Preventing & Managing Abusive & Aggressive Behaviour SD13
Two Day Course
Trainer’s Manual
Helen Garratt Aquarius
October 2002
Competency Based Drug and Alcohol Modules
Module Title: Preventing and Managing Abusive and Aggressive Behaviour
AB3: Contribute to the prevention and management of abusive and aggressive behaviour. AB4: Contribute to the protection of individuals from abuse.
Learning Objectives
By developing the attitudes, skills and knowledge addressed in this module participants will be able to: i) Demonstrate effective communication which shows respect and reduces abusive/aggressive behaviour. Recognise and know how to appropriately deal with triggers to abusive/aggressive behaviour, protect the individual, self and others and defuse the situation. Understand the importance of constructively reviewing incidents of abusive/aggressive behaviour by all involved including managing own feelings and behaviour. Understand their role in reporting and recording information in regard to abusive/aggressive behaviour and individuals who are at risk from abuse, and individuals who may be at risk of danger due to their substance use. Recognise the need for collaborative working with partner agencies.
ii)
iii)
iv)
v)
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Preventing & Managing Abusive & Aggressive Behaviour PROGRAMME
DAY 1
9.30 Start Introductions Definitions 9.30
DAY 2
Working Environment & Documentation
11-11.15
COFFEE
11-11.15
COFFEE
11.15
Triggers & Communication
11.15
Defusion Techniques & Legislation
12.30-1.15 LUNCH
12.30-1.15 LUNCH
1.15
Warning Signs & Communicating Effectively
1.15
Practice Session
2.30-2.45
TEA
2.45-3.00
TEA
3.15
The Assault Cycle
3.15
Evaluation
4.20
Finishing the day
4.30
END
4.00
END OF COURSE
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DAY ONE
SESSION 1 45 mins
Introductions
Materials
Time
Organisation, Method & Content 1 Trainer welcome participants to the course introduce self hand out name badges/sticky labels & pens detail venue and domestics: toilet facilities fire procedure & exits, ask participants to switch off mobile phones/bleepers, smoking etc. give background and overview of the course, hand out course programme & objectives establish ground rules onto flipchart, include: - confidentiality - anti-discrimination - respect - open learning forum - time keeping
programmes course objectives name badges/sticky labels & pens flipchart, stand paper & pens
10 mins
10 mins
2 Pairs Exercise choose someone you do not know or who has a different job/workplace use OHP 1 as instructions tell them they will introduce themselves to the whole group afterwards take 5 mins each to introduce yourself to your partner Plenary in large group, participants in turn introduce themselves use flipchart to note key words/themes for what they hope to gain from the course
25 mins
3
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DAY ONE
SESSION 1 45 mins
Trainer’s Notes Session 1 Introductions
Session Objectives To introduce participants to one another. To explore learning needs of participants in relation to the course. To determine experience of participants.
1
Within this trainer introduction is the background and overview of the course. Inform participants that this part of a pilot of national training connected with the National Occupational Standards for Substance Misuse. Therefore their evaluations are very important in shaping future courses. It is important throughout the course that trainers demonstrate sensitivity to the potential personal impacts that course material may have on participants. Inform participants that this training is focusing on preventing and managing abusive/aggressive behaviours occurring in the workplace. Clarify that this course is not teaching physical interventions, ie breakaway techniques/care and restraints, etc. The purpose of this exercise is to create an atmosphere conductive to open participative learning. It gives participants the opportunity to focus on their experience, what they‟re bringing to the training, and what their learning needs are. From participants‟ feedback into the whole group, note on the flipchart key words or themes of what they hope to gain from the day‟s training. In ending the exercise, indicate when the issues raised onto the flipchart will be addressed, and highlight any areas the course cannot cover, with suggestions of where/how these needs might otherwise be met. Stress that the course uses participative learning techniques, so they can raise and discuss the issues in more detail over the course of the day.
2
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DAY ONE
SESSION 2 45 mins
Definitions
Materials
Time
Organisation, Method & Content 1 Trainer informs group that the rest of the session will be spent defining the terms. Split group into small groups of 3/4s. Onto flipchart paper note: (a) Take 5 mins to define what abuse is. Then ask groups to: (b) Discuss the range of abusive behaviour for 10 mins.
flipchart paper & pens OHP 2, 3, 4, 5, 6 & 7 handouts “Definition”
15 mins
15 mins
2 Plenary Each group feeds back their definitions of abuse, use OHP 2 to give broad definitions. Each group feeds back their identified range of abusive behaviour. Encourage large group discussion.
15 mins
3 Trainer summarises abusive behaviour noting this training takes a broad definition. Use OHP 3 & 4 to assist summary. Using OHP 5, 6 & 7, discuss as large group aggression and violence. Ask group for comments/encourage discussion. Ask how this differs from assertiveness. Give handout to participants
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DAY ONE
SESSION 2 45 mins
Trainer’s Notes Session 2 Definitions
Session Objectives To ensure a common definition of what constitutes abuse and aggression. To consider the range of abusive and aggressive behaviour.
This session concentrates on ensuring that the group is working with a common broad definition of what constitutes abuse. It considers the range of abusive behaviours. Abuse can take many forms, ranging from ways of speaking to physical attack. Abuse can occur within relationships, families, peer groups, institutions and in all care settings. Wherever one person is interacting with another person there is a potential for abuse to occur. The first exercise enables participants to start to define abuse and to think through examples of abusive behaviour. Participants may at this point disclose incidents they have been involved in, or witnessed, so sensitivity is needed throughout this training. There are various definitions used. In fact, in books and articles, different authors use different definitions. This is also the case in working practice. Therefore it is important to clarify what is actually meant in discussions regarding abuse. This training takes a broad definition of abuse, and takes seriously the negative impacts abusive behaviour can have on individuals. It is worth noting that whilst obviously enduring actual abuse is potentially very damaging, the threat of potential abuse can also have lasting effects. Allow large group discussion, within the time constraints, in the plenary, as there is much potential for participants to increase the breadth of their understanding of the range of abusive behaviour from each other‟s contributions. Trainer to ensure participants‟ discussion covers the wide range of abusive behaviour.
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DAY ONE
SESSION 2 45 mins cont…
An important factor of this exercise is highlighting that different people view certain acts differently, depending on their personal experiences, professional training and client group they work with. In defining abuse, it is important for participants to recognise where their assumptions/stereotypes may hinder the recognition of abuse. For example: (1) Society often views the seduction of teenage boys by older experienced women as non-abusive, whereas when the genders are reversed there is a recognised opinion that abusive behaviour has occurred. “Flashing” by some people is deemed funny, rather than abusive.
(2)
Trainer may need to give more examples to the group. Suggestions: Sexual abuse (1) Myths abound that women especially mothers do not sexually abuse their children. (2) Denial regarding multi-perpetrator abuse of children. Domestic Violence Low acceptance of violence occurring within same sex relationships, and in heterosexual relationships where the woman is in a high achieving career. In summarising the session, pull together the themes discussed and clarify any issues in definitions. Use OHP 3 and 4. Using OHP 5, 6 and 7 define aggression and violence. Physical aggression = violence. Abusive behaviour and aggressive behaviour are often the same. The words “abusive” and “aggressive” are often interchangeable. For example, a child who is involved in obtaining drugs for parents is experiencing abusive behaviour, and instrumentally aggressive behaviour. Shaming, frightening or threatening someone all constitute aggression, and are often components of emotional abuse.
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DAY ONE
SESSION 3 75 mins
Triggers & Communication
Materials Time Organisation, Method & Content
1 Trainer reiterates that this 2 days training is focusing on the workplace. Using OHP 8 highlight channels of abusive / aggressive behaviour. 2 Split group into smaller groups 3 / 4‟s Onto flipchart paper write “Why do people become abusive / aggressive?” 3 Plenary Each group feeds back their list. Then trainer summaries using OHP 9 & 10 4 Personal Reflection Exercise Which of these triggers relates to you? 5 Trainer checks with the group if there is anything any participant wants to say / question. - are there any new triggers that we hadn‟t listed? The potential to become abusive / aggressive is within all of us. 6 Focus on Communication Trainer input using trainer‟s notes and OHP 11, 12, 13, 14, 15, 16, 17 & 18. Give handout to participants. 15 mins 7 Small Group Exercise Back to the groups of 3 / 4‟s participants were in earlier. Instruction to Groups Fun exercise – pack of cards for each group. Take turns individually to mime the feeling on one card. When the other participants have guessed one correctly, it‟s the next person‟s turn. 8 Plenary Ask groups to feedback their experience of the exercise. Inform group we‟ll continue to look at communication after lunch. LUNCH
Flipchart, Paper & pens OHP 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 & 18
5 mins
10 mins Feelings cards Handout Communication 15 mins
2 mins
5 mins
15 mins
8 mins
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DAY ONE
SESSION 3 75 mins
Trainer’s Notes Session 3 Triggers & Communication
Session Objectives To recognise the possible triggers to abusive/aggressive behaviour. To understand the significance of non-verbal and verbal communication, and personal space.
1
Trainer starts this session by reiterating that this training will focus on abusive and aggressive behaviour occurring within the workplace (other modules focus on abuse issues occurring past / present away from the workplace). In highlighting the channels in which abusive/aggressive behaviour may occur inform participants that we‟ll look at self-harm tomorrow. Restate that there are risks of any type of abusive/aggressive behaviour taking place in the workplace (e.g. financial – workers using clients‟ money for themselves). However, the majority of abusive/ aggressive behaviour staff have to deal with from clients is verbal and to a lesser extent physical.
2 & 3 The purpose of this exercise is to start to explore possible triggers to abusive / aggressive behaviour. If groups are finding it difficult to start an exercise, a pointer could be “what makes you more likely to feel like becoming abusive/aggressive”. Summarise using OHP 9 – stress everyone is different, have different triggers. 4 & 5 This personal reflection exercise demonstrates how we all have the potential to be abusive/aggressive, our triggers may be the same although our choices to become abusive/aggressive may be different. Staff should not demonstrate abusive/aggressive behaviour towards other people. In the large group after the exercise trainer needs to take special care not to become censorious. We‟ll continue to identify potential triggers throughout the course.
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DAY ONE
SESSION 3 75 mins cont…
6 For the rest of this session, and after lunch, we will focus on one of the potential triggers – communication, because understanding how and what we are communicating to others, and they to us, is a fundamental key to preventing and managing aggressive behaviour. Trainer input using OHP 11, 12, 13, 14, 15, 16, 17 & 18 can be verbal and non-verbal. Each of us has a zone of personal space around us; for some people the zone is very large, for others very small – this can be culturally influenced. It can feel offensive or aggressive if someone comes too close and invades our zone. This zone/territory can increase three-fold when we are angry. The OHP‟s show general guides for proximity. 7 The purpose of this exercise is to show that non-verbal communication is very effective. It is usual for individuals to be able to accurately identify emotions with mine. This is a fun exercise and also serves to assist the forming of trust within the training group.
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DAY ONE
SESSION 4 75 mins
Warning Signs & Effective Communication
Materials Time Organisation, Method & Content 1 Split the group into 3 small groups Instructions for exercise: Draw an outline of a person onto flipchart paper (portrait) - just outline. Into the room comes a mad-axe wielding murderer. He has not touched you. Draw onto the outline all the physical changes that happen as a result of him. No writing. 15 mins 2 Plenary Look at each other‟s drawing. Trainer then highlights these are the same signs/ symptoms/body signs that both aggressor and victim have. Can potentially be a mirror image. Link with fight/flight mechanism. Give handout. 5 mins 3 Brainstorm What are the likely warning signs of someone becoming aggressive? 15 mins 4 Trainer input regarding what studies have shown using OHP 19, 20 & 21 & handout. Trainers are encouraged to read „Coping with Aggressive Behaviour‟ by Glynis M Breakwell – Chapter 3. Give handout to participants. “Assessing the risk……” Ask group for comments/questions. 15 mins 5 Split into small groups. (of 4 participants) From what we‟ve done today regarding communication draw up guidelines for effective communication 20 mins 6 Plenary Each group outlines effective communication including trainer summarises with OHP22 & 23. TEA. Page 11 of 52
Flipchart, Paper & pens OHP 19, 20, 21, 22, 23, Handout: Assessing the Risk of Violence Fight/Flight Mechanism
5 mins
DAY ONE
SESSION 4 75 mins
Trainer’s Notes Session 4 Warning Signs & Effective Communication
Session Objectives To highlight the links between anger and anxiety. To identify signs of potential aggression. To identify the elements of effective communication.
1 & 2 This is a warm up exercise that demonstrates the similarities in symptoms / body signals of someone who is fearful and someone who is angry. The internal automatic process prepares you to fight/ flight. If you notice these physiological changes occurring in you, you must pay attention - this is your body telling you that you are afraid - it is a good indication that something threatening is happening. 3 In introducing the brainstorm acknowledge that already identified some signs, but there may be other behavioural signs to watch for. The following list is not exhaustive, but give pointers for the trainer. staring, muscle tension - clenching fists/face, over-sensitivity, fidgeting - hand wringing, pacing, rapid mood swings, pointing - finger wagging/jabbing, loud speech - shouting/screaming, sweating - face pale/red, swearing 4 Trainer input regarding empirical studies. Structure the input around the OHP’s 19, 20 & 21, and the handout. Assessing the risk of violence. This exercise allows participants to pull together the elements we‟ve covered so far today, to identify the elements of effective communication when there is a potential for aggression. Summarise with OHP 22 & 23.
5
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DAY ONE
SESSION 5 105 mins
The Assault Cycle
Materials
Time
Organisation, Method & Content 1 Trainer Input Prepared flipchart with diagram of The Assault Cycle - see trainer notes. Describe the Assault cycle using OHP 24, 25, 26, 27, 28 & 29. Encourage participants to raise questions/comments. Give handout - The Assault Cycle. 2 Split into groups of 4’s Handout the scenario: (a) In groups discuss – how you proceed? (b) You are Ann‟s team/manager – what do you do? 3 Plenary 2 groups feed back (a) then ask other two groups if anything else they want to add. Then these 2 groups feed back (b) and ask first 2 groups if they‟ve anything to add. (see trainer‟s notes for guidance)
Flipchart, Paper & pens OHP 24, 25, 26, 27, 28 & 29 Handouts: The Assault Cycle Scenario Documenting a Violent Incident
25 mins
15 mins 15 mins 20 mins
20 mins
4 Trainer summarises main points including legislation & documenting a violent incident. Encourage participants to question / comment during input. 5 Finish the day. Recognise covered a lot of information today. Check whether participants have concerns/ questions/issues needing clarification.
10 mins
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DAY ONE
SESSION 5 75 mins
Trainer’s Notes Session 5 The Assault Cycle
Session Objectives To have an awareness of the Assault Cycle. Recognise and know how to appropriately deal with triggers, protect the individual, self and others. To understand the importance of constructively reviewing incidents of abusive/ aggressive behaviour by all involved including managing own feelings & behaviour. Understand their role in reporting and recording information in regard to abusive/ aggressive behaviour. Recognise the need for collaborative working with partner agencies.
1
This trainer input is designed around the OHP‟s 24–29, prepared flipchart with a diagram of The Assault Cycle, and the handout The Assault Cycle. Trainers are encouraged to read „Coping with Aggressive Behaviour by Glynis M Breakwell Chapter 4. This input is to raise participants awareness of the cycle and the possible interventions and when not to intervene but to escape.
2 & 3 This scenario relates the cycle to practice and encourages participants to look at the practitioner & possibly victim needs and in good practice terms what support should exist for the person. Trainer ensures that 4 Those involved in incident contribute to reviewing the incident. Time / space / support – everyone involved to express feelings & examine their behaviour. Constructively explore reasons for & consequences of the abusive/ aggressive behaviour. Referrals Recognition of right to have feelings and that not all incidents are capable of prevention. Recording/documenting incident. Trainer outlines documenting a violent incident using handouts. Inform participants that we will be covering legislation more tomorrow morning. Page 14 of 52
DAY ONE
The Assault Cycle Diagram
Crisis Phase
(Possible additional assaults)
Post-crisis Depression Phase
Trigger Phase
Escalation Phase
Recovery Phase
ne aviour
Baseline Behaviour
From Coping with Aggressive Behaviour – Glynis M Breakwell Page 15 of 52
DAY TWO
SESSION 6 90 mins
Working Environment & Documentation
Materials
Time
Organisation, Method & Content
1 Check with participants if there is anything left over from yesterday.
OHP 8 + 30 flipchart paper and pens
5 mins
2 mins 3 mins
2
Outline of today.
3 Introduce this session, use OHP 8. 4 Small group exercise - use OHP 30.
Think of your workplace.
10 mins (a) identify potential vulnerabilities/ environmental triggers to abusive/aggressive behaviour, including: building/layout working practices staffing/skill mix what contexts clients meet one another client‟s mood state/level of drug in body 15 mins (b) what solutions/options do you suggest for your list? (c) what has already been done to reduce the likelihood of abuse/aggression in your workplace? eg: alarms policies guidelines training supervision collaboration working with other agencies 25 mins 3 Plenary Feedback (a) and (b). When each group has done above, ask for feedback (c). Trainer input - documentation.
10 mins
10 mins
5
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10 mins
6
Whole Group discussion of points raised this session.
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DAY TWO
SESSION 6 90 mins
Trainer’s Notes Session 6
Working Environment & Documentation
Session Objectives To recognise and minimise triggers to abusive/aggressive behaviour in the workplace environment. To understand their role in reporting and recording information regarding abusive/aggressive behaviour and in protecting individuals who are at risk of abuse. To recognise the need for collaborative working with partner agencies.
1
In giving an outline of today‟s training, reiterate to participants that this module has two components, each regarding abusive/aggressive behaviour in the workplace. Yesterday concentrated on aggression, which will continue today, but also focus on contributing to protecting individuals who are at risk from abuse. Introduce session by highlighting that yesterday explored potential triggers to abusive/aggressive behaviour and concentrated on one of these - communication. This session will focus on our specific workplaces and identify possible triggers/risks in these. Remind participants of the potential channels of behaviour (OHP 8). Small Group Exercise: Give groups instructions instruction (a) first; after allotted time give instructions to (b), then to (c). If participants work for the same organisation, they may choose to work together. *** OHP 30 INSERT Prompts include: practitioner style working practices, including venues opportunities for clients to suffer
2
3
victimisation/abuse
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in what contexts clients meet one another Ask groups to be specific.
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DAY TWO cont..
SESSION 6 90 mins
In Plenary, ask groups to feedback (a) and (b) first, when each group has done this, then ask for feedback from (c). NB Personal alarms may be used in the workplace to summon help, but primary aim when using a high pitched alarm is to stun the aggressor, and give the practitioner time to get away. The trainer ensures that groups have explored the potential contexts in which clients can be abusive towards other clients, including physically, financially, emotionally, sexually. Collaborative working with other agencies should be highlighted. 4 This input is to highlight the importance of accurate, legible documentation. Yesterday, session 4 outlined the recording of a violent incident; this is in conjunction with that material. All documentation needs to be in line with oganisational polices. Trainer raises the importance of reporting/recording information consistent with all available evidence and observation. Records should be complete, signed and dated. Entries should be made in all relevant case files, and incident forms completed. Trainer asks participants if they have: anti-harassment policies whistle-blowing policies complaints policies equal opportunities policies confidentiality policies health and safety policies, etc
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DAY TWO
SESSION 7 75ins
Defusion Techniques & Legislation
Materials
Time
Organisation, Method & Content
1 Trainer input Outline session and raise awareness of defusion techniques used in trigger and early escalation phases of the Assault Cycle. Use OHPs 31-46. Give handout to participants.
OHPs 31 - 56 Defusion techniques & legislation Scenarios Handouts: Defusing the Aggressive/Abusive situation Legislation
20ins
20 mins
2
Small Group Exercise Discuss the scenarios. What would you do/say? Formulate some immediate responses (add any interventions you would use later on).
20 mins
3
Plenary Groups feedback their responses. Notice differences/similarities.
15 mins
4
Trainer input Outline legislation related to this area using OHPs 47 - 56.
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DAY TWO
SESSION 7 75 mins
Trainer’s Notes Session 7
Defusion Techniques & Legislation
Session Objectives To have an awareness of the potential ways of defusing an aggressive situation. To demonstrate effective communication, which shows respect and reduces the aggressive/abusive behaviour.
1
Trainer input outlining the session and covering OHPs 31 - 46. Encourage the group to comment/raise questions as you go through the acetates. These techniques listed are not exhaustive, and participants may have others to offer. Important to note that these techniques are for use in the TRIGGER AND EARLY ESCALATION phases of the Assault Cycle. Some are common-sense, but evidence suggests that the more individuals have thought through likely interventions, the more able they feel in the situation.
2 & 3 This small group exercise highlights different people‟s preferred interventions - it is OK to have disagreement in how to respond in the small groups. The important factors are: (i) practitioners are supported to intervene within their areas of confidence and competence, different aggressors will require different responses depending on situation, your relationship to them, what has triggered the incident, spectators, risk, etc, etc.
(ii)
It is important that practitioners are aware of any prejudices/stereotypes that hamper their interventions and discriminate individuals. 4 In finishing the session, the trainer highlights the current legislation using OHPs 47 0 56.
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DAY TWO
SESSION 8 90 mins
Practice Session - Role-Play
Materials
Time
Organisation, Method & Content
1 Trainer input: Set exercise up Split group into 3/4s practitioner client (aggressor) observer Give observer guidelines to participants
Observer Guidelines Scenarios
5 mins
15 mins 10 mins 50 mins
Role-play De-role and feedback Repeat Role-play x 2 De-role/feeback x 2
10 mins
2 Plenary Large group discussion. What are key learning points?
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DAY TWO
SESSION 8 90 mins
Trainer’s Notes Session 8
Working Environment & Documentation
Session Objectives To practise skills that demonstrate effective communication sharing, respect and reducing abusive/aggressive behaviour.
1
Some participants may have had previous negative experiences of role-play. Therefore, reassure participants that this is an opportunity to make mistakes. Practitioner role can ask for support from the observer at any time, eg asking for alternative responses. The purpose of this exercise is to encourage participants to think about and practise responses. Acknowledge that it is artificial, eg the person role-playing the aggressor is not going to hit anyone - you know that the situation is not going to get out of control. However, it provides a useful forum to develop skills and find out individual weak spots which is important for you to know about yourself. Research tells us that the more you think about and practise your responses, the grater the likelihood is of being able to respond appropriately, and overcome the “freeze moment”, in an aggressive incident Groups can use the scenarios from previous session or can use own material.
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DAY TWO
SESSION 9 45 mins
Evaluation
Materials
Time
Organisation, Method & Content
1 Trainer recaps on areas covered over the training. Ask group to raise any outstanding questions/issues. Discuss
Evaluation forms
10 mins
15 mins
2 Pairs Exercise Discuss with partner (1) what you have learnt and (2) how it will impact on your practice.
10 mins
3 Feedback to large group. Trainer finishes by thanking participants for their contributions.
10 mins
4 Handout evaluation forms to be completed and handed back to trainer.
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PREVENTING & MANAGING ABUSIVE & AGGRESSIVE BEHAVIOUR PROGRAMME
DAY 1
9.30 Start Introductions Definitions 9.30
DAY 2
Working Environment & Documentation
11-11.15
COFFEE
11-11.15
COFFEE
11.15
Triggers & Communication
11.15
Defusion Techniques & Legislation
12.30-1.15 LUNCH
12.30-1.15 LUNCH
1.15
Warning Signs & Communicating Effectively
1.15
Practice Session
2.30-2.45
TEA
2.45-3.00
TEA
3.15
The Assault Cycle
3.15
Evaluation
4.20
Finishing the day
4.30
END
4.00
END OF COURSE
SD10 learning objectives
1. Demonstrate an awareness of the key theoretical models and approaches used within the field 2. Describe the model of change 3. Demonstrate the key principles of working within a motivational framework 4. Show an understanding of the cognitive behavioural approach and its applications 5. Understand the importance of goal setting and the benefits of working with therapeutic contracts 6. Understand the components of relapse prevention and management 7. Have an awareness of the functions, roles and dynamics within groups 8. Identify ways of working in groups with service-users
DEFINITIONS General Definitions of Abuse
Abuse “misuse, make bad use of, deceive, maltreat, revile, an established unjust or corrupt practice” (Fowlers Dictionary) Abuse “an act of misuse, exploitation, deceit, wrong or improper use or action so as to injure, damage, maltreat or corrupt “ (Stuart & Sindeen)
Defining Abuse
Abuse can be categorised as: Physical Emotional Sexual Psychological Financial Neglect
- Actual - Short term
- Potential - Long term
Aggression
Any form of behaviour intended to harm or injure someone against his/her wishes Includes any form of injury, including psychological or emotional injuries Instrumental - a means towards some other end Emotional - angry aggression/deliberately inflicts injury
Violence
Deliberate attempts to inflict physical harm
Assertiveness
Insisting on your rights/opinions. Claiming recognition from others that, within constraints of the law you have the right to decide how you think, feel and act.
AGGRESSION
Any form of behaviour intended to harm or injure someone against his/her wishes.
Includes any form of injury, including psychological or emotional injuries.
VIOLENCE
Deliberate attempts to inflict physical harm.
COMMUNICATION & PERSONAL SPACE
This handout has been prepared with material from B Bluck and L Bennett, Northamptonshire Health Authority
Verbal Communication
7% Verbal What we say, Words, phrases and content
38% Vocal How we say it, Tone, intonation, pitch and pace Sarcasm comes into this category
Non-verbal Communication
55% Body movement Body language Gestures Facial Expressions Eye contact
Personal Space
Everyone has their own personal territorial needs. They may vary from time to time depending on several factors. Culture Familiarity Emotion Sex Emotion
This zone/territory can increase three-fold when we are angry.
Rules of Distance
Public distance: Public gatherings (eg, the choice of distance on a beach) Used for unknown people Touch not possible without moving A distance of 10 to 18 feet
It must be remembered that when someone is seated, to lean over them is to enter their intimate space in a most threatening manner.
Social Distance
From 18 inches to two arms‟ length, or more Shaking hands distance Touch not possible without moving Used when parties have limited choice about relating to each other, or when the person is relatively unknown
Personal Distance
One arm‟s length Touch requires consent For private conversation used only when sure of the boundaries of the relationship
If the rule is broken, it is likely to produce a backward movement, eye contact is avoided and attempts at distance are made.
Intimate Distance
Less than one arm‟s length Either person can choose to touch the other without them having a chance to avoid the touch Belongs to a very close relationship
When rules are necessarily broken (ie on a bus), the impact is reduced by avoiding eye contact.
The Reactionary Gap
The time it would take to cover: 6 feet 12 feet 21 feet Less than half a second Less than a second Less than one and half seconds
THIS IS A LIST OF FEELINGS TO BE PUT ONTO CARDS
BORED
NERVOUS
SURPRISED
SCARED
DISINTERESTED
SHY
EXCITED
FRUSTRATED
HAPPY
SAD
CONFIDENT
PUZZLED
ANGRY
DISGUSTED
INTERESTED
ASSESSING THE RISK OF VIOLENCE
The handout has been compiled with material from – Coping with Aggressive Behaviour by Glynis M Breakwell, Chapter 3. From empirical studies (Webster et al 1994) there are indicators of the risk of violence being higher if the person: Is a member of a group/subculture where violence is the norm. Has a history of violence. Is aroused by some aversive stimuli. Is dis-inhibited, eg by alcohol/drugs. Expects the violence to be rewarded materially or through social approval. Believes no other action is possible.
Empirical studies on the expression of aggression offer more clues. Risk is greater in a specific situation if: The person has been threatening violence. Threats can be an end in themselves but can also represent a statement of intention. There are clues, eg weapons, knives, or someone else already acting in a violent way. The person is displaying the signs of high arousal e.g. flushed skin, increased muscle tension etc. Although signs can be misleading – real clue to look for is any shift from the person‟s typical state. The person is being verbally abusive – this can often lead to physical violence. Also tone, pitch, speed of talk can change. Again real clue is to look for any variation of the person‟s typical voice/speech. There is peer group pressure to be violent. The person is showing non-verbal signs of imminent violence, eg invasion of personal space, maintenance of eye contact for prolonged periods, rapid unpredictable arm movements, including pointing, clenching and unclenching teeth/fists etc.
These can be useful indicators of the likelihood of violence. However, it must be stressed that all people are individuals and there are no perfect ways of predicting violence. Each violent incident is unique. In some incidents none of the above will be present but in most cases at the least some of the above warning signs will be present.
Trigger Factors
The situational analysis of violent incidents has led psychologists to suggest that there are trigger factors that can change an interaction between a practitioner and client from a potentially violent one to an actually violent one. The most common trigger factors are: 1. An intensification of the aversive – stimulation. 2. Onset of dis-inhibition created by the use of drugs, etc. 3. The sudden perceived absence of an alternative option. 4. The arrival in the situation of ones which reinforce violence e.g. pictures depicting violence, peer group members who approve violence. 5. A perceived increase in the potential reward for violence. 6. The use of words or phrases known to be provocative to the person (barbs). 7. The experience of sudden major life changes or advent of new stressors. 8. Attempts to interpret the individual‟s behaviour as psychotic when the individual regards his/her behaviour as normal.
FIGHT/FLIGHT MECHANISM
When we are faced with something/someone which we perceive as threatening, our body automatically prepares itself to either stay and fight the threat, or to be able to run away (flight) from the threat. The following physiological changes occur when adrenaline is released into the bloodstream:
Breathing quickens Heart beats faster Blood is diverted from stomach and intestines to the heart, central nervous system and muscle. Blood glucose level rises Muscles tense for action Pupils dilate Sweating cools the body
The physiological response in fear is similar to the response in anger. Therefore, in an attack, the changes taking place in the attacker and the victim are virtually identical, resulting in both parties being in an aroused state. It is important to pay attention to these changes occurring in ourselves, because these are the signals that the body is telling us we are afraid.
THE ASSAULT CYCLE
This handout was compiled with material from B Bluck and L Bennett, Northamptonshire Health Authority
When someone is becoming aggressive, they give off clear signals. The Assault cycle is a tool to look at the process that occurs during an episode of violent/aggressive behaviour. There are 5 phases: The Trigger phase The Escalation phase The Crisis phase The Recovery phase The Post Crisis Depression phase
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The Trigger Phase Everyone has their own set of behaviours, which for almost everyone are non-violent most of the time. We call this set of behaviours the normal baseline. The triggering phase is the point where the person first shows a movement away from their normal baseline set of behaviours. This movement away from their baseline may be exhibited in verbal or non-verbal behaviour. The individual may start to become very solitary or the opposite of this, they may become very loud and noisy. They may use language in a very different way to which they would „normally‟. This highlights the point that the better you know an individual the easier it is to recognise a deviation away from their normal baseline set of behaviours. Therefore, a movement away from their „normal‟ is a good indicator that all is not well, and should be taken as a warning sign. In this phase, the aggressor is likely to be anxious and suspicious. Your goal at this point is to try to reduce these feelings by being non-threatening, use listening skills, show concern, utilise defusion skills/tactics. Do not over-react try to give the person a feeling of confidence in you.
The Escalation Phase
All your tactics to reduce anxiety to clam the person may have failed, so look at clearing the area of potential weapons/missiles. Explain that you can see they are angry, but be sure that you make them aware of the consequences of any further aggression, eg you won‟t be able to help them, etc. Be specific in what it is you expect or want from them. compromise, offer concessions if they stop their behaviour, eg if they stop you will do this or that, etc. Assailants who accede to small concessions are subsequently more likely to agree to larger ones. You may also call in a colleague for back up/support, or leave the area. The Crisis Phase During the previous phase, the person has become unresponsive to rational intervention, their behaviour continues to escalate until it reaches this phase - the crisis phase. In this phase, due to the heightened physical, emotional and psychological states of arousal, the control over the violent behaviours dramatically lessens. It is therefore dangerous to attempt any defusion technique, the safety of yourself and others in the area is now paramount.
GET OUT
The Recovery Phase After the violent incident has occurred the person will then very gradually return to their normal baseline set of behaviours. Due to the emotional and physical peak this person has just gone through it can take up to 90 minutes to come down. Hence this is a very dangerous time, as during this phase most errors by the carer are made. The person is very susceptible to triggering off again, so attempts at intervention may lead to further violent attacks. Do not try to analyse the problem during this phase, make it clear there will be a return to „normality‟. Give clear instructions about what you expect of them, and try to prepare them for the likely impact of the next phase.
The Post Crisis Depression Phase During this phase, the person may well drop below their normal baseline set of behaviours and become very tearful, guilty or ashamed. The person may now become amenable to interventions to look at the incident. Our aims should be relieve the person‟s guilt, and look at ways of preventing the incident happening again. The Post Crisis Depression Phase It must be remembered that this phase is not inevitable, for some there will be no guilt, sadness shame or remorse. Also present will be the realisation that the problem will still be there. The carer must be appropriately skilled at this point to use, for example, problem solving techniques to analyse the cause of the difficulties, giving information offering advice, etc. If you were the assaulted party, then it is unlikely that you are the best person to cope with the attacker in either the recovery, or post crisis depression, phase. Intervening in the Cycle Intervention is possible at all times except in the crisis phase, intervention in the recovery phase is fraught with risks if not handled carefully. Both parties, the aggressor and the carer, go through high states of physical and emotional arousal, which affects how they both behave. Most violent incidents are understandable and can be prevented or at least lessened with the correct interventions at the right time. The Victim’s Experience of the Assault Cycle The assault cycle looks at how the aggressor is affected. There is now evidence that show the individual who is dealing with this behaviour experiences a very similar set of phases during, and after, the incident. During the escalation phase, the carer is just as likely to have increased arousal that peaks at the crisis phase. At the very moment you need all your wits about you to remain calm and rational, you - like the attacker - are more likely not to be able to do so. The victim‟s experiences during the post crisis phase are, again, similar to that of the attacker, eg exhaustion, tearfulness, etc. Reference 1 Coping with Aggressive Behaviour, Chapter 4, GLYNIS M BREAKWELL 2 Management of Violence and Aggression in Health Care, edited by BRIAN KIDD, Cameron Star.
The Assault Cycle Diagram
Crisis Phase
(Possible additional assaults)
Post-crisis Depression Phase
Trigger Phase
Escalation Phase
Recovery Phase
Baseline Behaviour
Baseline Behaviour
From Coping with Aggressive Behaviour – Glynis M Breakwell
SCENARIO
There has been a violent incident in your workplace. Joe is a 38 year old who has been using the service for about 3 months on and off. He has a history of violent offences. He attended the dropin service this afternoon and had to wait for about ¾ hour to be seen. It was a very busy session with the 2 members of staff full to capacity. A mistake had happened and Joe had seen 2 clients who had arrived after him, be seen before him. He had presented originally this afternoon as agitated and when he complained to the reception staff that 2 people had jumped the queue his behaviour rapidly deteriorated. Ann, one of the drug team tried to talk him down but he started turning over the coffee tables and chairs, shouting abuse. There are 2 women clients waiting in the reception. You are Ann, how do you proceed?
DOCUMENTING AN AGGRESSIVE/VIOLENT INCIDENT
It is a legal requirement for all staff to report any incident in which their safety is compromised. (Riddor 1995) Where agency policy makes it clear that staff are expected to report violent incidents, staff could be held to account by Courts and Tribunals for any breaches, and may find compensation or insurance claims are affected. In the event of something going wrong, of a compensation claim being made against an agency and/or staff, or of a criminal investigation of a possible assault, both the agency and the member of staff may be required to demonstrate that agency policy, including proper reporting and recording, has been followed.
Recording the Violent Incident
All recording must be in line with agency policy. If the agency has specific “incident and witness statement forms” these should be filled in. The following list is a guide of the areas to be covered. who you are and place of work day, date and hours of work you were working, and what staff were on duty with you. state time (approximately) your attention was brought to the incident and where you were situated. state where the subject was located, and what he/she/they were doing, eg note down their behaviour (body language/actions) quote the subject directly if possible state what action from the subject prompted you to intervene state what action you employed and what staff were assisting you state what time (approximately) your intervention had come to an end state how situation ended note any injuries sustained by yourself/staff/subject note if there wee no injuries sustained state after care given - to self/staff/subject eg first aid/de-briefing sign at the bottom with job title and date if witness statement/incident form not completed on the same day as the incident, state as to why
SCENARIOS
You walk into a communal area, and two male clients - Tom and Reuben are having an argument. You know that they have not got on with one another for some time. Tom is shaking and swearing at Reuben calling him “… a black bastard …”. Reuben looks ready to hit him. ***** Sarah has used amphetamines and alcohol problematically for five years. Two months ago she hit a receptionist at her GP practice when she couldn‟t see her sympathetic GP. She was directed to the drugs service by the Courts. This is the second time you have seen her. Ten minutes into your “one to one” session, you are aware that she has been drinking, and probably used prior to your session. When you ask her, she becomes verbally abusive and suddenly stands up and starts shouting at you “You‟re no help, you‟re always on my back.” ***** You facilitate a support group. Alex, a powerful group member, has started to provoke a newer group member Jon. Alex disagrees with Jon at every opportunity, and has started “smiling knowingly” at another group member, Pat, whenever Jon starts to speak. This has happened over the last two weeks, and you haven‟t said anything, as you are a little intimidated by Alex and you know he has a sharp, quick mind. You are in the group, and you notice this happen again. ***** You work in a residential rehabilitation unit which operates a “no drugs/ alcohol policy”. Douglas is a muscular 6ft 3in resident, who is suspected of using cocaine. He has a long history of drug related violence, including assault and ABH. He has gone to his bedroom after a row with another resident, and you now need to go to his room to drug test him. When you knock on his door, there is no answer.
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DEFUSING THE AGGRESSIVE/ABUSIVE SITUATION
The time to use defusion techniques is in the trigger and early escalation phases of the Assault Cycle.
Tactics For Defusion
Maintain adequate distance . Avoid corners, move towards a safe place. Explain intentions to the person and others. Appear calm, self-controlled and confident. Acknowledge the person‟s anger, feelings and concerns. Ensure your own non-verbal communication is non-threatening. Ask for facts, encourage reasoning. Be aware of how to call for help. Leave the area.
Defusion Techniques
Look and behave Non-Aggressively
Appear calm, self controlled, think of the message you are giving out with your body language. Check your own posture - sit down, but only if you are in no immediate physical danger.
Do Not Lose Your Temper
Keep to normal tone of voice, be assertive. The aggressor may raise their voice or start shouting, be sure you do not mirror this behaviour.
Show Concern
Show concern for the aggressor and their problem. If it is appropriate, then apologise. Be honest if under he same circumstances you would be upset, then say so,
Choices
When they start to calm down, offer a menu of possible solutions. Be honest, realistic and open. Do not make promises that can‟t be kept just to rid you of the immediate problem. - unless your physical safety is in danger. Offer allegiance, be an ally.
Location
Change location if thought helpful - move away from an audience, but remember not to put yourself at further risk. If at all possible, try to separate a group or a pair.
Offensive Behaviour/Language
Do not allow this behaviour to go without comment. Recognise their behaviour, and ask for it to stop. Address the aggressive behaviour first before delivering a service or information. Responses: “If you stop threatening me, then I will be able to help you look at …”
The Cost
Make it clear the cost of behaving aggressively. Inform the aggressor that if their behaviour continues you will not be able, or prepared, to help look for solutions. An intervention you may consider is to inform the aggressor that if the behaviour doesn‟t stop you will call the Police.
Repeat Verbal Responses
Broken record techniques or memorise verbal responses in advance.
Acknowledge Their Anger
Make it clear you have heard how angry or upset they are. Acknowledge their feelings and rights, but don‟t necessarily agree. Never be dismissive or overbearing.
Express Your need
What I would like in this situation, what is bothering me … Use this if you feel it may help the other person be responsive, but not if is going to be judgemental or blaming.
Appeal to Past Good Behaviour
Say things like: “We never had this trouble before …” Try to help the aggressor save face and not look foolish for their anger when they have settled down.
Diversion
Change the subject or move the topic on. Be careful if you offer a cup of tea and perhaps a cigarette.
Lightening the Mood
A well timed joke may help, but not in the heat of the encounter. This is a difficult technique, as judgement on the right time to joke in a potentially dangerous situation has to be spot on.
Get Information
Ask the aggressor what the problem is, what the aggressor needs, what is causing concern, what is it that is bothering them.
Acknowledge the Information
Check that you have fully understood the problem. Repeat back what you have heard.
Imminent Physical Assault
If you feel concerned for your physical safety, then leave. Use any method at your disposal to ensure your safety, for example deception, etc.
It Didn’t Work
With the best will in the world, there will be occasions where it is just not possible to defuse the violent incident/individual.
Bluck/Bennett Northamptonshire Health Support Services
LEGISLATION
Employment Rights Act 1966 Section 44
Prevents an employer from taking action such as dismissing or disciplining an employee who leaves their place of work because of danger which they believe to be ‘Serious and Imminent’ and which they could not be reasonably expected to prevent. This includes taking any appropriate steps to protect themselves or others from danger.
Health & Safety at Work Act 1974 Section 2 (1)
It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare of all his employees.
Section 2 (2) (c)
It is the employers responsibility to ensure that employees receive such information, instruction, training and supervision, as is necessary, to ensure the health, safety and welfare of staff by ensuring staff are competent.
Section 7
It shall be the duty of every employee while at work to take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions at work.
Management of Health & Safety at Work Regulations 1992
This imposes a new requirement for employees to bring to the attention of employers any situation or condition which the employees consider to be a serious danger and any shortcomings in the employer‟s health and safety arrangements.
Criminal Law Act 1967 Section 3
Any person may use reasonable force in self defence. Whilst the law imposes a duty on a potential victim to retreat and escape it may not always be possible. In this case the use of force and or restriction of liberty in self defence is likely to be considered legitimate.
Terms used in both civil and criminal law
Assault and Battery: Criminal assault occurs when one person, either by a physical action or possibly a verbal utterance, causes another to believe that they are about to be subjected to any form of physical violence (apprehension).
Battery occurs only if actual violence is inflicted. However under civil law assault and battery include the simple act of touching. A nurse touching or making as if to touch a patient without lawful authority or the patient‟s consent could, under civil law, be accused of committing assault and or battery. (Gajos 1998)
How do we define reasonableness?
Reasonableness is: a) No more than necessary to accomplish the object for which it is allowed (not for punishment, retaliation etc). In proportion to the harm which is threatened - the greater the danger the greater the force is considered reasonable.
b)
The law in some circumstances takes into consideration that the defender may only have a brief moment to decide their actions.
Any use of force must be …
Proportionate Legal Accountable Necessary
OBSERVER GUIDELINES FOR ROLE-PLAYS
make written notes
pay attention non-verbal communication between counsellor and client
record helpful/unhelpful interventions and what happened as a result
Be prepared for the counsellor in the role-play to stop at any time and ask you for support/suggestions.