Dealing with Difficult

Behavior

Mamta Gautam MD, MBA, FRCPC, CPDC, CCPE

Objectives

1. What is disruptive behavior?

2. Why does it occur?

3. How can we best manage it?

Disruptive Behaviors

• Incivility, acts of disregard, rudeness

• Personal and unprofessional verbal attacks

• Impertinent and inappropriate comments or in written form

• Sexual harassment of staff, peers, patients

• Intimidating, belittling, non-constructive criticism

• Requiring unnecessarily burdensome activities of staff, unrelated to work to be done

• Public criticism of colleagues, dept, hospital

Bullying

• a form of aggression, “the assertion of power

through aggression”

• incivility that is pervasive and ongoing; a

pattern of behaviour

• intended to intimidate, harm, offend, degrade

or humiliate a particular person or group of

people

2008 Crisis Prevention Institute Inc.

Occasional outbursts can be normal

responses to stress at home or at

work

This is not our focus.

Possible Causes

• Anger in Grief and Loss

• Stress and Burnout

• Substance Abuse

• Psychiatric Disorders – depression, anxiety,

manic episodes, obsessive-compulsive

behaviors

• Personality Disorders – antisocial,

narcissistic, histrionic

Anger is always a

Secondary Emotion.

Identify what is

underlying it.

Remember that we can appear quite

intimidating.

Anger in Grief

• Anger is normal part of the Grief Reaction

• Expect it.

• Do not personalize.

• Allow it.

• Help the person identify the loss, and grieve

it.

Ten Types of Personality Disorders

• Cluster A: Odd, Eccentric, socially awkward

• Paranoid

• Schizoid

• Schizotypal

• Cluster B: Dramatic, emotional

• Antisocial

• Histrionic

• Narcissistic

• Borderline

• Cluster C: Anxious, fearful

– Avoidant

– Dependant

– Obsessive Compulsive

Cluster B Personality Disorders

• 1-3% of adult males

• 0.5-1% adult females

• Some cultures encourage and reward such

characteristics.

• Seek out and promote this – high achievers,

charming, good for business

Common Characteristics

• Lack remorse or guilt

• Superficial charm

• Grandiose self-worth

• Impulsive, spontaneous

• Prone to boredom

• Manipulative, lying, splitting

• Highly functioning and successful

People with a Personality Disorder

don’t know they have one.

View their symptoms as strengths!

People with a Personality Disorder do not

behave consistently…

Or do they?

Three Main Features

1. Lack insight, accept no responsibility

2. Projection

3. Splitting

Our Usual Responses

Want to be nice, understanding, avoid conflicts, positive and hopeful

• Let behavior go - deny

• Look the other way - minimize

• Hope it stops - rationalize

• Avoid direct discussion

• Become frustrated

• Eventually, leads to confrontation

Self Awareness

• Identify past incidents when others were

angry.

• What is your usual response to anger?

• Understand your own anger before you

can deal with someone else’s anger.

Why is it difficult to address?

• Makes us uncomfortable

• People tend to avoid conflict

• Feel disloyal to colleague

• Feel won’t be believed or heard, have no

power

• Worry about burden of proof, liability

• Fear of reprisals

Why should we address it?

• Costs to the person

• Costs to their family

• Costs to the coworkers

• Costs to the organization

• Costs both emotional and financial

Key points

• You can only change your own behavior.

However, you can create conditions which

can encourage others to make different,

more effective behavioural choices.

• Lack of insight can contribute to poor

behavioural choices

• Feedback creates conditions for personal

reflection and change

At organizational level

• Ensure that your department has:

– Clearly articulated cultural values regarding

communication, respect, professionalism

– Zero tolerance policy for disruptive behavior

– RCPSC Policy on Harassment and Intimidation

– Consider visual signs and reminders

“What you permit, you promote.”

At individual level

• Intent: Positive, compassionate

• Timely: Intervene early

• Privacy: Set limits with the person directly, privately

• Address each incident specifically, with suggestions

for improvement. Focus on behaviors and facts,

not people and interpretations

• Focus on clear expectations for conduct

• Ask them to tell you so you know they heard it

• Expect and prepare to deal with their anger

Managing Your Own Anger

• Acknowledge it - Every feeling is OK; it’s how

we express it that is/not OK.

• Write out feelings - use the Four Letter

Technique.

• Pick the fights you want to fight.

• Relax, stay calm.

Consider in a Confrontation

• Before: If. Use Rule of Thirds.

If so, Why?

• During: Who, What, When, Where,

How?

• After Possible Outcomes?

Avoid CLM’s.

Conflict Management is easy,

until you get ANGRY.

“Anger is when the tongue works faster than the mind.”

The best way to take the

wind out of someone’s sails

is to

AGREE with them.

Managing Anger from Others

MY FOUR A’S:

1. Admit, agree

2. Acknowledge

3. Apologize

4. Act

Conflict Resolution

Four Key Steps:

1. Define your needs.

2. State your needs.

3. Listen to the other person state their needs.

4. Negotiate a compromise.

CONFLICT RESOLUTION

• Decide on your “Bottom Line”

• Be specific and direct. Use documented facts to support your views.

• Use I/Me Statements

• Broken Record. “Yes…and” bottom line

• Give constructive suggestions, not just complaints.

• Don’t get stuck on Solutions; focus on Needs.

• You do not deserve to be yelled at.

• Say:

“Stop. I do not like to be yelled at.”

“I will discuss this later / in private.

• If continues later, repeat as above.

The Bully

• enjoys hurting people and making them cry - not want a productive relationship.

• becomes a bully because others freeze at the thought of confronting them.

• will trivialize your concerns.

• needs to be called on their behavior:

“I beg your pardon...That sounds like an insult, did you mean it that way?”

• Name the behavior, tell them you do not like it, tell them to stop.

Setting Limits

• Acknowledge : “It’s clear that...”

• Commit Involvement : “I’ll help you sort it out”. This is optional.

• Describe: “Words like...When I get told that..”

• Effect: “..I get defensive...I shut down...I can’t hear what you’re telling me”.

• Specified/Preferred Scenario: “I want you to slow down and tell me what you want...”

• Consequence: Mutual, positive.“That way, we can work together to solve this...sort it out”.

Don’t give away the control over how

you are going to feel that day!