Want to keep learning?

This content is taken from the University of Birmingham's online course, Dementia: Understanding and Managing Challenging Behaviour. Join the course to learn more.

Skip to 0 minutes and 4 seconds SPEAKER: Welcome to this short presentation on how to reduce and prevent conflict.

Skip to 0 minutes and 10 seconds In this presentation, we will briefly discuss conflict. We’ll look at how aggression progresses, we’ll look at how you may be able to prevent conflict, and what to do if conflict does occur.

Skip to 0 minutes and 26 seconds We will not cover what to do if somebody becomes violent, including how to break free if somebody grabs you, and how to physically restrain someone who has become violent. These require specialist training and should not be attempted if you have not had this training.

Skip to 0 minutes and 44 seconds Interpersonal relationships by their very nature have the potential for conflict. Different people manage this conflict in different ways. Commonly, people avoid or deny the existence of any conflict. Others may become angry, while some try to resolve the conflict by using power or manipulation. We will look at how your actions can prevent or reduce conflict by explaining the basics of de-escalation. Most aggressive incidents follow a similar pattern involving five phases. This is known as the assault cycle. This is based on the idea that everyone has a baseline set of behaviours, which are nonaggressive. The assault cycle begins with a trigger. This is the event that sets off the anger reaction. It could be something obvious, like having an argument with someone.

Skip to 1 minute and 36 seconds It could be something that happened hours or days ago, in which the person has been ruminating on. Or it could be something that seems unimportant to an observer, but is nonetheless a trigger for the person. At this stage, it’s still possible to calm the person down, or for the person to calm himself or herself down. The second phase is escalation, where the body prepares for fight or flight, and the anger increases. Adrenaline builds up, and this can affect the person’s ability to think and act rationally. It’s less likely that the person will calm him or herself down during this stage, but it’s still possible to help them to calm down.

Skip to 2 minutes and 17 seconds The crisis phase is the culmination of the assault cycle, when the person is out of control or physically violent. At this point, they’re unlikely to respond to calming techniques, and it will be difficult to get them to respond rationally. Following the crisis, the person gradually returns to that baseline mood. It can take at least 90 minutes for adrenaline to leave the body. So although the immediate crisis has passed, it’s still possible to reignite the anger. Finally, as the person’s ability to think rationally begins to return, they may feel remorse for what has happened and experience of post-crisis depression, where their mood dips below that baseline before returning to normal.

Skip to 3 minutes and 3 seconds The best way to prevent the assault cycle is to be aware of triggers and avoid them where possible.

Skip to 3 minutes and 11 seconds To prevent a trigger from escalating to a crisis, de-escalation techniques can be used. De-escalation involves the use of verbal and physical expressions of empathy, alliance, and nonconfrontational limit-setting based on respect. Taking a person-centered approach will aid de-escalation by focusing on the person’s perspective, and how relationship with the person can guide the process. The most effective de-escalators are honest, nonjudgmental, and have confidence, a permissive, non-authoritarian manner, and the ability to empathise. As soon as you realise that you’re in a situation that has the potential to escalate, there are a couple of things you can do to prepare yourself. Take a slow, deep breath, breathing into the abdomen. This helps you to remain calm, even if you’re feeling anxious.

Skip to 4 minutes and 7 seconds Remind yourself that you’re going to respond to the situation, not react to it. This means that you’re going to help the person recover from that heightened emotional state without reacting emotionally or becoming defensive or aggressive yourself. You need to remain calm and in control throughout the de-escalation. And deep breathing can help with this, especially if you feel that you’re becoming angry or impatient yourself. Communication isn’t just about what you say. It’s also about how you say it. Communication is made up of three elements. Verbal communication is the words you use. Paraverbal communication is the way you speak. And this includes the tone, pitch, and volume. And finally, non-verbal communication is the way you present yourself.

Skip to 5 minutes and 0 seconds And this includes your facial expressions, eye contact, posture, body language, and proximity. Being aware of all the elements of communication is central to de-escalation. Earlier, we looked at how communication needs to be modified when working with a person with dementia. We’ll now explore in more detail what to do when that person is becoming angry or agitated. As much as 70% of communications is nonverbal So that’s where we will start. If you’re relaxed, it’s easy to project good nonverbal communication. Your facial features should be relaxed, serious, without appearing stone or angry, and attentive, to show that you are listening. Too much eye contact can appear threatening, or challenging, while too little may be interpreted as disinterested.

Skip to 5 minutes and 52 seconds Your posture should be relaxed, but alert. Don’t cross your arms, as this can appear defensive. Keep your hands in front of you in an open position. If you’re standing, have a straight back, with your feet shoulder-width apart. However, it’s best to be at eye-level with the person. So it may be more appropriate to be seated. Imagine how intimidating it feels to have someone standing over you. Keep movement and gestures to a minimum, as excessive gesturing, fidgeting, and pacing can communicate anxiety, thus increasing the person’s own agitation. Finally, try to stay at least two arm lengths away from the individual, as the personal space needed when angry is likely to be much greater than usual.

Skip to 6 minutes and 39 seconds Thinking about verbal communication, it’s always important to be honest. Lying to someone, although maybe you think it might help in the short-term, has the potential to cause further escalation, either now, or in the future, if they realise you’re being dishonest. You can empathise with the feelings the person is experiencing without condoning the behaviour. Be authentic in your communication by making a connection with the person. Really allow yourself to see them, and allow them to see you. Use simple, clear, concise language. Don’t overload the person with information, as this can be confusing for them. Be prepared to repeat what you say. It may not be understood the first, or even the second time.

Skip to 7 minutes and 29 seconds Don’t be afraid of silence. If you ask a question, give the person time to process what you’ve said and formulate a response. Being silent also allows you to really listen to what the person’s saying. It’s important to remember that everyone has their own truth. Instead of trying to bring them from their truth to yours, it’s better to find some common ground. Try to steer the conversation to explore their truth. Even if you don’t agree with what they’re saying, you can acknowledge their experiences. There are no absolute rules for what you should say to a person. But there are also some phrases that can be useful. Try to elicit more information from the person.

Skip to 8 minutes and 10 seconds This shows that you’re interested in their point of view and may also guide in problem-solving. Use phrases such as, “please tell me more about what’s happened”, and “I’d like to see if we can work this out.” Sometimes, you may need to set limits. And this can be done firmly, but fairly. For example, “I understand that you are angry. But shouting at me is not acceptable.” Of equal or even greater importance than the words themselves is the way you say them. When we are anxious or frightened, our voices tend to get high-pitched, tight, and louder. To aid de-escalation, it’s best to speak in a slow, modulated, low tone of voice.

Skip to 8 minutes and 56 seconds If the other person is shouting, don’t raise your voice to be heard over them, but wait until they stopped before speaking quietly. However, ensure that you speak at a volume that can be heard, taking into account any hearing difficulties the person may have. Individuals will often subconsciously mirror the tone, volume, and cadence of another person’s speech, meaning that by talking quietly and calmly, you can influence the person to do the same.

Skip to 9 minutes and 27 seconds Over the past few weeks, we have looked to how life has changed for Peter now that he’s in a care home, and the kind of life he had before. Using this knowledge may help with avoiding anger and aggression by reducing or removing triggers or with de-escalating it by knowing it might help Peter calm down. The more you know about a person, the easier it is to help them. The following clip shows one of Peter’s triggers. [VIDEO PLAYBACK] - –through his feeling back then and– or since then, they’ve really become a corporate Goliath so they no longer feature anything that would highlight [? this in a ?] [? negative way.

Skip to 10 minutes and 2 seconds ?] [END PLAYBACK] Following an incident of anger or aggression, it’s helpful to reflect on what happened. You can think about if the outcome was positive or negative. How did you feel afterwards? How do you think the person felt? Could the incident have been prevented? What did you do well? What could you have done better? Asking yourself a few simple questions may help if a similar situation arises. In this presentation, we’ve looked at how taking a person-centered approach can help to prevent and reduce conflict. To prevent anger and aggression, you need to be aware of potential triggers and reduce or remove them where possible. But sometimes, this won’t be possible, and a person may become angry. When this happens, remain calm.

Skip to 10 minutes and 55 seconds Deep breathing will help with this. Be aware of how you present yourself. And use verbal, paraverbal, and nonverbal skills to de-escalate the situation. Using your knowledge of the person will help to guide the process. And finally, reflect on what happened to help guide you in the future.

The basics of de-escalation

This video provides an overview of de-escalation. An important part of this is both verbal and non-verbal communication.

As you watch the video, consider:

  • If a person with dementia is triggered into an incident of anger or aggression, what can you do?
  • How can you prevent and reduce conflict?

Share your thoughts with your fellow learners in the Comments.

Share this video:

This video is from the free online course:

Dementia: Understanding and Managing Challenging Behaviour

University of Birmingham