. This may mean an increase or a decrease in activity. • In your setting, what would you look for?

37. Crisis Stage #1 – Anxiety • Your Response: Be empathetic; convey to the individual that you know he or she is anxious and that you would like to help alleviate it. • What might you say?

38. Crisis Stage #2 –Defensive • Defensive: His or her emotional level is increasing and rationality is decreasing. He or she may begin challenging you or the authority you represent and become belligerent. • There are verbal and nonverbal cues that he/she is losing control. What are they?

39. Crisis Stage #2 –Defensive • Your Response: Provide guidance, be directive. Take control of the escalating situation and set limits. Focus on what you can do and what they should do. • What might you say?

40. Crisis Stage #3 – Acting Out • Acting Out: The person has lost control of his/her behavior and can be verbal and/or physically acting out. Not usually capable of reasoning at this point.

41. Crisis Stage #3 – Acting Out • Your Response: Make sure that you and those around you are safe and activate your emergency procedures as directed for your location. Request assistance as needed.

42. Crisis Stage #4 – Tension Reduction • Tension Reduction: After an episode subsides. The emotion fades, the individual regains rationality and in many cases realizes he or she has done something inappropriate.

43. Crisis Stage #4 – Tension Reduction • Your Response: Reconnection and problem solving. Communicate with the person as they calm down. They look to “make amends” this affords an opportunity to effect positive growth. • What might you say here?

44. A Deeper Look at Verbal Escalation & Intervention What to look for and what to say

45. Overview • Now we will dig deeper and look specifically at verbal escalation as it begins in stage 2. This is the crisis level we are usually confronted with on the job. We’ll explore the action  reaction steps so we can respond more quickly, effectively, and hopefully, move things towards a positive outcome.

46. Level #1: Questioning • Questioning: • Information Seeking – A rational question seeking a rational response. • Question Authority – Power struggle – evasiveness.

47. Level #1: Questioning • Intervention: • Rational response • Stay on topic ,focus on the issue at hand and what can be done about it. • How would you say it?

48. Level #2: Refusal • Refusal: • Non-compliance. Slight loss of rationalization.

49. Level #2: Refusal • Intervention: Set Limits (simple negotiations) If not, then this will happen. If you do this, this can happen

50. Level #3: Release • Release: • Acting out, emotional outburst, loss of rationality. Venting, screaming, swearing. High energy output, no focus.