1. Conflict Resolution Training
For PSTS - Discuss reasons for CRT, Who the SMS are etc. Who our LSMS is and what he does. Where does the training come from. 1

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” ( ) 4

5. NHS Protect (Security Management Service)
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?
Are we always aware of conflict and who it is with. Think about wars, dissent, sedition, anarchy, student protests etc.
Next group to shout out common causes of conflict. Write a list on flip chart, Make it fun
Trainer Note- No single cause of conflict but there may be issues common to the group or society at large PSTS Cognitive theory of violence

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
Message
Receiver
Examples if people are struggling:
Language differences-noise-weather-stress-alcohol-confused state-cultural differences-anger-stereotyping-jargon-emotional state-NVC not matching VC
I think this would make a good flipchart fun exercise
Link back to cultural awareness slide. Discuss how cultural mores may impact on communication
Examples might include: language differences, confused state, stereotyping, background noise, cultural differences, jargon, weather conditions, too loud, emotional state, stress, too quiet, triggers, drugs and alcohol, anger, NVC not matching verbal contact.
Ask group for personal experiences.
Message

9. How do we communicate? COMMUNICATION NON-VERBAL VERBAL Words Tone
…..% of meaning is in the way the words are said
Words
…..% of meaning is the words that are spoken
Body Language
…..% of meaning is facial expression and body language
Percentages are as follows 55% body Language 38% Tone etc 7% spoken word
Body language and facial expressions do not always match up. Group to act out opposite body language and facial expressions. Just for fun!
Instructor to give first examples

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. Transactional Analysis
3 EGO STATES
PARENT
ADULT
CHILD
Nurturing
Critical
Adapted
Free
Draw on flip chart the picture of a person with the ego states in their various locations. It is thought that we return to these ego states when under stress.

13. Transactional Analysis
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
Do simpsons exercise. Which of the Simpsons characters responds to which ego state. Laminated pictures of Simpsons, group to identify which is which of the ego states

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.
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. Attitude and Behavioural Cycle
Sometimes known as Betaris Box
My Behaviour
Your Behaviour
My attitude
Your attitude
It is the role of the employee to break the cycle of negativity
This session should also introduce to the delegate how individuals react in conflict situations and how their resistance or behaviour can progress from verbal resistance to physical assault
Consider exercise, delegates to write down an example of this process they had recently witnessed,
“The way we see them is the way we treat them and the way we treat them is how they often become” Zig Ziglar

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
Patterns of Behaviour
Serious or aggravated resistance
Aggressive resistance
Active resistance
Passive resistance
Verbal Resistance
Compliance
Link to Betaris box and how behaviour can escalate.

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. Agitation decreases, anxiety lessens, communication becomes possible.
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. 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
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
Talk through confrontation i.e. making self big to win fight before it has started moving through to the fighting stance getting smaller, minimising target ready to rumble. Discuss how a lot of the things that happen are physiological and to an extent the person has no or limited control over them. Possibly discuss Kaplan and Wheeler Assault cycle

33. Impact factors People Objects Places Sex-Age-Size-Build Alcohol
Excessive Noise
Specialist Knowledge
Drugs
Safe exits/Layout
Skill-Boxing/Martial Arts
Potential weapons (that could be used to cause injury)
Public or private premises
Mental State
Offensive Weapons
Deliberately made to cause injury
Being in a position of disadvantage
Numbers Present
Items of value
Slip/Trip Hazards
Tiredness or exhaustion
(Physical or Mental)
Time of day
Imminent danger
Impact factors is like carrying out a mini risk assessment. Discuss Reaction Gap The distance we should adopt when dealing with conflict. It is the distance between the extremities of your reach and that of your opponents including any weapons. Fighting Arc – Draw on flipchart to explain

34. Distances
Exercise to demonstrate personal space, link back to last slide and reaction gap. Discuss how distances expand as we become angry.
Further discuss how when care giving we may have to enter further into peoples personal zones than either they or us feel comfortable with. What can we do to make the person feel less uncomfortable with that. Discuss if opportunity presents itself.

35. The Fighting Arc Offside Positioning 90º 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 Non-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
Property is not worth being attacked for!!!!

38. Reasonable force
The Criminal Justice and Immigration Act 2008 provides 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. 38

39. Using Reasonable Force
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 39

40. Assessing reasonableness
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 40

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. Assessing reasonableness
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”? 42

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. Key messages: how would you rather manage violence and aggression?
With this?
Think people…
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 45

46. Challenge the language…
Change the culture…
Challenge the language…
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.
Tormented
Angry
Upset
He is bad
not mad
He kicked
off 46

47. Thank you for participating…
Any Questions?