Jodi Flick, ACSW, LCSWUNC School of Social Work

University of North Carolina at Chapel Hill joflick@email.unc.edu

Client Violence:Keeping yourself and others safe

§ 50-75% of professionals assaulted at least once in career; males at greater risk

§ Common occurrence and has increased§ Seriously underreported

§ “Just part of the job”§ Too much paperwork§ Fear of retaliation

by client or employer§ Fear of looking incompetent

to supervisor / coworkers

Violence against clinicians

§ Recruitment and retention issue in mental health and child protection

§ Training proven to:§ decrease number of incidents / assaults§ decrease severity of injury§ increase staff confidence

and morale

Violence against clinicians

A - B - CAwareness: of surroundings, risk factors,

personal strengths / weaknessesBalance: physical and emotionalControl: over your thoughts, your body

and your situation

§ Increase strength§ Improve physical

reaction time§ Make hearing and

vision more acute§ Increase alertness

and focus§ Mobilize energy

§ Increase errors§ Decrease judgment§ Decrease attention

span§ Decrease ability

to discriminate between trivial and dangerous

Fight or Flight: the body’s Emergency Response System

§ Involves intervention in very personal, private matters, but we become desensitized

§ Highly emotionally-charged; vulnerable§ “Public” embarrassment§ Frequently puts

professionals in danger themselves

Working with families in crisis

Care vs. Control■ We protect clients; but we also

protect society from clients.■ Staff mistakenly think clients do not

view us as having power / authority.■ You have:

• official power• professional knowledge

■ How clients react depends on how you use your authority.

Robbed of power and controlover their own life,

people often “act out” as a way to reclaim some control.

§ Most clinicians insufficiently informed§ Ask routinely, like suicide assessment§ “Have you ever lost your temper?”§ Recency, severity and frequency§ Use of assessment scales

History taking

1. History of violence2. Substance abuse3. Non-compliance with

medications

§ Command hallucinations§ Paranoid

§ Targets are predominantly family members

§ Mother living with adult child with schizophrenia at greatest risk

Mental Illness and Dangerousness

Prevention vs. Response

■ Many Safety programs focus on what to do once an incident occurs

■ Once client strikes you (or someone else) they will be labeled violent from then on and many services closed to them

■ Must focus on preventing incidents from occurring in the first place

Slaby

Pattern of Escalation

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Kaplan and Wheeler

1. Triggering2. Escalation3. Crisis4. Recovery

Pattern of Escalation

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Kaplan and Wheeler

1.Triggering: person gives non-verbal clues of their distress

Supportive response • Recognize their reaction• Do not ignore / belittle concerns• “Vent” enough to understand,

then redirect.• Joint problem-solving

Pattern of Escalation

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2. Escalation: losing rationality, increased anger, abusiveness, limit testing

Directive response• Take away audience• Do not touch person• Break eye contact• Distract • Keep on topic• Help see options• Slow down

Pattern of Escalation

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3. Crisis: physical violence• Not usually premeditated;

explosion of pent-up frustration• Focus changes

to protecting yourself and others; escape

If situation turns physical:§ Block with arms, clipboard, pillows§ Fall: keep feet toward person§ Grab: twist toward thumbs§ Choke: Arms up and turn§ Bite or hair pull: PUSH into§ Weapon: Encourage to talk / put down.

Focus on person, not weapon.

Pattern of Escalation

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4. Recovery: reduction of anxiety

Supportive communication• remorseful, crying, apologetic, worried• do not process what happened;

likely to reactivate assaultive behavior• deep breaths

Age

Size of room

Gender Size

Front / Rear

Emotions: liking vs. fear / anxiety

Rate of approach Number

Angle: sitting, lying

Personal Space Factors

Your body language can convey a message you don’t want to send…

annoyance?

arrogance?

authority?

■Non-threatening: relaxed, caring, assured• Avoid hands on hips or waist, bravado

■ At an angle■ Balanced footing■ Safe distance:

out of reach■Hands free■Head tilt

Body Posture

What do you mean?

= faster, louder, higher pitched

Think about the way you speak…

§ Drop the volume – demonstrate control

§ Drop the tone of your voice

§ Decrease your rate of speech

§ Be simple, direct, explain and repeat: When under stress, people hear less than a third of what is said to them.

Speech

§ Give back control: ask for client’s opinions and participation

§ Take responsibility for your mistakes§ Make a fresh start§ Don’t use humor; easily misunderstood§ Interrupt the rhythm: use time / space

for cooling off and planning

Verbal Intervention Techniques

§ Allow to save face; give them a way out§ Use silence; don’t respond to insults§ If you must deny someone,

give something§ Avoid “why” questions§ Follow Tarasoff decision: “duty to warn”

Verbal Interventions

§ Failing to introduce self or explain task§ Acting annoyed or authoritarian§ Using jargon§ Quoting rules without explanation§ Becoming overly familiar with clients

Common errors to avoid

Evidence shows: Workplace design impacts aggression

CPTED: Crime Prevention Through Environmental Design

o Natural observation – sight lineso Access control – impede movemento Territory – familiarity with surroundings

and each othero Maintenance – image / pride

§ Monitor noise, temperature, crowding§ Keep waiting time to a minimum§ Limit access to treatment areas§ Create pleasant surroundings

• decoration• lighting• colors

Prevention Tips

Paradigm shiftfrom reacting to incidents and

environment tolerant of violent acts…to preventive, systematic, proactive approach

Change in culture: i.e. no blame attached to victims…

and violence is NOT ‘part of the job.’

§ Maintain confidentiality in waiting and reception areas

§ Strict limits on use of disinhibiting substances prior to visits

§ Careful assessment of ability to tolerate discussion without agitation: How will I know when you’re mad / upset?

§ PRACTICE techniques in role play, fantasy, supervision: what if?

Prevention Tips

Know your agency’s emergency call system

Most agencies have a way for worker to notify someone that they need help immediately.

Agencies have:• alarm buzzers that ring where someone is

always present, like reception desk• code word that means, “I need help!”

Office arrangementMost offices are arranged with worker sitting behind desk, and client sitting between worker and the door.

This means that, in an emergency, worker must go around desk and past client to get out.

Office arrangementIdeal seating arrangementallows both people unobstructed access to the door.

If this will not work, rule of thumb is, “Never put the client between you and the door.”

continued

Many things around you can become dangerous weapons when someone is angry…

weapons of opportunity

What could I use to protect myself?

Think about it ahead of time and have a plan!

Workplace safety guidelines

Flag client records: dangerous clients are easily identified, but symbol has meaning only to agency staff

• colors• tabs• risk assessment sheets• computer icons

Risk room

§ Cleared of weapons of opportunity§ Window: privacy without isolation§ Pleasant; sparsely furnished§ Easy exit / safe chair arrangement§ Alarm call button; phone in drawer

In office interview when hostility anticipated, there are things you can do to be safer:

• Notify co-worker / supervisor; check-in. • Interview in larger, less confined area.• Interview in observable area.• Leave the door open.• Give client the choice

to take a break or leave.

Plan for safety on home visitsPrior to visit

§ Wear comfortable shoes and clothing that doesn’t restrict your movement. Limit jewelry.

§ Charge your cell phone. § Go early in day.

§ Make sure agency knows itineraryCall in any changes

§ Note safe places enroute: restaurant, gas station

X

Know your agency’s safety protocol

Buddy system?Visit in pairs on high risk calls

Law enforcement to accompany staff?

Plan for safety in your carBefore you go:§ Lock valuables / personal items in trunk§ Carry only agency ID§ Take county car if available§ Vehicle in good working order§ Have gas, phone or emergency call device,

flashlight, directions, maps

Plan for safety on home visits

During visitObserve for dangers

Outside: • unleashed animals, broken steps• crowds, noise of fighting

Inside: • exits (doors and windows)• dangerous items

Plan for safety on home visits

During visit

• Stand to one side when knocking on door.• Remember you’re in their home.• Ask family to advise you of safety concerns• Trust your “instincts” – don’t second guess

At home visit

As you arrive, park facing out of the driveway.

As you leave, have keys in hand as you approach car.

§ As caution to other workers§ To evaluate problem areas

and procedures

§ For liability: show data gathered, thinking process and decision re: dangerousness

§ ASAP: delay alters accuracy and details

Documentation

§ Immediate treatment: decreaserisk of PTSD / impact on work life

§ Debriefing: non-blaming,process what worked, what didn’t, alternatives

§ Counseling: paid for time; develop sense of mastery, good support, make sense of event

§ Consequences: prosecution; hospitalize;ban or trespass; be seen by pair of workers

§ Additional agency training needs

After an Incident

§ Orientation / training for safety skills§ Violence plan; rehearse like fire drill§ Prosecution on behalf of employees§ Keep disposable gloves available§ Adopt inexpensive safety features:

• Visitor identification badges• Wider reception desks

Administration Support

§ No reprisals against employees who report or experience violence

§ Aftermath plan: fatalities / hospitalizations reported to OSHA within 8 hours

§ Ensure adequate staffing: for peak census;no one left in building alone.

§ Encourage safety training in undergraduate and graduate schools

continued

Administration Support

§ mandatory reporting, regardless of injury§ equal emphasis on worker and client safety§ trained response teams for emergencies§ set up sick bank for employees who

lose time because of assaults§ safety committee to do worksite analysis:

assess problem areas

Management and employees commit to: