Wojtek WojcikMary Docherty

Management of Conflict

Content Map

• The distressed/anxious/depressed patient• The agitated/confused patient• The substance misusing patient• Patients who present with medically

unexplained symptoms and frequent attenders

• Management of conflict.

Session Overview

Today aims to give you basic skills in -

• Recognition - of conflict arising• Patterns - of common conflict in hospital• Framework – for de-escalation

This pre-teaching handout will introduce core ideas which we use in mental health practice.

Recognition and awareness

Before we start thinking about conflict, we first need to think about thinking , and about feeling.

We can think about others, but we can also think about ourselves. Both are important when working with conflict.

Question

Before the teaching day, ask yourself: • What do patients expect of an ‘ideal’ me?• What do I expect of an ‘ideal’ patient ?

• Try and make a long-list of ideal expectations, for both staff and patients. We will compare notes on the day!

Recognition and awareness

This is both simple and difficult. Do we expect an ‘ideal’ patient to get better? In turn, how, deep down, do we feel when real patients don’t? We might feel sad, and feel like something more ought to be done. Or sometimes, might we feel frustrated and angry – with patient himself?

We work in a hospital day in, day out. Are there some things which become ‘normal’ to us, but which might not be to some patients?

Recognising conflict

What is conflict? What is happening when a patient ‘refuses treatment’ or ‘is being non-compliant’? Underpinning today is the theme that conflict is what happens in a relationship. Between patient and - specifically you or all staff on the ward or hospitals in general or even the world (if someone is delirious or very overwhelmed).

Recognising conflict

Working to reduce conflict we have to be aware of the environment, of the relationship between patient and hospital, and what the patient might be experiencing.

Recognising conflict

We are going to think about what we can do with not to the patient.

In de-escalation we prefer to think of not ‘calming the patient down’ but ‘helping the patient calm themselves’.

Recognising conflict: skills

There are some common skills which mental health workers practice in their work, and which are helpful in dealing with conflict. These may be simply put as:• Empathy• Mentalisation

And awareness of:• Transference, counter-transference, reciprocal

roles and splitting

Recognising conflict: skills

We will describe these briefly. Some of the terms come from psychotherapy. Their descriptive power is useful, even if we are not ‘doing’ formal psychotherapy.

Empathy

When we ‘feel for someone’ we are being empathic. Empathy is when we ‘simulate’ how another person might be feeling, and feel that way ourselves. Some people are more empathic than others. For example, people in caring professions are more likely to be.

Mentalization

Mentalizing is what we do when we are guessing what someone else might be thinking. In our very socialized world, this is something very important and involved in lots of simple daily judgements. We also apply it to ourselves, connecting how we are feeling and thinking. Some people are good at it, some people are bad at it, but it improves with practice, and is much harder to do when we are overwhelmed or stressed.

Mentalisation

Some people, for example patients with emotionally unstable personality disorder, may appear to be very good at it, and to use it to be manipulative. In fact, they are often very bad at it, or ‘mind-blind’ and dependent on surface cues. They fill in the blanks with their own expectations of how others might think about them. These can be very black-or-white.

Question

Try to think what it would be like if you were not aware of thoughts, desires and intentions in others, and found it hard to link these up in yourself.

• Can you think of any examples of situations which would be particularly difficult?

• How would you make decisions about whether you can trust your partner? Or trust a friend?

• How would you feel if your guesses about who to trust nad other peoples’ intentions kept being wrong, and were misunderstood?

Transference and Counter-transference

These two terms are very simple ways to think about feelings which arise in a relationship, that is to say any exchange with another person. Transference is what a patient might feel about you, informed by their past experiences, but without being conscious of that link.Counter-transference is how you might feel when in the company of the patient.

Transference and Counter-transference

The concept is that feelings are ‘transferred’ without us being necessarily conscious of it. Psychodynamic therapists attend carefully to picking out which feelings come from them ( for example, if you happen to dislike obese people), and which feelings may be coming from the relationship with the patient (for example, who might behave ‘as if’ ward staff were his or her oppressive and abusive parents).

An example

Sue, a 57 year-old woman admitted to the medical ward with unexplained fever and malaise is rude and hostile to staff, and takes issue with blood tests and observations much more than other patients. Nurses avoid seeing her, and get upset being with her and want to leave her side room.

Her relatives say she was always weary of hospitals and preferred ‘natural remedies’ and yoga. However, her sister died two years previously after being admitted to hospital for a simple operation: she developed a post-op infection and a reaction to antibiotics. Sue found it difficult to grieve, was very angry with herself for not convincing her sister to not have the operation and is convinced it was the hospital’s fault.

Question

• What feelings might be ‘transferred’ here between patient and staff?

Reciprocal roles: “takes two to tango”

Transference and counter-transference are about unconscious feelings we have about others. These come from our past learned experiences. It can be surprising to realize that when we experience a relationship – for example a child and its parent – we learn about not just our role, but the role of the other. For key relationships, we learn the pattern of both roles. So a child learns the role of a child, but also retains a memory of the role of the parent.

Reciprocal roles: “takes two to tango”

This concept that you learn two roles in a relationship and can swap around and play either one is called reciprocal roles. Our exercise earlier was about the specific roles of nurse – patient , which might generalize to care giving – care receiving. Some patients have had difficult experiences in life and when stressed revert to the role of abused-abuser.

Question

• Can you think of any situations in your work where you might have been working with the expectation of a ‘nurse-patient’ relationship, but a distressed and ‘difficult’ patient may have been stuck in a ‘abused-abuser’ relationship with the hospital?

• What might their experience of receiving acute care be like if they experience it ‘as if’ being delivered by an ‘abuser’?

Splitting

This is something which we encounter in patients with emotionally unstable personality disorder, who struggle with holding a nuanced idea of person in their mind. They tend to see people in a black and white way, and struggle with desperately needing more intimacy, feeling devastated when this is not met.

Question

• Have you ever experienced a patient who divides staff?

For example - Some of the team feel he or she is not really ill and should be discharged, whereas others are very concerned for her and angrily dispute this.Some staff may be told “You are the best nurse I’ve ever met. You’re special…. I’ve never told this to anyone else “ If a patient is idealising of you, they may be thinking in a black and white way – and be denigrating of others.

Thinking under stress

Put very simply, we have evolved to make nuanced judgements about what is happening around us, weigh up different strategies for dealing with problems, and adapt to the situation around us. These activities are so-called ‘executive function’ and are relayed in our pre-frontal cortex in our frontal lobes. Crucially, when we get stressed and activate our ‘fight or flight’ hormones, our ability to do this diminishes, and we revert to a quicker, simpler way of thinking – what can be thought of as our older, ‘reptilian’ brain.

Thinking under stress

This is good for knee-jerk survival strategies (such as running away from a tiger), but very bad for complex social situations (getting into an argument with others). The trouble is we use crude judgements such as good-bad, and ingrained patterns of ‘dealing with’ a problem. Different people have lesser or greater susceptibility to feeling overwhelmed, and healthier or less helpful ingrained behaviours which are then activated.

Question

• What do you understand by the expression “reverting to type?”

• Can you think of any situations when you have felt overwhelmed and acted in a way which you wouldn’t have ordinarily?

Patterns

Conflict often arises in predictable patterns. Whilst grave errors can be made when we mistake a useful shorthand for actual patient experience (assuming you don’t need to know any more about the patient), it is nonetheless helpful to be aware of some. Can you think of example of the following patterns:

Patterns

• An angry, upset self-harming patient who is refusing treatment on the ward and increasingly hostile.

• An intimidating, mildly threatening drug-seeking patient who makes repeated requests for opioid analgesia.

• A seemingly pleasant but very particular elderly patient who makes staff feel not good enough and demands to see the consultant.

Patterns

• We will discuss common patterns and try out different approaches during the teaching day.

• If you can think of any difficult situations which have recurred in your work, please bring up them up to discuss during the Case-Based Discussion session.

Framework

Once we have explored the concepts above, we will introduce a simple framework for de-escalation.

This can act as a scaffolding to help you think more clearly when dealing with conflict at work, and practice the thinking and reflecting skills we have mentioned.

Framework

The ten points we will cover are:• Respect personal space • Do not be provocative • Establish verbal contact • Be concise • Identify wants and feelings • Listen closely to the patient- respect their experience• Agree or agree to disagree • Set clear limits and boundaries • Offer choices and empower • Debrief the patient and staff

Summary

We have described some simple points about conflict at work • Recognition and awareness– Empathy, mentalization, (counter)transference

• Patterns– Common patterns; personality and mental health

• Framework– Ten steps for de-escalation in an acute setting