Day-to-Day Dos and Don’ts

Defusion is a term for verbal and non-verbal ways of reducing tension. These tips work – they were developed from practice and experience. The more you try these tips the better you will become.The principle is: change ‘acting out to talking out’: try talking things through, rather than acting impulsively.

Here are some practical tips below which we hope will help you with difficult situations and to look after yourself in your care-giving role.

Body language and physical space

Don’t invade defensible space: people like their own bit of territory – their own chair etc.

• Stay an arm’s length away.
• Avoid being in a corner, or cornering the person.
• Always knock on their door.

Get to know signs of rising tension

• rocking
• stuttering
• colouring of the face
• pacing
• hand wringing

Keep neutral body postures.

• Keep hands in sight – showing the palms is a sign of peaceful intentions.
• NO clenched fists, hands on hips, pointing, leaning over people.
• Make eye contact – but don’t stare!
• 90% of communication is non-verbal so SMILE!

If you defuse the situation you are successful. If the person has not lost face, and has kept their pride – then they are successful.Self-awareness is not a vague thing. If you are in a grotty mood don’t pretend you are feeling great, or that it doesn’t matter. Just being aware of your mood can help you make adjustments on how to deal with any given situation.

• Establish a warm environment
• Physically turn up heat (a side effect of some medication can be to feel chilly).
• Sit in a warm place to talk.
• Be sensitive about colour schemes – décor, clothing etc.
• Keep a quiet place for talking or for space to get away.

“Walk don’t run” – apply this in different ways: lower your voice, walk slowly.Count to ten really does work. When first faced with a situation start counting. As you do: check your mood, assess the situation, decide on a first course of action, confirm it to yourself then do it.

You will be more likely to gain control because unwell people are very often frightened people and do not know what will happen next. If you come up with safe solutions the unwell person will develop confidence in you.Use humour. A good one-liner can be worth all the other tips put together.Avoid negative humour like sarcasm, put-downs or jumping to conclusions – one may jump back!

Try to empathise. This means that you are identifying with or feeling for e.g. “This must be very difficult for you’. You can’t always understand how the other person feels, but if you think you do then use it.

Sympathise. This means, “I agree with you.” Someone may be right to show anger or distress – develop this by talking about ways of doing something about it.Ventilation – once someone is talking, let them let off steam, don’t try to stop them. Don’t interrupt and don’t argue with them.Ask open-ended questions. “How did that make you feel?” rather than closed ones like “Did you do that?”

Make general statements of acknowledgement:

• “Lots of people feel like that when they’re ill.”
• You’re not alone in thinking like that.”
• That’s not you that’s the illness.”

Dealing with argumentative / threatening situations

• Split up the antagonists and take one off for a chat or get them both talking to you rather than at each other.
• Sit out a threat or employ a stand-off – NEVER join in a fight. This will be appreciated because you become safe. By setting a limit you reassure.
• Always take threatened violence to an individual seriously. Ask for weapons to be put down NOT handed over. Individuals have different strengths in defusing situations.
• There are natural differences between the sexes. So if your partner is dealing successfully with the situation just be visible; be around to be called on.
• Physical contact – don’t wake someone abruptly or aggressively; this carries a high risk of an equal response. Don’t touch the back of the neck during tension and don’t take a grip on an arm.
• Don’t put up with the unacceptable. Zero tolerance of violence or aggression has to be the rule. Discuss this in a calm setting not when a situation has reached crisis. Set limits and keep to agreed ground rules.
• Know who to call and how to call for help in an emergency. Keep important numbers (e.g. Crisis team), next to the phone or in the phone memory.
• Don’t become involved in an argument. Try to divert the conversation to a subject which is not controversial.
• Develop ways of defusing situations. Make sure that they are appropriate to your family, your personality, or the person who is ill. Apply the solution that fits at the time.
• Discussion after a tense situation. Wait for a cooling off period. Then have a discussion to devise a plan. Always try to have a plan in place that has been agreed by everybody for an emergency or crisis. If you think things through before a problem arises you will be better able to cope and to continue coping.
• Down tools. Accept that your life has changed – at least for as long as your loved one is ill. There may be times when you just have to stop everything, in order to keep yourself or your loved one safe. It won’t hurt to ignore a deadline or be late for something. Take breaks yourself – even if that inconveniences someone – no-one is indispensable! If you become unwell you cannot continue to care. Your health and well-being is crucial too!

Talking to someone with delusions

• Don’t dismiss the delusions. Recognise that these ideas and fears are very real to the person – but show that you do not agree with them. Try, for example, “I don’t believe … is out to get you, but I can see you are really upset about it.“Don’t be obviously alarmed by bizarre words or unfinished sentences etc. Say, “I don’t really understand what that means.” Or remind them what the conversation was about “Remember we were talking about…”
• Don’t let others laugh about the hallucinations or the strange talk.
• Don’t ask the person to try to force the voices to stop.
• Do act calmly.
• Do try to distract the person by involving them in something interesting.
• Try looking for something, chatting or mixing with close friends or family.
• Do give the person space and time if they don’t want to talk.
• Say, “I can see you don’t want to talk now, but I’ll be here if you want to talk later.” Allow them time to recover their thoughts, their composure etc.

Helping someone who self-harms

People injure themselves for many reasons. It may replace emotional distress with physical pain. Many people say that when they cut themselves they experience a release of tension and so they often feel calmer. In a strange way, self-injury may help people feel that they can achieve some degree of control back in their lives.

Self-injury is very often not a suicide attempt, however, people who do self-harm are at a greater risk of suicide than the general population and should never be dismissed as just ‘attention seeking’ or being ‘manipulative’.

Relatives, friends or professionals trying to help the person can find it very stressful, especially when the person does not want to talk about or explain their behaviour.

It is easy to feel ‘shut out’ and just left to pick up the pieces at times of crisis. If someone we care about is deliberately damaging his or herself and not willing to let us help, we can feel isolated and powerless.The person usually has very low self-esteem and poor self- worth and they think that others will see them in the same light and be critical. There are therapies which can be used that have been shown to be effective in breaking the negative cycle.

Useful pointers

• Respond to an incident of self-harm in the same way that you would for the victim of an accident; provide first aid as for any other physical injury or contact emergency services if the physical injury is serious and needs expert medical attention.
• Do not assume that the person either enjoys or does not feel pain. A response which implies criticism or some form of punishment simply reinforces the person’s feelings of self-blame and guilt.
• Acknowledge the person’s distress. Say something like ‘I can see you are very upset. How can I help you?’ This can be very reassuring and can help the process of communication.
• Aim to be positive and comforting; don’t be negative or highly emotional. It may be hard but don’t be judgemental, critical or dismissive. This applies to non-verbal as well as verbal communication. Try to show concern rather than disapproval, facially as well as in what you say.
• Try not to be over protective i.e. promising that everything will be alright. Acknowledge that there is a problem, but that it is possible to get help. Help them to think about their self-harm not as a shameful secret, but as a problem to be sorted out.
• Having contingency plans in place ready to use in times of crisis is vital and can often prevent a crisis happening. Knowing what to do and who to contact in an emergency can be very reassuring for the person and those who care for them.
• If you think someone may be suicidal then contact the relevant agencies such as the emergency services and anyone else involved in their care, like their CPN, social worker or the GP.

Planning for an emergency

Crises happen at all the most inconvenient times – late at night, over a weekend etc. At such times it is not easy to respond in the best or most appropriate way.

It is helpful, therefore, to try to think about some of the worst-case scenarios in advance, how you might respond, who you might call on and where to keep this information safe and handy. In this way if things do get difficult you have some sort of plan set up to help you through.

You will need to know the numbers of out of hours services that are available in your area and have them by the phone or in the phone book or saved in your mobile.

Similarly, you need the numbers for relatives and friends who can be called on at short notice, either to give you support in your home or, if you have to go away, to support for those left behind (e.g. children / other people you may also care for).This is especially vital if it is you that has an accident or crisis rather than the relative or friend with the mental illness.

Contact numbers for all services involved in your loved one’s care and others who support you should be kept with you at all times. With agreement, they should also be written in to your loved one’s medical notes / care records so that they are readily accessible to professionals who might need them.

These plans should be drawn up and agreed by you and the relative/friend you provide care for when that person is calm and in a stable condition so that everyone is clear about what will happen. This is not always easy, when someone is well, you are trying to be positive and not think about the bad times. However, if you can have some contingency plan it may be helpful in actually avoiding a really serious crisis.

Confidentiality and information exchange – helping to plan

This might also be the time to think about drawing up a confidentiality agreement. If you are the person responsible for your relative/friend being sectioned or admitted to hospital even voluntarily, you will possibly be the last person that they will wish to be told about what is being done for them.

Patient confidentiality can sometimes be a source of frustration between professionals and carers: carers can often feel excluded professionals on the basis of patient confidentiality in exchanging / getting information relevant to their loved one’s care or treatment.

For more information on the issue of confidentiality, click on this excellent guide from the Partners in Care campaign.

As you are likely to be the one helping your relative/friend when they leave hospital, you will obviously wish to be informed about what is happening and how things will be managed in the future and how you will be included in the process. You may need to find some way of encouraging your loved one to include you in the discharge planning, helping them to realise that you will be a useful ally in their care.

In order for the agreement to carry weight with professionals you need to ensure that you have discussed it thoroughly with your loved one and have it signed by the independent third party. It will probably be a more acceptable arrangement to your relative/friend if he/she feels that some pieces of information are retained as being confidential e.g. discussions in therapy groups or individual counselling sessions or seeing the written notes kept on the ward. In this way they can still keep a sense of independence, dignity and thinking for themselves, while allowing you access to information which they feel is in their best interest for you to know. This is beneficial for all parties and ensures that professionals do not breach any of their guidelines.

Telephone numbers you will need in an emergency

• G.P.
• Emergency Out of Hours GP’s
• Crisis Home Team
• Community Psychiatric Nurse (CPN)
• Social Worker
• Relatives/Friends/Others
• Carer support / key worker
• Crisis lines such as Lifeline, Samaritans etc.

Working with professionals in caring – The Triangle of Care

The Triangle of Care describes the therapeutic alliance that needs to exist between service user, staff and carer to ensure informed care planning, support recovery and sustain wellbeing of both service user and carer. It was developed to address the clear evidence from carers that they need to be listened to and consulted more closely.

• The Triangle of Care
• The Triangle of Care update

Looking after your own health and well-being as a carer

• Do find someone to talk to, to let off steam yourself – another carer, a support group, a professional who can listen to you / help you / advise you on caring for your loved one.
• Know what other help you can get: your rights and entitlements. Knowing what is out there to support you is crucial and what help you can access. It can be one of the first steps in effectively managing everyday as a carer. For more information, click on the Carers UK guide to carers’ rights and benefits.
• Take a break to recharge your batteries, you will need it. Have a carers’ assessment – it’s a legal right – it can help you to identify where help and support may be available to further enhance your ability to care and to help you stay well yourself. It may be difficult to go through this process, for example, admitting how much you actually do, but it should help you to resolve things in a more positive light.
• Learning how to manage stress; this is one of the biggest problems carers can face in dealing with pressurised situations at home.

Here are some useful links to practical stress management tips for you:

• Coping with stress (Carers UK)
• 20 tips for a low mood (Carers UK)
• BBC Health: Managing stress
• Steps for Stress: guide to stressing less and enjoying life more

• Be aware of your own psychical and emotional needs and your quality of life. You cannot do everything… Think about your well-being in the broader sense and look at some simple things you do to make time for yourself as a person as well as a carer. Check this short guide Five Ways to Well-Being to get you thinking about you.
• Get more balance between your work and caring. For many carers, it is a financial necessity to combine work and caring in order to support their household. You do have rights as a carer to flexible working to help you juggle work and care. We have put some links below to practical advice and your rights as a carer and employee from Carers UK and http://www.nidirect.gov.uk

• Your right to flexible working
• Flexible working – work life balance
• Time off for dependents
• Caring for someone while working
• Other rights at work
• Getting support at work.

If you have a specific query on a work situation and your rights as a carer, contact the Labour Relations Agency (LRA)