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Illness Management and the Promotion of Recovery

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					  FORUM OF CANADIAN OMBUDSMAN
 3rd Biennial Conference: Montréal 2007




Understanding and Responding
    to Difficult Behaviours

                    Warren Steiner MD, FRCP(C)
                    Psychiatrist-in-Chief
                    McGill University Health Centre
   What is an "Ombudsman"?

“An ombudsman is an independent, objective
investigator of people's complaints against
government agencies and other organizations, both
public and private sectors. After a fair, thorough
review, the ombudsman decides if the complaint is
justified and makes recommendations to the
organization in order to resolve the problem.”

           Forum of Canadian Ombudsman website
   What is an "Ombudsman"?

“An ombudsman is an independent, objective
investigator of people's complaints against
government agencies and other organizations, both
public and private sectors. After a fair, thorough
review, the ombudsman decides if the complaint is
justified and makes recommendations to the
organization in order to resolve the problem.”

           Forum of Canadian Ombudsman website
   What are difficult behaviours?

 Aggression:
     yelling, name-calling, sarcasm, mocking,
      threats, belittling, intimidating
 Irrational thinking:
     misinterpretation, distortion, paranoia
 Disorganisation:
     confusion, repetition, changing stories
Understanding Difficult Behaviours
   Origins of difficult behaviours


 Predisposing factors

 Precipitating factors

 Perpetuating factors
        Predisposing factors


 Personality traits or disorders

 Psychiatric illness

 Organisational traits
   Personality Traits or Disorders

 Paranoid: distrust and suspicion
Paranoid
   Personality Traits or Disorders

 Paranoid: distrust and suspicion
 Antisocial: disregard for the rights of others
Antisocial
   Personality Traits or Disorders

 Paranoid: distrust and suspicion
 Antisocial: disregard for the rights of others
 Borderline: impulsivity and instability
Borderline
   Personality Traits or Disorders

 Paranoid: distrust and suspicion
 Antisocial: disregard for the rights of others
 Borderline: impulsivity and instability
 Narcissistic: grandiosity, lack of empathy
Narcissistic
   Personality Traits or Disorders

 Paranoid: distrust and suspicion
 Antisocial: disregard for the rights of others
 Borderline: impulsivity and instability
 Narcissistic: grandiosity, lack of empathy
 Histrionic: attention seeking, overemotional
Histrionic
          Psychiatric illness


 Anxiety Disorders
 Psychotic Illness

 Substance Abuse
       Organisational traits


 Overly bureaucratic
 Non-responsive

 Defensive
            Precipitating factors

 Personal or professional crisis
      perceived threat

      psychological safety

 Repeated establishment-specific situation
      specific individual

      specific barrier
          Perpetuating factors


 Organisational traits:
     Overly bureaucratic

     Non-responsive to concerns

     Defensive
       Perpetuating behaviours

 Organisational behaviours

     Rewarding bad behaviours

     Reluctance to set limits

     Reluctance to address organisational factors
Responding to Difficult Behaviours
        Think at the meta level

 Go beyond the complaint
     process rather than content

 Recognize the behaviour as abusive

 Try to understanding the origin
     Predisposing, precipitating and perpetuating
                Limit setting

 Internal discussion
     Why am I an ombudsman?

     What are my own limits?

     What am I willing to tolerate?

     Are my limits reasonable?
                    Limit setting

 External discussion
     Explain the limits: what do you expect

     Explain the consequences

     Be consistent

     Be flexible
    Rewarding the behaviour

 Special attention

 Special treatment
    Is it ever OK to say no?

Young woman with an attention-seeking,
unstable personality who demanded treatment
but refused what was offered. She stalked both
the first and second doctor who attempted to
treat her in individual therapy, was abusive and
threatening. Alternative treatment in group
therapy was arranged but she threatened the
therapist, broke furniture in the office and
stalked other group members.
     Team-based responses


 Force a process discussion
 Reduce individual “blind-spots”
 Reduce misinterpretations
 Reduce personalized responses
 Reinforce limits
 Reassure
                The Team

 Ombudsman
 Expert resources
     Mental health
     Legal
     Security
     Human resources
     Senior management
       When to use the team


 Psychological safety: respect your instincts
 Is the complainant seeking resolution or
  conflict?
 Overly personalized situation
 Repeated distortions and misunderstandings
 Know what you don’t know

				
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posted:4/24/2011
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