Strategies for Dealing with Challenging Interpersonal Interactions in a Mental Health Setting Liam E. Marshall, PhD Waypoint Centre for Mental Health Care & Rockwood Psychological Services 1
Objectives To develop awareness of the possible underlying causes of the problematic behaviours of others To learn possible approaches to dealing with a difficult situation To gain specific skills which will enable the ability to deal effectively with problematic situations 2
Possible Causes of Problematic Interpersonal Interactions 3
Some of the possible underlying causes of interpersonal difficulties Poor coping styles and skills Inability to communicate effectively E.g., Inquiry versus Complaint Attention seeking Shame Physical problems Personality Disorder, e.g., Psychopathy Narcissism Borderline Low sense of selfworth Intimacy deficits Empathy deficits Other unmet needs 4
Joe Harry Window SELF SELF & OTHERS OTHERS UNKNOWN 5
Stages of change Precontemplation - people who are not intending to take action in the foreseeable future Contemplation - people are intending to change in the near future Action - people who are making specific overt modifications in their life styles Maintenance - people who are working to prevent relapse a stage which is estimated to last from 6 months to about 5 years" 6
Moving through stages of change Precontemplation to Contemplation: consciousness/awareness raising. Contemplation to Action: provide information on how to change (e.g., comply with treatment) and support efforts at self-efficacy Action to Maintenance: Examine and modify future life circumstances to match changes 7
Emotional (angry) Avoidable upsets Person feels promises not delivered Person feels others have been indifferent, rude or discourteous Person was made to feel stupid or small Person feels they are not being listened to Person feels their honesty or integrity was questioned 8
Components of a difficult encounter Situation Issues: Language literacy issues Environmental issues Number of people around Purpose of interaction issues (e.g., delivering bad news) Other Person Issues Angry, defensive, frightened, resistant Manipulative Grieving Attention or drug seeking Personal Issues Angry or defensive Fatigue and other health issues Confidence and personality 9
Dealing with a difficult person Be objective Stay focused on your goals Recognise the person s motivations Be aware of your own emotional reaction Stop and think before you speak What am I trying to achieve right now? What am I trying to achieve long-term? 10
Dealing with a difficult person Take Their Side Listen actively Agree whenever possible Acknowledge their viewpoint Offer an apology Project confidence Express your views without provoking 11
Dealing with a difficult person Bridge differences Ask open-ended, problem-solving questions Ask for the person s opinion Don t rush them to agree Make it Hard to Disagree Convince rather than threaten Keep choices open Enlist support from others Don t rush the person to agree with you 12
What to do with an angry person - Immediate responses Goal is to win in the long run, not the current conflict Validate the person s feelings (collude?) Gently ask for an underlying cause of the behaviour (e.g., has something changed ) Ask if there is anything that could be done to solve the problem, that is possible to do If you can, offer a non-threatening alternative Possibly an avoidance strategy for now Look for something positive in what they are doing and tell them Stay positive and solution focussed with the person for as long as possible 13
What to do with an angry person After person has calmed down Review episode and reward them for what they did well in the situation may need to be creative Ask what, if anything, he/she could do differently next time If issue still relevant, offer options Refer to a specialist, if appropriate 14
How to overcome resistance/anger Attire & Body Language appear relaxed Vocabulary appropriate intellectual level Collaboration with person, with others Information reduces anxiety Confidence & Reflection - motivates Face saving ways to change Be patient 15
How to overcome resistance/anger Accept small steps Have an agenda but be flexible Give the person some task to do Ask for questions Allow person to be the expert Be responsive: ask for and accept feedback Allow person to feel like they have some control over process 16
Examples Mike Diagnosed with narcissistic disorder Generally demanding, stubborn, and highly emotional Inability to form friendships with other residents who complain about him to staff Was angry and insisting on one-to-one therapy of a particular style which he claimed had been promised to him Approach: validated his concerns and empathized with his feelings Then asked what style of therapy he wanted; explained similarities to available treatment. Outcome: Calmed and agreed to enter treatment Worked on skills in group and developed friendships 17
Examples Jeff Extreme anger control problems In constant conflict with co-patients and staff Expresses extreme anger at system Had never finished a treatment group Felt betrayed by staff and was extremely agitated Approach Acknowledged feelings of betrayal would be painful Asked if he still had confidence in any staff Outcome: Finished anger management group and was generally more cooperative on unit 18
John - Behaviour tracking 19
Behaviourism 101 Behavior increases Behavior decreases Stimulus applied Positive reinforcement Positive punishment Stimulus removed Negative reinforcement Negative punishment 20
Punishment NOTE: punishment will suppress a behavior but will not eliminate or weaken it. Punishment should only be used to get a very problematic behavior under control. Punishment should only be used with reinforcement not instead of reinforcement Progressively increasing punishment will result in habituation which will diminish its effectiveness 21
Using reinforcers Reinforce as soon as possible after the target behaviour has been performed. Make it clear what behaviour is being reinforced Level of reinforcement should be proportional to effort made avoid satiation Use reinforcement continuously at first, then intermittently. 22
Using reinforcement Provide person with opportunities for success. What works as a reinforcer may be different for each person. Praise as a reinforcer should be specific to the behaviour. Reinforce person when they are doing well, not just when they are a problem Shaping 23
Reinforcing behaviour Verbal clarification of the relationship between a behaviour and the delivery of reinforcement increases the effectiveness, as do verbal and physical prompts. Bear in mind the level of effort that the behaviour took to perform and make the reinforcer proportional. Satiation can occur if the magnitude of the reinforcer is too great. 24
What not to reinforce Negative self statements ( I m hopeless ). Vague or benign contributions (unless shaping). General good behaviour ( You ve all done very well today ). Agreeing with you ( I m so glad you now see it my way ). 25
What to reinforce Statements of responsibility Statements of motivation/intention to change Self esteem, perspective taking, empathy, concern for others, etc. New skills or attitudes Harm reduction Achievement of any other prosocial goal You may need to reinforce approximations of any of these goals to shape appropriate behaviour
Excuse making 27
Your experiences of Denial? Think back to an occasion when you denied something outright even though you knew you had really done it. Why do we deny it? What are we protecting? What emotions and thoughts are behind this decision? What might you lose? Why not become honest later? 28
EXCUSE-MAKING RESEARCH 1. All people lie: (a) To avoid hurting others (b) When they feel the truth is threatening 2. What is the possibility of us knowing the truth particularly when only two people were present and both have different versions 3. Excuse-making is both psychologically and physically, beneficial (Dodge, 1993; Schlenker et al, 2001) 29
EXCUSE-MAKING RESEARCH When people take full responsibility for failures or negative actions, they are at risk for depression Excuses help to avoid a loss of self-esteem or the experience of shame, both of which are blocks to effective engagement in treatment and shame increases criminal behaviour Offenders, of all types, who make excuses for their crimes are at lower risk to reoffend! (Maruna, 2001, 2004) As Hansen pointed out, Offenders who minimize their crimes are at least indicating that what they did was wrong. 30
Empathy 31
STAGE MODEL OF EMPATHY STAGES 1. RECOGNIZE EMOTIONAL STATE OF OTHER 2. PERSPECTIVE TAKING 3. EVOCATION OF AN APPROPRIATE/ SYMPATHETIC EMOTIONAL RESPONSE 4. ATTEMPT TO EASE OTHER S DISTRESS, WHEN POSSIBLE AND APPROPRIATE 32
Low selfesteem Blocks recognition of harm Empathic Process Unempathic response to victim Low selfesteem Recognize harm Overwhelmed by personal distress Self- Soothing Unempathic response to victim Falsely High self-esteem Uncaring or hostile toward victim, or sadisticallydisposed Unempathic response to victim Adequate self-esteem Recognize harm perspective taking emotional response Reparative action Empathic accuracy Sympathy Empathy
Proposed Path Model of Empathy Problems Marshall & Marshall, 2011, Journal of Forensic Psychiatry & Psychology ATTACHMENT SELF-ESTEEM SHAME/GUILT EMPATHY STAGE MODEL 1 2 3 4 Secure Adequate Guilt Preoccupied Low Shame (Internal) Fearful Dismissive Low Unrealistic High but Shaky Shame (Internal & External) Detachment
TREATMENT OF EMPATHY DEFICITS 1. Emotional recognition Recognize emotions in self and others 2. Perspective taking Empathy for staff/patients, spouse, any others 3. Appropriate emotional response Emotional self-regulation 4. Ease the suffering of others How to be helpful to others Appropriate boundaries 36
Strategies for Dealing with Challenging Interpersonal Interactions in a Mental Health Setting Liam E. Marshall, PhD Waypoint Centre for Mental Health Care & Rockwood Psychological Services 37