Liam E. Marshall, PhD

Waypoint Centre for Mental Health Care

& Rockwood Psychological Services

Strategies for Dealing with Challenging

Interpersonal Interactions in a Mental

Health Setting

1

Objectives

• To develop awareness of the possible underlying

causes of the problematic behaviours of others

• To learn possible approaches to dealing with a

difficult situation

• To gain specific skills which will enable the ability

to deal effectively with problematic situations

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3

Possible Causes of Problematic

Interpersonal Interactions

Some of the possible underlying causes

of interpersonal difficulties

Poor coping styles and

skills

Inability to

communicate

effectively

E.g., Inquiry versus

Complaint

Attention seeking

Shame

Physical problems

Personality Disorder,

e.g.,

Psychopathy

Narcissism

Borderline

Low sense of self-

worth

Intimacy deficits

Empathy deficits

Other unmet needs

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Joe Harry Window

5

SELF

OTHERS

SELF &

OTHERS

UNKNOWN

Stages of change

Precontemplation - people who are not intending

to take action in the foreseeable future

Contemplation - people are intending to change

in the near future

Action - people who are making specific overt

modifications in their life styles

Maintenance - people who are working to

prevent relapse ”a stage which is estimated to

last from 6 months to about 5 years"

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Moving through stages of change

• Precontemplation to Contemplation:

– consciousness/awareness raising.

• Contemplation to Action:

– provide information on how to change (e.g., comply with treatment) and support efforts at self-efficacy

• Action to Maintenance:

– Examine and modify future life circumstances to match changes

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Emotional (angry)

Avoidable upsets

• Person feels promises not delivered

• Person feels others have been indifferent,

rude or discourteous

• Person was made to feel stupid or small

• Person feels they are not being listened to

• Person feels their honesty or integrity was

questioned

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Components of a difficult encounter

Situation Issues:

Other Person

Issues Personal Issues

• Language literacy

issues

• Environmental

issues

• Number of people

around

• Purpose of

interaction issues

(e.g., delivering

bad news)

• Angry, defensive,

frightened,

resistant

• Manipulative

• Grieving

• Attention or drug

seeking

• Angry or

defensive

• Fatigue and other

health issues

• Confidence and

personality

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Dealing with a “difficult” person

• Be objective

• Stay focused on your goals

• Recognise the person’s motivations

• Be aware of your own emotional reaction

• Stop and think before you speak

– What am I trying to achieve right now?

– What am I trying to achieve long-term?

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Dealing with a “difficult” person

Take Their Side

• Listen actively

• Agree whenever possible

• Acknowledge their viewpoint

• Offer an apology

• Project confidence

• Express your views without provoking

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Dealing with a “difficult” person

Bridge differences

• Ask open-ended, problem-solving questions

• Ask for the person’s opinion

• Don’t rush them to agree

Make it Hard to Disagree

• Convince rather than threaten

• Keep choices open

• Enlist support from others

• Don’t rush the person to agree with you

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What to do with an angry person -

Immediate responses Goal is to “win” in the long run, not the current conflict

Validate the person’s feelings (collude?)

Gently ask for an underlying cause of the behaviour (e.g.,

“has something changed”)

Ask if there is anything that could be done to solve the

problem, that is possible to do

If you can, offer a non-threatening alternative

Possibly an avoidance strategy for now

Look for something positive in what they are doing and tell

them

Stay positive and solution focussed with the person for as

long as possible

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What to do with an angry person

After person has calmed down

• Review episode and reward them for what

they did well in the situation – may need to be

creative

• Ask what, if anything, he/she could do

differently next time

• If issue still relevant, offer options

• Refer to a specialist, if appropriate

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How to overcome resistance/anger

• Attire & Body Language – appear relaxed

• Vocabulary – appropriate intellectual level

• Collaboration – with person, with others

• Information – reduces anxiety

• Confidence & Reflection - motivates

• Face saving ways to change

• Be patient

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How to overcome resistance/anger

• Accept small steps

• Have an agenda but be flexible

• Give the person some task to do

• Ask for questions

• Allow person to be the expert

• Be responsive: ask for and accept feedback

• Allow person to feel like they have some control over process

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Examples – “Mike” • Diagnosed with narcissistic disorder

• Generally demanding, stubborn, and highly emotional

• Inability to form friendships with other residents who complain

about him to staff

• Was angry and insisting on one-to-one therapy of a particular

style which he claimed had been promised to him

• Approach:

– validated his concerns and empathized with his feelings

– Then asked what style of therapy he wanted; explained

similarities to available treatment.

• Outcome: Calmed and agreed to enter treatment

• Worked on skills in group and developed friendships

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Examples – “Jeff”

• Extreme anger control problems

• In constant conflict with co-patients and staff

• Expresses extreme anger at system

• Had never finished a treatment group

• Felt betrayed by staff and was extremely agitated

• Approach

– Acknowledged feelings of betrayal would be painful

– Asked if he still had confidence in any staff

• Outcome: Finished anger management group and was

generally more cooperative on unit

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“John” - Behaviour tracking

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Behaviourism 101

Negative

punishment

Negative

reinforcement

Stimulus

removed

Positive

punishment

Positive

reinforcement

Stimulus

applied

Behavior

decreases

Behavior

increases

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Punishment

• NOTE: punishment will suppress a

behavior but will not eliminate or weaken it.

• Punishment should only be used to get a

very problematic behavior under control.

• Punishment should only be used with

reinforcement not instead of reinforcement

• Progressively increasing punishment will

result in habituation which will diminish its

effectiveness

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Using reinforcers

Reinforce as soon as possible after the

target behaviour has been performed.

Make it clear what behaviour is being

reinforced

Level of reinforcement should be

proportional to effort made – avoid satiation

Use reinforcement continuously at first, then

intermittently.

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Using reinforcement

• Provide person with opportunities for success.

• What works as a reinforcer may be different for each person.

• Praise as a reinforcer should be specific to the behaviour.

• Reinforce person when they are doing well, not just when they are a problem

• Shaping

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Reinforcing behaviour

• Verbal clarification of the relationship between a behaviour and the delivery of reinforcement increases the effectiveness, as do verbal and physical prompts.

• Bear in mind the level of effort that the behaviour took to perform and make the reinforcer proportional. Satiation can occur if the magnitude of the reinforcer is too great.

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What not to reinforce

• Negative self statements (“I’m hopeless…”).

• Vague or benign contributions (unless

shaping).

• General good behaviour (“You’ve all done

very well today”).

• Agreeing with you (“I’m so glad you now see it

my way”).

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What to reinforce • Statements of responsibility

• Statements of motivation/intention to change

• Self esteem, perspective taking, empathy, concern for

others, etc.

• New skills or attitudes

• Harm reduction

• Achievement of any other prosocial goal

• You may need to reinforce approximations of any

of these goals to shape appropriate behaviour

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Excuse making

Your experiences of Denial?

• Think back to an occasion when you denied

something outright even though you knew you

had really done it.

• Why do we deny it?

• What are we protecting?

• What emotions and thoughts are behind this

decision?

• What might you lose?

• Why not become honest later?

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EXCUSE-MAKING RESEARCH

1. All people lie:

(a) To avoid hurting others

(b) When they feel the truth is threatening

2. What is the possibility of us knowing the truth

particularly when only two people were present

and both have different versions

3. Excuse-making is both psychologically and

physically, beneficial (Dodge, 1993; Schlenker et

al, 2001)

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EXCUSE-MAKING RESEARCH

•When people take full responsibility for failures or negative

actions, they are at risk for depression

•Excuses help to avoid a loss of self-esteem or the experience

of shame, both of which are blocks to effective

engagement in treatment and shame increases criminal

behaviour

•Offenders, of all types, who make excuses for their crimes are

at lower risk to reoffend! (Maruna, 2001, 2004)

•As Hansen pointed out, “Offenders who minimize their

crimes are at least indicating that what they did was

wrong”.

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Empathy

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STAGE MODEL OF EMPATHY

STAGES

1. RECOGNIZE EMOTIONAL STATE OF OTHER

2. PERSPECTIVE TAKING

3. EVOCATION OF AN APPROPRIATE/ SYMPATHETIC EMOTIONAL RESPONSE

4. ATTEMPT TO EASE OTHER’S DISTRESS, WHEN POSSIBLE AND APPROPRIATE

Overwhelmed

by personal

distress

Self-

Soothing

Unempathic

response to

victim

Blocks recognition

of harm

Unempathic

response to

victim

Low self-

esteem

Low self-

esteem

Recognize

harm

Falsely High

self-esteem

Uncaring or hostile toward

victim, or sadistically-

disposed

Unempathic

response to

victim

perspective

taking

Adequate

self-esteem

Recognize

harm

emotional

response

Reparative

action

Empathic

accuracy Sympathy

Empathy

Empathic Process

Proposed Path Model of Empathy Problems Marshall & Marshall, 2011, Journal of Forensic Psychiatry & Psychology

ATTACHMENT SELF-ESTEEM SHAME/GUILT EMPATHY STAGE MODEL

1 2 3 4

Secure Adequate Guilt

Preoccupied Low Shame (Internal)

Fearful Low Shame (Internal & External)

Dismissive Unrealistic High but Shaky

Detachment

TREATMENT OF EMPATHY DEFICITS

1. Emotional recognition

– Recognize emotions in self and others

2. Perspective taking

– Empathy for staff/patients, spouse, any others

3. Appropriate emotional response

– Emotional self-regulation

4. Ease the suffering of others

– How to be helpful to others

– Appropriate boundaries

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Liam E. Marshall, PhD

Waypoint Centre for Mental Health Care

& Rockwood Psychological Services

Strategies for Dealing with Challenging

Interpersonal Interactions in a Mental

Health Setting

37