Managing Challenging Behaviours of Family Members & Persons Who Cause Harm PDF

Managing Challenging Behaviours of Family Members and Persons who Cause Harm (PCH) In the context of vulnerable adult protection Day 1 1 No portion of this d...

Managing Challenging Behaviours of Family Members and Persons who Cause Harm (PCH) In the context of vulnerable adult protection Day 1 1 No portion of this document is to be used, reproduced or circulated without written permission from APS  CONTENT Day 1 Day 2 Day 3 1. Learning Outcomes 1. Pre-Engagement 1. Recap 2. Ice-breaker Preparations 2. Role-Play 3. Statutory Powers for 2. Effective Practices Effective Protection Communication Skills for Active Engagement 3. Self-Care 4. Understanding Challenging Behaviours 3. Assertive 4. Assessment Communication 5. Escalation of Behaviours 6. Negotiation as a Way of De-Escalation No portion of this document is to be used, reproduced or circulated without written permission from2 © Tsao Foundation. No unauthorised reproduction. APS (MSF). LEARNING OUTCOMES 1. List signs of escalation. 2. Explain the behavioural change stairway. 3. Apply verbal and non-verbal communication skills to manage challenging behaviours from VAs’ family members. 4. Demonstrate approaches in managing challenging behaviours. 5. Apply self-care strategies to address burnout, secondary traumatic stress and vicarious trauma. No portion of this document is to be used, reproduced or circulated without written permission from3 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  ICE-BREAKER (15MIN) 1. Take a post-it, write your name and 1 key takeaway you would like to achieve from the training. 2. Walk around the room and using your post-it, introduce yourself and share what you hope to takeaway from the training. 3. You should share with at least 2 different people in the room. 4. Paste your post-it on the tree of growth. No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). STATUTORY POWERS FOR EFFECTIVE PROTECTION 5  MANAGING CHALLENGING BEHAVIOURS WITH STATUTORY INTERVENTION  Protective Orders  AP-Only Orders  Restraining Order  Short Committal Order  Exclusion  Extended Committal Order  Non-Access  Specified Production Order  Non-Visitation and Non-  Supervision Order Communication Order  Counselling Order  Expedited  Safety Order  Disposal Order  Interim Order No portion of this document is to be used, reproduced or circulated without written permission from6 © Tsao Foundation. No unauthorised reproduction. APS (MSF). MANAGING CHALLENGING BEHAVIOURS WITH STATUTORY INTERVENTION  Enforcement Powers by the Police  Case worker could inform the Community Police Officers on the case and collaborate with the Police on enforcement matters (e.g. breach of PPO or possible POHA / Penal Code violations)  Visitation Guide on handling of challenging NOK  Case Management Support  Case Management Support by APS/community agencies especially in initial period of placement for management of challenging cases/clients (e.g. arranging for supervised visits if necessary) No portion of this document is to be used, reproduced or circulated without written permission from7 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  Key Principles For VAA Operationalization If a VA lacks mental capacity, A VA, where not lacking mental Duty performed or power the VA’s views (past and capacity, is generally best exercised is for the purpose of present), wishes, feelings, placed to decide how he or protecting the VA from abuse, values and beliefs, where she wishes to live and whether neglect, self-neglect. reasonably ascertainable, must or not to accept assistance. be considered. Regard must be had to whether the purpose for which the duty In all matters relating to the performed or power exercised administration or application of can be achieved in a way that is the VAA, the welfare and best less restrictive of the VA’s interests of the VA must be rights and freedom of the first and paramount action. consideration. No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF).  Practice Principles Protection of VA Client Centric VA’s views are considered In the best interest of the VA Family Supported to be first line of care Encourage involvement Community (e.g. Detect, Befriend, Support) SSAs and relevant Social work intervention agencies Support Services Policy oversight of Vulnerable Adults Act Investigation and Enforcement State Intervene as a last resort in view of intrusive nature No portion of this document is to be used, reproduced or circulated without written permission from9 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  Translating Policy into Practice (Case Study 1) Case Background: A 90-year-old vulnerable adult (VA) suffering from dementia and chronic health conditions was verbally abused by her son, who was her main caregiver, thereby affecting her emotional and psychological well-being. The VA was also made to undergo rigorous and excessive exercises. Collaboration with family and different stakeholders to ensure VA’s well-being and safety  VA’s other children, community partners and the person who caused harm (PCH) were engaged to put in place a safety plan to keep the VA safe at home, while interim Court Orders were passed to support the safety and well-being of the VA at home. State intervention as a last resort  Prior to the referral to Adult Protective Service (APS), the case was managed by a community agency in collaboration with healthcare professionals.  The case was referred to APS when management of the case by the professionals was assessed to be insufficient in keeping the VA safe The characters in the case study have been renamed, with case details modified for training purpose. at home. No portion of this document is to be used, reproduced or circulated without written permission from 10 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  Translating Policy into Practice (Case Study 2) CASE BACKGROUND: A 65-YEAR-OLD VA WITH SCHIZOPHRENIA AND COGNITIVE CHALLENGES EXPERIENCED PHYSICAL, EMOTIONAL AND PSYCHOLOGICAL ABUSE FROM HER 91-YEAR-OLD MOTHER (PCH), DIAGNOSED WITH ORGANIC MOOD DISORDER. DUE TO REPEATED AGGRESSION, IT WAS ASSESSED THAT VA AND PCH LIVING TOGETHER POSED A HIGH RISK TO THE VA, WHO ALSO LACKED SOCIAL SUPPORT AND HAD LIMITED CONTACT WITH HER SIBLINGS. ALTHOUGH THE VA HAD THE MENTAL CAPACITY TO CONSENT TO OUT-OF-HOME PLACEMENT, SHE INITIALLY DECLINED THE OPTION. AS A RESULT, APS SOUGHT COURT ORDER TO RELOCATE VA TO A SAFER ENVIRONMENT. Collaboration with family and different stakeholders to ensure VA’s well-being and safety  Despite limited contact between VA and her siblings, APS had approached the latter to explore the possibility of their involvement in protecting and caring for the VA. However, VA’s siblings shared that they did not wish to be further involved. State intervention as a last resort  Prior to the state intervention, community agencies had worked with the family for years to keep VA safe at home.  There was a Personal Protective Order (PPO) in place to all PCH to participate in interventions and safety planning services provided by community agencies.  However, the recurrence of harm and assessment of the high risk inflicted on the VA The characters in the case study have been renamed, with case details modified for training warranted State involvement to address breaches of the PPO. purpose. No portion of this document is to be used, reproduced or circulated without written permission from 11 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  UNDERSTANDING CHALLENGING BEHAVIOURS No portion of this document is to be used, reproduced or circulated without written permission from 12 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  Go to menti.com and enter the code on the screen. Use a word or phrase to describe what conflict is. No portion of this document is to be used, reproduced or circulated without written permission from 13 © Tsao Foundation. No unauthorised reproduction. APS (MSF). CONFLICT IS DEFINED AS… An active disagreement between people with opposing opinions or principles. https://dictionary.cambridge.or No portion of this document is to be used, reproduced or circulated without written permission from 14 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  Group Activity (5min) In groups of 5, discuss and list common challenging behaviours you face from family members and persons who cause harm. No portion of this document is to be used, reproduced or circulated without written permission from 15 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  ESCALATIONS No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CRISIS DEVELOPMENT MODEL An Integrated Experience Crisis Development/Behaviour Staff Attitudes/Approaches Levels 1. Anxiety / A change in behaviour 1. Supportive / Empathic, non- judgemental approach 2. Defensive / Beginning to lose 2. Directive / Decelerating an rationality escalating behaviour 3. Risk behaviour / Behaviour that 3. Physical intervention / presents an imminent or immediate disengagement and/or holding skills risk to self or others to manage risk behaviour 4. Tension reduction / Decrease in 4. Therapeutic Rapport / Re-establish physical and emotional energy communication No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  VERBAL ESCALATION CONTINUUM No portion of this document is to be used, reproduced or circulated without written permission from 18 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  WHAT YOU MAY OBSERVE Verbal Cues Non-Verbal Cues  Repetitive word use, parroting  Finger pointing or echoing  Violating personal space  Forced or strained speech  Making fists  Nervous laugh or laughing at  Intensive staring inappropriate times  Yelling or screaming  Flushed face  Non-stop use of profanity  Heavy breathing  Refuses eye contact No portion of this document is to be used, reproduced or circulated without written permission from 19 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  Group Activity (20min) 1. In groups of 3, share your experience in an escalating situation when engaging with a family member or PCH. 2. Identify which stage on the verbal escalation continuum the situation had reached. List the verbal and non-verbal cues you had observed. No portion of this document is to be used, reproduced or circulated without written permission from 20 © Tsao Foundation. No unauthorised reproduction. APS (MSF). 15min Break No portion of this document is to be used, reproduced or circulated without written permission from 21 © Tsao Foundation. No unauthorised reproduction. APS (MSF).  NEGOTIATION AS A WAY OF DE-ESCALATION No portion of this document is to be used, reproduced or circulated without written permission22 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  Group Activity (15min) In groups of 5, discuss: 1. What is negotiation? 2. How is negotiation relevant to de- escalation? 3. How does successful negotiation look like? No portion of this document is to be used, reproduced or circulated without written permission from 23 © Tsao Foundation. No unauthorised reproduction. APS (MSF). WHAT IS NEGOTIATION?  Negotiation is the process in which a specific skillset is applied in working persons in crisis towards a peaceful solution.  Negotiation is used in many enforcement agencies as a complement to ground operations to: Defuse crisis situations Guide a subject to end a standoff safely Excerpt from: Harvard, Program on Negotiation No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 24 WHAT IS NEGOTIATION?  Negotiations fail when extensively focused on problem-solving alone  Problem-solving strategies only work after addressing and defusing the subject’s emotional state Image: Munich Massacre, 1972  Modern negotiation techniques take the emotional state into consideration and have been effective in resolving many crisis cases without the need for enforcement response Image: Attica Riots, 1971 Excerpt from: Crisis (hostage) negotiation: current strategies and issues in high-risk conflict resolution No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 25 USES OF NEGOTIATION  Use negotiation techniques in a first responder capacity before resorting to Police intervention  Enhance existing trainings in problem solving and client engagement with negotiation concepts  Better prepared to handle difficult clients and high intensity cases Excerpt from: Modern day hostage (crisis) negotiation: The evolution of an art form within t policing arena No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 26 WHAT NEGOTIATION SKILLS CAN OR CANNOT DO? What Negotiation Skills can do:  Allows an opportunity to reach a resolution amicably without using an enforcement response  Proper negotiation can help you to preserve the long-term relationship with the client, helping future interventions What Negotiation Skills cannot do:  Keep you safe from a physically hostile person that is attacking you  Always help you to resolve situations quickly No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 27 HOW DO WE PERSUADE SOMEONE? How much thought is put into a decision  Understanding persuasion through the lens of the Elaboration Likelihood Model How likely the person is to think about a  There are two main routes to persuasion: decision Central Route Peripheral Route Based on careful and thoughtful Based on “feel” factors such as considerations based on the perceived credibility/attractiveness argument, facts, logic etc and trustworthiness of the source of information Higher level of elaboration needed Lower level Excerpt from: Communication, ofcognition, social elaboration needed and affect (PLE: Emotion) No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 28 28 PERSUASION AND NEGOTIATION  When do people use the central and peripheral route? Central Peripheral When person has mental energy When the person is more tired and capacity to process Long-term engagement Short-term / new engagement  Which route is more effective in negotiation?  What is the mental state of the client?  What information is available to you to convince the client through logic?  How likely is the client to listen to your logical statements? No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 29 UNDERSTANDING THE PROCESS OF NEGOTIATION  Negotiation typically approaches persuasion via the peripheral route  With limited information and the stressful circumstances, clients are more likely to place an emphasis on relations and respond to a peripheral approach compared to a logical approach  This does not mean that responder should not present the facts and reasoning to the client  Responder should place equal emphasis on the development of the relationship with the client and in how the information is delivered Excerpt from: Harvard, Program on No portion of this document is to be Negotiation used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 30 UNDERSTANDING THE PROCESS OF NEGOTIATION No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 31  BEHAVIOURAL CHANGE STAIRWAY Law enforcement uses the Behavioural Change Stairway Model when negotiating with subjects. 5 steps to affecting behavioural change: 1. Active listening: Making sure the client knows you are listening and invested 2. Empathy: Understanding where the client is coming from and their feelings 3. Rapport: Making the client know that you understand – building trust 4. Influence: Exploring a solution 5. Behavioural change Excerpt from: Crisis (hostage) negotiation: current strategies and issues in high-risk conflic How to Negotiate using the FBI’s 5-step Hostage Strategy No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 32 WHAT SUPPORTS BEHAVIOUR CHANGE IN THE NEGOTIATION PROCESS? 1. Effective communication skills 2. Patience & Calm Disposition 3. Respect & Empathy 4. Adaptability 5. Understanding the Power of Time Excerpt from: Harvard, Program on Negotiation No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 33  Class Discussion Why time is a crucial factor in negotiation? No portion of this document is to be used, reproduced or circulated without written permission from APS (M © Tsao Foundation. No unauthorised reproduction. UNDERSTANDING THE IMPORTANCE OF TIME IN NEGOTIATION  The first moments of engagement are the most critical and dangerous  Consider the client’s emotions when you engage them:  Indignance – How can you judge my caregiving?  Defensiveness – I was just doing my part as a caregiver  Apprehension – Will they ever discharge my family member home?  Anger – Who are you to tell me this? Excerpt from: Negotiating in the skies of Hong Kong: The efficacy of the Behavioral Influence Stairway Model (BISM) in suicidal crisis situations; Should we Negotiate with Terrorist Hostage Takers? No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 35 UNDERSTANDING THE IMPORTANCE OF TIME IN NEGOTIATION More time allows for the client to:  Calm down  Reframe their negative emotions  Understand our perspective  Take on a collaborative mindset More time allows for us to:  Build rapport and gather information  Understand client’s concerns & ensure VA’s safety Excerpt from:  Activate extra resources if needed Negotiating in the skies of Hong Kong: The efficacy of the Behavioral Influence Stairway Model (BISM) in suicidal crisis situations Should we Negotiate with Terrorist Hostage Takers? No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 36 UNDERSTANDING THE PROCESS OF NEGOTIATION  Changes in perspective and thoughts are incremental rather than wholesale  Focus on persuading a person in degrees through encouraging slow and small changes  Recognising positive behaviours and changes “I will never This officer seems ok, maybe it’s “Maybe I’m willing to work with the ok to follow the go to FSC” FSC” recommendations No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). 37  Group Activity (20min) 1. Go back to your earlier groups of 3 where you discussed an escalation case and its stage on the verbal escalation continuum. 2. Using the same case, input 3 narratives from the client as he/she progresses on the persuasion continuum. No portion of this document is to be used, reproduced or circulated without written permission from APS38 © Tsao Foundation. No unauthorised reproduction. (MS SUCCESSFUL NEGOTIATION What other factors can increase the chances of success? 1. A positive first impression (presenting credibility & social attractiveness) 2. Mood and emotional state (helping them to calm down through positive communication) Excerpt from: Communication, social cognition, and affect (PLE: Emoti No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 39 © Tsao Foundation. No unauthorised reproduction. 40 Managing Challenging Behaviours of Family Members and Persons who Cause Harm (PCH) In the context of vulnerable adult protection Day 2 41 No portion of this document is to be used, reproduced or circulated without written permission from APS CONTENT 1. Learning Outcomes 2. Recap 3. Pre-Engagement Preparations 4. Effective Communication Skills for Active Engagement 5. Assertive Communication No portion of this document is to be used, reproduced or circulated without written permission 42 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). LEARNING OUTCOMES 1. List signs of escalation. 2. Explain the behavioural change stairway. 3. Apply verbal and non-verbal communication skills to manage challenging behaviours from VAs’ family members. 4. Demonstrate approaches in managing challenging behaviours. 5. Apply self-care strategies to address burnout, secondary traumatic stress and vicarious trauma. No portion of this document is to be used, reproduced or circulated without written permission from43 APS © Tsao Foundation. No unauthorised reproduction. (MSF). RECAP 1. At your table, match the stages of escalation and their descriptions on the verbal escalation continuum. 2. At your table, list examples of verbal and non- verbal cues of escalation. 3. Describe the behaviour change stairway. 4. How is time a crucial factor in negotiation? No portion of this document is to be used, reproduced or circulated without written permission 44 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  PRE-ENGAGEMENT PREPARATIONS No portion of this document is to be used, reproduced or circulated without written permission 45 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  Group Activity (10min) In your groups, discuss how would you prepare yourself to speak to a verbally aggressive next- of-kin (NOK) who is demanding for the VA’s discharge? 46 © Tsao Foundation. No unauthorised reproduction. No portion of this document is to be used, reproduced or circulated without written permission from APS (MSF PREPARING YOURSELF  Before you contact the client, consider the following details:  What is your end-goal for the engagement? (e.g. safe access)  Where do you want to do the engagement? Is it dangerous?  What is the client’s profile? Any risk factors?  Anticipate the client’s potential response and prepare yourself for it  Prepare yourself mentally to receive a negative response from client and maintain your calm  Be aware of your own trigger points and be mindful to not react to them  Be aware of the potential trigger points for clients as well No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). 47  Individual Reflection List your common triggers when engaging with a challenging NOK/PCH. No portion of this document is to be used, reproduced or circulated without written permission from48 © Tsao Foundation. No unauthorised reproduction. APS (MSF). CASE INFORMATION Reason for Engagement: You were called by the nurse in the ward attending to VA, Mdm Sim, informing you that Mdm Sim’s son demanded to discharge Mdm Sim from the NH. He had alleged the nurse of providing inappropriate care to Mdm Sim. Background Info: Mr Simon, Mdm Sim’s son, shares a close relationship with Mdm Sim. Mdm Sim suffers from dementia and was physically abused by his father who was suffering from mental health conditions. Mdm Sim was placed in the NH with consent from Mr Simon as there were no feasible alternatives to keep Mdm Sim safe at home. Mr Simon has been feeling guilty about having to place his mother in a NH, but his hands are tied due to hisNo own © Tsao Foundation. No unauthorised reproduction. family portion of commitments. this document is to be used, reproduced or circulated without written permission fro APS (MSF). 49 GROUP ACTIVITY (10MIN) Discuss how you would prepare for the engagement, considering: 1. Potential risk profiles 2. What information you can gather 3. What would you prioritise in this case (emotions or information?) 4. NOK’s potential triggers No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 50 SELF-INTRODUCTIONS If this is your first time engaging the NOK/PCH, ask how they prefer to be addressed.  Ask the client how they would like to be addressed  This builds rapport and shows that you see them as a person Example “Good day Mr XYZ, my name is ABC and I am a in this Nursing Home. I hear you have some concerns and I hope to be able to find out more and help your family if possible. How should I address you?” No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 51  EFFECTIVE COMMUNICATION SKILLS FOR ACTIVE ENGAGEMENT No portion of this document is to be used, reproduced or circulated without written permission 52 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). WHY EFFECTIVE COMMUNICATION?  To establish rapport and influence behavioural change  To buy more time to allow the client to calm down and rationalize their thought processes  To gather more information or request for support if needed  One way to achieve this is through Excerpt from: Negotiating in the skies of Hong effective communication Kong: The efficacy of the Behavioral Influence Stairway Model (BISM) in suicidal crisis situations No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). 53 SCOPE 1. Effective Communication – non-verbal & verbal communication 2. Finding the hook 3. Common scenarios No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). 54  Quick Quiz Go to menti.com and enter the code on the screen to enter the quiz. No portion of this document is to be used, reproduced or circulated without written permission 55 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). EFFECTIVE COMMUNICATION: NON-VERBAL Type of non- Description verbal communication Facial expressions Our expressions express our emotions and these expressions are universal. Body movement Allows your listener to form perceptions about you. and posture Gestures Help to convey messages, express feelings, and enhance understanding between individuals. Eye contact It is important in maintaining the flow of conversation and for gauging the other person's interest and response. Space Maintain a comfortable physical space. Adapted from https://www.helpguide.org/articles/relationships-communication/nonverbal-communication.htm No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). 56 SOLER FOR NON-VERBAL COMMUNICATIONS Sit at a comfortable angle and distance Open posture with legs and arms uncrossed Lean forward from time to time, look engaged Eye contact should be maintained without staring Retain a relaxed posture Excerpt from: The Skilled Helper: A Problem- Management and Opportunity-Development Approach to Helping No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). 57 EFFECTIVE COMMUNICATION: VERBAL  The aim of verbal communication is to encourage further dialogue, build trust and display empathy  General tips when communicating:  Keep an even and calm pace / tone  Adapt your vocabulary to the client’s level  Speak from an angle of curiosity  Re-affirm client’s positives  Focus your conversation on the NOK/PCH you are engaging, not the VA No portion of this document is to be used, reproduced or circulated without written permission fro © Tsao Foundation. No unauthorised reproduction. APS (MSF). 58 3 KEY ELEMENTS OF EFFECTIVE COMMUNICATION 1. Active listening skills 2. Effective questioning 3. Assertive communication No portion of this document is to be used, reproduced or circulated without written permission from © Tsao Foundation. No unauthorised reproduction. APS (MSF). 59 ACTIVE LISTENING Comprises of: 1. Clarifying 2. Paraphrasing 3. Reflecting 4. Summarising No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 60  Group Activity (10min) In your groups, discuss and present the why, what and how of each component of active listening. Example: 1. What is clarifying? 2. Why is it important to clarify? 3. Give at least 2 examples of how you make clarifications. 61 © Tsao Foundation. No unauthorised reproduction. No portion of this document is to be used, reproduced or circulated without written permission from APS (M ACTIVE LISTENING SKILL: CLARIFYING What: To make something clear, to check understanding of what was communicated to us. Importance: Shows the speaker that we are interested in them and in what they have to say. Examples: “If I understood you correctly, …” “You mentioned..., what do you mean?” “Help me understand what you mean when you said…” Excerpts from: Never Split the Difference. Negotiating as if your life depe Crisis Intervention: Using Active Listening Skills in Negoti No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 62 ACTIVE LISTENING SKILL: PARAPHRASING What: Use your own words to highlight the main essence of what the speaker has shared. Importance: Prevents misunderstanding and makes the speaker feel heard. Examples: “What I’m hearing is…” “It sounds like you…” “In your opinion, …” No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 63 ACTIVE LISTENING SKILL: REFLECTING What: Recognises and verbalizes the speaker’s emotions Importance: Helps speaker feel heard and understood. Examples: ”You sound frustrated.” “Sounds to me you are feeling helpless.” No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 64 ACTIVE LISTENING SKILL: SUMMARISING What: Provide a concise overview of what has been spoken, paying attention to the key points. Importance: Verifies that you understand the speaker and can make communication more efficient. Examples: “From what you have shared, I gathered the key ideas are …” “Thank you for highlighting to me your concerns over…” No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 65 EFFECTIVE QUESTIONING  Watch the video and list the benefits of effective questioning. No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 66 TIPS ON EFFECTIVE QUESTIONING  Use a combination of questions  E.g. open-ended, close-ended, clarifying questions, scaling questions, platform questions, etc.  Be comfortable with silence and allow speaker to think before answering you  Ask one question at a time No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 67 15min Break No portion of this document is to be used, reproduced or circulated without written permission68 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). ASSERTIVE COMMUNICATION No portion of this document is to be used, reproduced or circulated without written permission69 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). ASSERTIVE COMMUNICATION  Striking a balance between permissive and aggressive communication Permissive styles Aggressive Assertive Use overly permissive Words and tone are Use of neutral words too aggressive language Sound unsure of Sound like you are Giving choices and yourself “challenging” them explaining the considerations Seen to ask client for Does not give client Keen to have the client “permission” avenue to speak and share their views seen as ordering them Overly defensive or Aggressive body Neutral body language avoidant body language (e.g. leaning language towards client with clenched fists) No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 70 TIPS ON ASSERTIVE COMMUNICATION  Manage expectations from the start-be direct and honest about what you can and cannot do  Answer questions honestly, but do not offer more details than needed  Be clear on the situation and details of your case plan, the access plan, treatment plan, etc.  Be clear on the non-negotiables and the consequences  For negotiables, actively seek the client’s input, clarifications and concerns. Seek out the middle ground from there Excerpts from: MSF-SDM PFS (Intervention) No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 71 COMMON TRIGGERS FOR CLIENTS  Raising your voice  Asking client to calm down  Stating overtly authoritarian statements  Making promises you cannot keep  Not explaining your decisions  Saying you understand  Not being familiar with the case Excerpts from: Interviews with MSF CPOs ( No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 72  What are some warning signs of escalation? No portion of this document is to be used, reproduced or circulated without written permission73 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). WARNING SIGNS OF ESCALATION  Client is defensive  Provides one-word answers  Aggressive body language, wild gesturing  Raising voice  Change in breathing  Challenges and questions you (e.g. “what do you mean by harm?”)  Begins moving towards you Excerpts from: Interviews with MSF CPOs (202 No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 74 ADDRESSING WARNING SIGNS  Acknowledge their feelings and encourage them to share  Reframe the focus to show that it is the situation and not the person that they are angry about  Be pre-emptive about de-escalation - give them time to calm down  Use simple words  Set limits  Gives choices and outcomes  Be calm and respectful  Keep the messages short and simple  Be reasonable  Examples: Interrupt and redirect; when and then; if and then No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 75 EXAMPLE “I can see that you are upset about this situation, and you feel you are being forced to make choices so suddenly. Why don’t we take some time to pen down your concerns and think about what we could explore to manage this situation better before continuing the discussion?” No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 76  PRACTICE Background Info: Mr Simon, Mdm Sim’s son, shares a close relationship with Mdm Sim. Mdm Sim suffers from dementia and was physically abused by his father who was suffering from mental health conditions. Mdm Sim was placed in the NH with consent from Mr Simon as there were no feasible alternatives to keep Mdm Sim safe at home. Mr Simon has been feeling guilty about having to place his mother in a NH, but his hands are tied due to his own family commitments. Scenario: You were called by the nurse in the ward attending to VA, Mdm Sim, informing you that Mdm Sim’s son demanded to discharge Mdm Sim from the NH. He had accused the nurse of providing inappropriate care to Mdm Sim. As you tried to address Mr Simon’s concerns, he started raising his voice and using profanities. In trios, practice limit setting with Mr Simon. No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 77  MANAGING MENTAL HEALTH CONDITIONS AND SUBSTANCE USE  Globally, cases of aggression that require police intervention typically involve clients with a history of prior mental health conditions or clients under the influence of substance use.  If you know that client has prior history, it is best not to engage them if they are experiencing an episode or have consumed substances.  If client is having an episode upon arrival:  Ask them if they have taken their medication  Use effective communication skills and acknowledge their statements  See if there is a person nearby to assist them  Disengage  Do not attempt to buy-in with their delusions / statements  Do not dismiss their statements or try to rationalize with them No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 78 ADDITIONAL NOTES  Negotiating in the presence of others is not recommended as it reduces the client’s ability to focus and calm down  Explain the situation and disengage if the discussion will not be productive  Sometimes a client is not ready to collaborate, and it is all right to disengage No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 79 © Tsao Foundation. No unauthorised reproduction. 80 Managing Challenging Behaviours of Family Members and Persons who Cause Harm (PCH) In the context of vulnerable adult protection Day 3 81 No portion of this document is to be used, reproduced or circulated without written permission from APS CONTENT 1. Learning Outcomes 2. Recap 3. Role-Play Practices 4. Self-Care Strategies 5. Assessment No portion of this document is to be used, reproduced or circulated without written permission82 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). LEARNING OUTCOMES 1. List signs of escalation. 2. Explain the behavioural change stairway. 3. Apply verbal and non-verbal communication skills to manage challenging behaviours from VAs’ family members. 4. Demonstrate approaches in managing challenging behaviours. 5. Apply self-care strategies to address burnout, secondary traumatic stress and vicarious trauma. No portion of this document is to be used, reproduced or circulated without written permission from83 APS © Tsao Foundation. No unauthorised reproduction. (MSF). RECAP 1. What are the 3 elements of effective communication? 2. What does active listening comprise of? 3. At your table, mix and match the statements according to: a. Permissive communication b. Assertive communication c. Aggressive communication 4. Each table to share an example of limit setting. No portion of this document is to be used, reproduced or circulated without written permission84 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  ROLE PLAY 1 No portion of this document is to be used, reproduced or circulated without written permission85 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  ROLES Negotiator NOK Observer Apply active Act according to Observe listening and the scrip provided. negotiator’s use of assertive May inject active listening communication feelings/verses and assertive when engaging the based on own communication. NOK. experience in Share what the De-escalate the similar situations. negotiator had situation and get done well. the NOK to at least Share one thing calm down for a you would do meaningful differently. conversation. If de-escalation is not possible, to No portion of this document is to be used, reproduced or circulated without written permission86 work on alerting © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CASE BACKGROUND  VA is 63 y/o with intellectual disability, epilepsy and lack mental capacity on personal welfare and finances.  VA was physically abused (forced feeding, severe biting) by her sister (aged 70+).  The sister showed lack of understanding to the VA’s condition and set unrealistic expectations on the VA.  APS applied for a Personal Protection Order (PPO) for the VA against her sister and placed VA in a NH.  Access between VA and her sister was supervised. No portion of this document is to be used, reproduced or circulated without written permission87 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CASE SCENARIO  VA’s sister persistently wrote complain letters about NH and APS to MOH and MSF.  During one of the supervised access sessions, VA’s sister approached you, a nurse of the ward, to feedback on the inadequate care VA was receiving.  As you tried to explain to VA’s sister the processes and standards of care of the NH, you noticed VA’s sister’s change in demeanor. She started frowning and getting impatient, cutting you off at mid-sentences.  Apply active listening and assertive communication skills to de- escalate the situation. No portion of this document is to be used, reproduced or circulated without written permission88 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  ROLE PLAY 2 No portion of this document is to be used, reproduced or circulated without written permission89 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CASE BACKGROUND  VA is 95yo/ M, lacks mental capacity, is fully bed bound, non-communicative, and suffers from diabetes, hyperlipidaemia, anaemia, heart disease, hypertension and other disease.  Family was unable to provide adequate care for VA by daughter (primary caregiver) and other family members. He is assessed have no rehabilitation potential.  Unmet medical needs  Multiple hospital visits  Bedbug infections  The daughter showed lack of understanding to the VA’s medical conditions, continues to ignore medical advice and refuses to be assessed for her caregiving capacity. She believes that VA will return to full functionality if he were to be reintegrated to her care.  As the daughter/ family could not provide alternative care plans and were objecting to OHP for VA, APS obtained relevant Court orders to mandate VA's placement in a nursing home. No portion of this document is to be used, reproduced or circulated without written permission90  Access between VA, VA's wife and daughter is supervised © Tsao Foundation. No unauthorised reproduction. from APSdue (MSF). to daughter's CASE BACKGROUND  PCH is inconsistent in attending access sessions. While supervised, she would default sessions or show up for access on non-access days  PCH would insist on the following during access:  Access to VA's medication list  Demonstration from care team on how they feed and clean VA  Draw curtains during access to prevent care team from observing or hearing interactions  During one of the access sessions, PCH is only arrived 30min prior to the end of the scheduled visit time due to bad weather. She demands that access is extended as she is unable to control the weather or traffic No portion of this document is to be used, reproduced or circulated without written permission91 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CASE SCENARIO  During one of the access sessions, PCH is late for access, arriving only 30min prior to the end of the scheduled session due to bad weather. She demands that access be extended as she is unable to control the weather or traffic.  While supervised access staff can facilitate the extension, NH is unable to as VA is scheduled for his evening cleaning routine.  PCH remains insistent that she will stay to observe how care team attend to VA. Apply negotiation skills to de-escalate the situation. No portion of this document is to be used, reproduced or circulated without written permission92 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). 15min Break No portion of this document is to be used, reproduced or circulated without written permission93 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  ROLE PLAY 3 No portion of this document is to be used, reproduced or circulated without written permission94 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CASE BACKGROUND  VA is 88yo/ F, lack mental capacity, diagnosed with moderate dementia and has cataract and uneven eyesight on both eyes.  VA referred to APS due to physical abuse perpetrated by daughter/ PCH (eg: hit VA's hand, reprimand VA to face the wall, using masking tape to restrict VA's movements, forcing VA to stand in a corner, asking VA to hit herself) and VA's high fall risk  PCH was assessed to be an unsuitable caregiver and there was no safety plan for VA to remain in the community. PCH was agreeable for VA to be placed in a care facility No portion of this document is to be used, reproduced or circulated without written permission95 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CASE SCENARIO  During one of the access sessions, PCH claims that care team broke VA's dentures and she witnessed a nurse administer wrong medication to VA.  PCH is escalated and confronts staff. She alleges that she has picture evidence of wrong medication being administered to staff but is unwilling to show said picture.  She also demands that NH refunds her immediately for VA's broken dentures.  Apply negotiation skills to de-escalate the situation. No portion of this document is to be used, reproduced or circulated without written permission96 © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  SELF-CARE No portion of this document is to be used, reproduced or circulated without written permission97 © Tsao Foundation. No unauthorised reproduction. from APS (MSF). Vicarious Trauma (VT) Secondary Traumatic Stress Changes in the worker’s inner experience, (STS) When helpers hear about the abuse/trauma beliefs and thoughts resulting from long term experiences of clients, there is an emotional exposure and empathic engagement with toll and helpers may themselves experience traumatized clients. PTSD symptoms. Compassion Fatigue (CF) Burnout (BO) “We feel the feelings of our clients. We Emotional exhaustion, depersonalization, experience their fears. We dream their & reduced personal accomplishment. dreams. Eventually, we lose a certain spark of optimism, humor and hope. We Develops as a result of general tire. We aren’t sick, but we aren’t occupational stress and increased ourselves.” workload. © Tsao Foundation. No No portion of this reproduction. unauthorised document is to be used, reproduced or circulated without written permission from APS (MSF).  De- personaliz ation Emotiona l - Feel Exhausti negative, on detached WHAT IS - No - energy Emotionally - detached Emotional from resources family/collea are depleted Reduced gues Prolonged response Personal - cynicism to chronic Accomplish emotional and -ment interpersonal - Evaluate yourself stressors on the job negatively No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF).  VICARIOUS TRAUMA Our reaction as a result of exposure to : Hearing clients’ stories, Dealing with the aftermath of their traumas  Behaviour, thinking, emotional responses We can also develop traumatic stress reactions: Dreaming or constantly thinking about those very stressful/traumatic events Trouble sleeping, nightmares Frequently being reminded about the event Being avoidant Feeling anxious/worried or fearful Feeling depressed, overwhelmed, or hopeless No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). EFFECTS OF VICARIOUS TRAUMA Changes our inner beliefs Safety Trust Esteem Intimacy Control E.g. the world is a cruel place, the weak get trodden on; I am a broken down machine; I have failed; men are the cause of all the violence in the world. I’m ashamed to be male. No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF).  VT: WARNING SIGNS Always exhauste Poor d Disconnec Boundari t/ es numbing Avoidanc Social e VICARIOUS withdraw TRAUMA al Diminish Insensitivi ed self- ty to care violence Anger/ or Cynical Illness injustice https://www.youtube.com/watch?v=tAKPgNZi_as&feature=youtu.be No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). Managing VT, STS and Burnout 1) A personal Barometer and body scan No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF).  Min d Hear ACTIVITY t ….BODY SCAN Bod y No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF).  Managing VT, STS and 2) Boundaries Burnout - With clients - With Colleagues - With stakeholders - With Self thoughts – managing intrusive thoughts - Rituals No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). WHY ARE RITUALS HELPFUL FOR SELF-CARE? No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). WHAT’S YOUR RITUAL? Have a chat with your mate ! No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). Managing VT, STS and Burnout 3) Resources and anchoring No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF).  SELF-CARE AND PREVENTING VT, STS AND BURNOUT: WHAT SUPPORTS RESILIENCE? Family support Spiritual belief Peer support Social resilience competenc connectedn ess e Self esteem Self- efficacy No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). A = AWARENESS  Recognize and identify VT/STS symptoms  Recognize and monitor changes in functioning  Supervision and consultation about the VT/STS  Seek help with your own traumas  Know your triggers No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). B = BALANCE No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). #28 C=COGNITIONS Your thoughts, beliefs, attitudes can block self-care 1. It would be selfish to take time to rest. 2. Others are working around the clock, so should I. 3. Clients’ needs are more important then our own needs. 4. I can contribute the most by working all the time. 5. Only I can connect with this client/family. 6. This all messed up, it’s not going to work. 7. None of my clients see what I am trying to do for them. 8. You’re never able to get anything right in this place. 9. I don’t want to call X because she’s going to yell at me like everyone else doe No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF). C = CONNECTION With your friends With your partner With your family “Hand drawing” No portion of this document is to be used, reproduced or circulated without written permission © Tsao Foundation. No unauthorised reproduction. from APS (MSF). CONNECTION  Make relationships with family and friends a priority  Review/renew your sense of life’s purpose and meaning  Develop a professional connection – professional support network  Remember why you do what you do  Refocus on the rewards of your work No portion of this document is to be used, reproduced or circulated without written permission from APS © Tsao Foundation. No unauthorised reproduction. (MSF).  ASSESSMENT 115 No portion of this document is to be used, reproduced or circulated without written permission from APS (MSF).  References https://dictionary.cambridge.org/ CPI’s Crisis Development Model (2021). Retrieved from https://www.crisisprevention.com/en-gb/Blog/CPI-Crisis-Development-Model Donohew, L., Sypher, H. E. & Tory Higgins, E. (2015). Retrieved from https://www.taylorfrancis.com/books/edit/10.4324/9781315743974/communication-social-cognition-affect- ple-emotion-lewis-donohew-howard-sypher-tory-higgins E. Wertheim. Negotiations and Resolving Conflicts: An Overview. (N.D.) Retrieved from https://www.europarc.org/communication-skills/pdf/Negotiation%20Skills.pdf Grubb, A. R. (2010). Modern day hostage (crisis) negotiation: The evolution of an art form within the policing arena. Aggression and Violent Behaviour 15(5), 341-348 Miller, L. (2005). Hostage Negotiation: Psychological Principles and Practices. International Journal of Emergency Mental Health, Vol. 7(4), 277-298 Thomposon, J. (2013). Hostage and Crisis Negotiators: Nonverbal Communication Basics. Retrieved from https://www.psychologytoday.com/sg/blog/beyond-words/201308/hostage-crisis-negotiators-nonverbal- communication-basics Vechhi, G. M., Van Hasselt, V. B. & Romano, S. J. (2005). Crisis (hostage) negotiation: current strategies and issues in high- risk conflict resolution. Aggression and Violent Behaviour 10 (533-551) Vechhi, G. M., Wong, G. K.H., Wong, P. W.C., Markey, M. A. (2019). Negotiating in the skies of Hong Kong: The efficacy of the Behavioral Influence Stairway Model (BISM) in suicidal crisis situations. Aggression and Violent Behaviour 48 (230-239) Verbal Escalation Continuum. Retrieved from https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.angelo.edu%2Fcontent%2Ffiles%2F27006-verbal- escalation-continuum&psig=AOvVaw156bNDCxyHcd9s0dMpS-PJ&ust=1684994380190000&source=images&cd =vfe&ved=0CBEQ3YkBahcKEwjI99zHo43_AhUAAAAAHQAAAAAQGA No portion of this document is to be used, reproduced or circulated without written permission from APS 116 (MSF).