Guiding your responses and controlling your reactions in tense situations.
We will discuss and share
examples of:
1. The advantages and limitations
of this training.
2. The definitions and outcomes of
anger;
3. Our reactions, both positive and
negative, to anger and strong
emotions and how to encourage
our positive responses;
4. The stages of crisis development, what to look for and
how to respond;
5. The verbal escalation continuum, what to look for and
what to say;
6. Nonverbal communication and how to present ourselves
in a way that will reduce emotion and encourage
reasoning; and
7. Engaging in joint problem solving with the concerned
parties.
What this training will and won’t provide
1.
2.
It promotes consistency and uniformity
when working with people. This will help us
be more predictable and thoughtful.
It will give us some ideas and insights into
why things may be happening. This will help
us to prevent some problems before they
occur and others from getting worse. It will
also help us to feel and show empathy for
the other person.
3.
4.
5.
It will help us to communicate more
effectively and consistently, especially
during emotionally charged events. If we do
this we may be able to stop a small problem
from escalating into a larger one.
It can enhance the delivery of services to our
patients and their families. It helps us to
better identify and meet their needs.
It provides a structured approach to
problem solving.
1.
2.
3.
4.
It will not prevent/stop all incidents;
It will not provide all of the answers;
It will not change the people we interact
with; and
It will not make us experts.
REMEMBER: Unfortunately, there are no guarantees when
working with people.
Why? Because empathy comes easier with understanding

According to the Random
House Dictionary of the
English Language
(Unabridged Edition)
Anger is . . . a strong
feeling of displeasure and
belligerence aroused by
real or supposed wrong.

The clinical description of
anger is much broader. It is
described as a state of
heightened activation or
arousal of the autonomic
nervous system that is
fueled by our cognitive
interpretations (Conscious
and subconscious).


We all have different things
that push our buttons. What
triggers your anger response?
What has or would trigger
your response in situations
like our patients and their
families face?

The Angry I’s from Mark Gorkin’s The Four Faces
of Anger:
 You have a palpable sense of:
▪ Injustice
▪ Injury
▪ Invasion
▪ Intention
INJUSTICE:
 A rule of conduct, a cherished
belief or instrumental goal is
being threatened or abused;
you see yourself (also others
with whom you are
psychologically dependent or
connected) as a victim of an
injustice, unfairness or
disloyalty.
INJURY:
 You feel disrespected,
discarded or ignored;
there's a sense of insult
and humiliation along
with injury - often
psychological, at times
also physical.
INVASION:
 Your freedom, autonomy,
boundary and personal space
are perceived to be
constricted, disrupted or
violated; your identity and
bodily and/or psychological
integrity are being
threatened or attacked.
INTENTION:
 There is an energy and determination to do
something about the aforementioned
injustices, injuries and invasions; you are
ready - reflexively and/or purposefully - to
challenge the status quo. When it goes from
internal to external.
No, but it certainly can be. So let’s set some
criteria so we can better describe it and
categorize it. Mark Gorkin, in Anger or
Aggression: Confronting the Passionate Edge
(1986) identified these four:
1.
2.
3.
4.
Purposeful
Spontaneous
Constructive
Destructive

Purposeful - When anger expression is
intentional, with a significant degree of
consideration or calculation; there is also a
significant degree of self-control.

Spontaneous - When anger expression is
immediate with little contemplation or
planning; there is little to moderate selfcontrol.

Constructive - When anger expression affirms and
acknowledges one's integrity and boundary
without objectively intending to threaten or violate
another's integrity or appropriate boundary.

Destructive - When the expression of anger
defensively projects and rigidly fortifies one's
identity and boundary by threatening or violating
another's integrity and appropriate boundary
(Whether the intention is conscious or not).
What do these criteria produce when combined?
Constructive
Destructive
Purposeful
Assertion
Hostility
Spontaneous
Passion
Rage
THE LEVEL OF EMOTION
 As the level of emotion
goes up; reasoning ability
goes down and when
that happens
communication breaks
down too.
Yes
 But first we need to be
calm and reasonable
ourselves. And that’s not
always easy, given our
natural reactions to the
strong emotions of
others. So what do we
do?
You can’t help others if you can’t control yourself

As we have already discussed when emotions
are high, reasoning suffers and also, what we
do can affect how it will proceed for us. Our
reactions matter! This is referred to as the
Reciprocal Reaction.
Low
High
High
Low

It is based on the simple
concept of action 
reaction. What you say and
do affects the behavior of
others and vice versa. In this
application it involves
consciously monitoring
yourself and getting
involved in order to defuse
an emotional situation.

How was anger expressed
in your family growing up?

How do you express it
now?

How does your experience
affect how you respond to
anger now?

The Fight or Flight Response

What is it? First described by
Walter Bradford Cannon The theory states that we
react to threats with a general
discharge of the sympathetic
nervous system, priming us
for fighting or fleeing.
1.
Freeze
 Inaction, inability to react to a
situation. Example: Stage fright
2.
Overreact
 Rationally – Misperceive
situation, make it worse than it
really is.
 Sensorimotor – Motor skills
don’t function normally.
3.
Inappropriate Response
 Verbally – Saying things that
are not pertinent to the
circumstances, not helpful, or
even damaging to the situation.
 Physically – Slamming, shoving,
throwing something
intentionally or unintentionally.
1.
Increase in Sensory Acuity
 Special alertness or sharpening of your
senses takes place.
2.
Decrease in Reaction Time
 We respond more quickly to
circumstances than normally.
3.
Increase in Speed and Strength
 Hormones released into our
bloodstream increase these abilities.
1.
Understand what about these
situations makes us fearful or
anxious.
2.
Learn what to do when such
situations arise.
3.
Use a team approach. Not being
the only one in the situation
helps.
4.
Know what to do in case of an
emergency.

Staying cool and calm is important and we need
to find techniques that work for us. Some of
these techniques are:
 Count to ten;
 Don’t personalize the person’s reaction;
 Controlled breathing;
 Positive self-talk (I am O.K., I can do this);
 Empathize – Walk in their shoes;
 Here them out, really listen; or
 Realize that the only person you can truly control is you.
What to look for and how to respond to them
1
2
3

Due to the nature of these situations, it is vital
that you stay calm and proceed with a plan. This
information will help you to respond
appropriately to the individual given their
current emotional state.

Even more important is the fact that crisis
moments don’t just sprout into being; there are
almost always warning signs that let you know
an individual’s behavior is escalating. The earlier
you intervene the better.
Crisis Stages
4
1. Anxiety
3
2
4. Tension
Reduction
Crisis
Development
2. Defensive
1
0
1. Anxiety
3. Acting
Out
2. Defensive
3. Acting Out
4. Tension
Reduction

Anxiety: An observable
and unusual change in
behavior. This may mean
an increase or a decrease
in activity.

In your setting, what
would you look for?

Your Response: Be
empathetic; convey to the
individual that you know he
or she is anxious and that
you would like to help
alleviate it.

What might you say?

Defensive: His or her emotional
level is increasing and rationality
is decreasing. He or she may
begin challenging you or the
authority you represent and
become belligerent.

There are verbal and nonverbal
cues that he/she is losing
control. What are they?

Your Response: Provide
guidance, be directive. Take
control of the escalating
situation and set limits. Focus
on what you can do and what
they should do.

What might you say?

Acting Out: The person
has lost control of
his/her behavior and
can be verbal and/or
physically acting out.
Not usually capable of
reasoning at this point.

Your Response: Make
sure that you and those
around you are safe and
activate your
emergency procedures
as directed for your
location. Request
assistance as needed.

Tension Reduction: After
an episode subsides. The
emotion fades, the
individual regains
rationality and in many
cases realizes he or she has
done something
inappropriate.

Your Response:
Reconnection and problem
solving. Communicate with
the person as they calm
down. They look to “make
amends” this affords an
opportunity to effect positive
growth.

What might you say here?
What to look for and what to say

Now we will dig deeper and look specifically
at verbal escalation as it begins in stage 2.
This is the crisis level we are usually
confronted with on the job. We’ll explore
the action  reaction steps so we can
respond more quickly, effectively, and
hopefully, move things towards a positive
outcome.

Questioning:
 Information Seeking – A
rational question seeking
a rational response.
 Question Authority –
Power struggle –
evasiveness.

Intervention:
 Rational response
 Stay on topic ,focus on the
issue at hand and what
can be done about it.

How would you say it?

Refusal:
 Non-compliance. Slight loss of rationalization.

Intervention: Set Limits (simple
negotiations)
If you do
this, this
can happen
If not, then
this will
happen.

Release:
 Acting out, emotional
outburst, loss of
rationality. Venting,
screaming, swearing. High
energy output, no focus.

Intervention:
 If possible, allow the person to vent.
 Remove audience or individual from
area.
 When individual starts to quiet,
state directives that are nonthreatening. Tone should be one of
understanding and reason.
 Be ready to enforce any limits you
impose.
Making sure that the message you’re sending is the message they’re
receiving!




We will define what communication is and
discuss its components;
Discuss why nonverbal communication is a
critical consideration when communicating;
Identify how to use nonverbal methods to
help communicate more effectively with
persons in emotional situations; and
Review and apply those nonverbal
techniques.

How would you define it?

Communication is a two or
more way, dynamic,
interactive process of
information exchange. It is
multi-level.

The more levels used, the
more likely the information is
to be received/understood as
sent.
7% of message pertaining
to feelings and attitudes is
in the words that are
spoken.
 38% of message pertaining
to feelings and attitudes is
paralinguistic (the way that
the words are said).
 55% of message pertaining
to feelings and attitudes is
in facial expression.

Albert Mehrabian, PhD: Professor Emeritus of Psychology, UCLA
7%
55%
38%
Spoken Words
Paralinguistic
Facial Expression & Body Language



15% of feelings and attitudes
is in the words that are
spoken.
85% of feelings and attitudes
is paralinguistic (the way that
the words are said). (From
38%  85%).
0% of feelings and attitudes
is in facial expression (From
55%  0%).
Deborah Edwards, PhD, Office of Information Technologies, University of Mass.
0%
15%
85%
Spoken Words
Paralinguistic
Facial Expression & Body Language
Considering this, just imagine the challenges we face with email!

Once we have figured out the words we need
to say, just saying them isn’t enough. If our
body and/or voice is sending a different
message it can confuse or even contradict
what we are trying to communicate. Body
language can also effect emotion.

As a wise friend of mine once said, “It doesn’t
matter what you said, it’s what they heard.”

There are three components to
consider in nonverbal
communication when
addressing an emotional
situation:
 Personal Space
 Body Posture and Movement
 Para-verbal Communication

Let’s examine the following nonverbal
behaviors to determine:
1. Is the person’s response to the interaction
learned or instinctive (Why is that important?)
2. Does the action likely increase emotion/anxiety
or promote reasoning/allow and encourage the
person to be calm?
Close (< 18”)
Normal (18” – 36”)
Far (> 36”)
X
X
X
Action
Learned
Response
Instinctive
Response
Side
X
Front
X
Rear
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Instinctive
Response
Above
X
Level/Equal
X
Below*
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Instinctive
Response
No Eye Contact
X
Staring
X
Neutral/Blinking
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Instinctive
Response
More/Bigger
X
Less/Smaller
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Apathetic/Sleepy
X
Alert/Engaged
X
Jumpy/Anxious
Instinctive
Response
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Slouching/Leaning Away
X
Relaxed, but Attentive
X
Appear Rigid or Stiff
Instinctive
Response
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Instinctive
Response
Volume – Loud
X
Volume - Moderate
X
Volume – Soft*
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Instinctive
Response
Tone – High Pitch
X
Tone – Moderate Pitch
X
Tone – Low Pitch
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Instinctive
Response
Sharp/Halting
X
Flowing
X
Increases
Emotion
Promotes
Reasoning
Action
Learned
Response
Instinctive
Response
Slow
X
Moderate
X
Fast
X
Increases
Emotion
Promotes
Reasoning
What is the most “non-threatening” approach?
1.
2.
3.
4.
5.
Personal Space
Body Juxtaposition
Height Relationship
Eye Contact
Gestures
6.
7.
8.
Energy Level
Posture
Para-verbal
Communication
a.Volume
b.Pitch
c.Inflection
d.Rate of Speech
Reviewing the key concepts presented

As was said before, due to the nature of these
situations it is vital that you stay calm and
proceed with a plan. Crisis moments don’t
just happen; there are almost always warning
signs that provide an opportunity to
intervene before a crisis occurs.

By following these tips, you can often
intervene before the crisis becomes
problematic.
1.
BE AWARE: Remember the
signs to watch out for when
someone is becoming anxious
or otherwise more emotional
such as:
▪ An observable and unusual change or
increase in behavior; or
▪ He or she may begin challenging you
or the authority you represent and
become belligerent.
2.
BE EMPATHETIC: Try not to
judge or discount the feelings
of others. Whether or not you
think their feelings are
justified, those feelings are
real to the other person. Pay
attention to them.
3.
CLARIFY MESSAGES:
Listen for the person’s
real message. What are
the feelings behind the
facts? Ask reflective
questions and use both
silence and restatements.
4.
RESPECT PERSONAL
SPACE: Stand at least
1.5 to 3 feet from an
acting-out person.
Invading personal space
tends to increase the
individual’s anxiety and
may lead to acting-out
behavior.
5.
BE AWARE OF YOUR
BODY POSITION:
Standing eye-to-eye and
toe-to-toe with a person
sends a challenging
message. Standing about 3’
away and at an angle off to
the side is less likely to
escalate the individual.
6.
IGNORE CHALLENGING
QUESTIONS: When a
person challenges your
authority or a facility policy,
redirect the individual’s
attention to the issue at
hand. Answering
challenging questions often
results in a power struggle.
Power struggles are a
“Lose – Lose”
7.
PERMIT VERBAL VENTING
WHEN POSSIBLE: Allow
the individual to release as
much energy as possible by
venting verbally. If you
cannot allow this, state
directives and reasonable
limits during lulls in the
venting process.
8.
SET AND ENFORCE
REASONABLE LIMITS: If the
person becomes belligerent,
defensive, or disruptive, state
limits and directives clearly and
concisely. When setting limits,
offer choices and consequences to
the acting-out individual. Of
course never promise any
consequence you can’t deliver on.
9.
KEEP YOUR NONVERBAL
CUES NONTHREATENING:
The more an individual loses
control, the less that individual
listens to your actual words.
More attention is paid to your
nonverbal communication. Be
aware of your gestures, facial
expressions, movements, and
tone of voice.
10. AVOID OVERREACTING:
Remain calm, rational, and
professional. Your
response will directly
affect the person’s
behavior.
11.
ASSUME THE PATIENT/
FAMILY MEMBER HAS A
RIGHT TO BE ANGRY: Don’t
use statements that minimize
their problems or their
feelings. “Apologize” and
focus on what you can do for
them, not what you can’t do.
Now that things have calmed down, where do we go from here?
Consider the Cost of an Upset “Customer”
1. Average business doesn’t hear from 96% of
unhappy customers.
2. For every one complaint received, there are 24
people with unvoiced problems, six of which are
serious.
3. >= 90% who are dissatisfied with the service they
receive will not come back.
4. Of those who complain, 50% - 70% will do
business again if complaint is resolved. 95% will
return if resolved quickly.
5. Average customer with a complaint tells 9 to 10
people, 13% tell more than 20 people.
6. Those who have complained and had resolution
tell five people.

Let’s take a moment to
address the single most
popular false idea about
customer service. It’s a great
slogan, credited to H. Gordon
Selfridge, “ The customer is
always right.” Unfortunately,
it’s wrong and misleading.

Clearly, they are not always right.
 They may make unreasonable
requests;
 Have unreasonable expectations;
 Perhaps even play fast and loose
with the truth; and
 They may not even understand how
your services operate and what you
can and can’t do for them.

Practically speaking, you
can’t operate under the
assumption that the
customer is always right
because you are not able to
give every customer what
he or she wants.

Here are two short phrases that set the tone for
how should we treat our patients and family
members.
1.
The patient/family member always deserves to be
treated as if he or she is important and his or her
opinions, needs, and wants are worth your
attention.
2. The patient/family member deserves to receive the
maximum effort of those serving him or her, even
when his or her expectations, wants, and needs may
be impractical.

The implications for customer service are simple:
1. The individual has other important wants and needs besides
what was requested that you likely can meet;
2. Even where you can’t do what the individual asks, you can
contribute to the individual’s positive impression about how
he or she is treated;
3. We focus not only on what we provide, but on how we
provide it. That’s the key to realistic and excellent service.
Now let’s get on with the problem solving.
1.
Listen actively and confirm your
understanding of the problem
expressed.
2.
Problem solve together, find
any solution that can work for
the individual and the
organization.
3.
Discuss possible options and
offer a choice if at all possible.
3.
Research and/or Reach
Out; don’t rely solely on
what you already know.
There may be additional
options or supports
available.
4.
Resolve the situation if you
can. If not, try to bring in
someone who can.

In so far as it is up to you,
always keep the discussion
POSITIVE!
 Always tell the person what
you can do, not what you can’t
do.
 Use positive statements and
keep your voice and body
language neutral/positive.
 If you cannot do what the
individual is asking, first
apologize and then explain
why.
 If at all possible, offer an
alternative if you cannot
meet their original need.

You will need to determine who
is best suited to address the
patient’s questions and
concerns and hand them off if
necessary.

For example, someone with
particular expertise or authority
such as your manager could be
contacted/brought in.

Some problems will result in
complaints, which generally must
be handled in accordance with
policies and procedures.

But often times we have the
chance to fix the problems or
suggest a solution before it
escalates further. Remember, the
earlier we intervene, the less
upset the patient will likely be.

What questions,
concerns, or situations
would you like to
discuss?
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Responding to Angry Patients and Upset Family Members