It's been an intense and emotional session. You push on, believing your client is on the verge of his first breakthrough, albeit a minor one. Suddenly, the mood changes; the client is becoming agitated. Years of counselor training tell you to remain calm, but raw instinct says this client is about to explode and you could be in danger.

How can you be sure? Well, you can't. When asked, counselors who work with violent and potentially violent clients were unable to come up with a profile of a client who is likely to become violent during a counseling session.

"Drug or alcohol users are more likely to go that route and a history of violence certainly sets up those kinds of possibilities but, aside from those basic things, I don't think there really is a profile or good prediction of who is going to become violent," said Robert Rencken, a mental health counselor in Tucson, Ariz. "I see people who have been convicted of violent crimes and are teddy bears in the counseling office."

That said, clients do provide some hints that they may become violent. Rencken urges counselors to use common sense and to be aware of the nonverbal clues a client may be sending.

"Motor activity is a very important indicator," he said. "Are they back and forth in their chair? Do they stand up? If I were to have someone stand up when it appears like they are getting angry about a particular situation, I will immediately back my chair up out of the way. It could be [he or she] just needs to pace or it could be that they intend on leaving, but either way I don't want to physically be in their way."

Robert Foster, who runs the Domestic Abuse Counseling Center in Pittsburgh asserts that the clients need to be educated on their own warning signs so that they will learn to control their violent urges. Tenseness, sweating palms, a tightening of the stomach, pressure in the chest and a surge to the head are just a few of the symptoms that the client may experience.

Others warn that counselors should be concerned about a client who does not show any remorse or discomfort when asked about previous violent incidents.

The who and when of violence

While admitting that violence can be a difficult thing to predict, Mark Kiselica, an assistant professor at the College of New Jersey in Trenton who has worked with gangs, incarcerated violent offenders and batterers, said it's important to know who is at risk of losing his or her temper. He recommends learning as much as possible about the client's history and then taking the appropriate precautions.

"Clients who have a history of impulse control problems, such as explosive rage, are more likely than other clients to lose control with a counselor," he said.

Sociopathic individuals and those with thought disorder-the irrational belief that others are out to hurt them-are also high risk populations, he said.

But perhaps more important than knowing "who" is knowing "when." Part of the trick here is monitoring what's going on outside of the counseling session, said Kiselica. If you learn that a client is using poor judgment, having outbursts or breaking things at home or in the workplace, that increases the odds that something will happen in the session.

"It also is important, during the actual session, to watch how agitated the client gets when talking about particular issues and knowing how to help your client modulate his or her anger," said Kiselica.

"I look for the buttons that escalate the individual," agreed Foster. "Once they have been identified, the work becomes reducing the size of those buttons."

Although he has worked with a number of violent clients, Kiselica recalled one incident that he remembers vividly involving a incarcerated male. The tier officer called Kiselica one day because an inmate was making threatening remarks toward the prison administrator and was becoming increasingly agitated. By the time he arrived at Kiselica's office, the client "was on the verge of an uncontrollable rage."

Kiselica knew the inmate had a history of aggravated assaults and was an emotional seesaw. "My job was to very carefully -from the moment I got the phone call throughout the time I saw this guy -make sure I was safe and to manage his behavior and help him to calm down."

After receiving the phone call, Kiselica immediately notified the tier officer on his floor that an unstable inmate was coming to see him and asked the officer to stand outside his door during the session. The office door remained closed to protect the client's confidentiality.

To avoid a transference of his anger, Kiselica repeatedly reassured the client that he was there to help him and commended the client for coming to see him rather than acting on his feelings of rage. He also asked the client what was keeping him in control thus far and used that as proof to reinforce the fact that he could indeed control himself.

After about 35 tense minutes the inmate calmed down. In all, Kiselica spent about 50 minutes with him that session.

"If you can get them through the rage, then you can access their better qualities, such as restraint and rational thinking," he said.

Setting boundaries

Kevin Kirley, a licensed psychologist in Minneapolis, has been counseling men who batter women for almost 20 years and has had his share of tense moments and close calls.

"I have had a number clients who escalated to the point where I felt that I and my colleagues or the rest of the clients were at somewhat of a risk," he said. "Fortunately, there have never been any physical assaults."

Kirley, director of the MESA domestic violence program, said the way he structures MESA's 32-week program goes a long way in minimizing the potential for violence. And it doesn't hurt that about 90 percent of Kirley's clients come to MESA as a condition of probation and therefore face significant consequences to any negative behavior.

Kirley said the staff works hard to detect the nonverbal signs of an escalation of violence and lets the clients know that the kind of behavior that brought them to the program is unacceptable. They also thoroughly explain to the client the concept of duty to warn and that any threats of violence will be reported.

"Putting all those parameters in place early on really decreases the likelihood that they will escalate and if they do escalate, we will use that opportunity to develop the skills and insight that are consistent with our long-term goals for them." said Kirley.

One skill that Kirley encourages his clients to learn is knowing when they are losing control. He said it is perfectly legitimate for a client to admit difficulty and ask to be excused from the group for 20 minutes. "We're seeing more clients who will do that or, in retrospect, will say they should have done it."

Foster agreed that setting clear boundaries is crucial when working with any clients, and particularly those with a history of violence. This includes getting them to accept responsibility for past and future actions.

Although much of what counselors who work with violent populations do is aimed at diffusing explosive situations, that doesn't mean giving in to the possible temptation of avoiding conversations that could cause an escalation. In fact, Kirley asserts that counselors can push these clients much harder and expect much more of them than they might imagine.

This means not being afraid to ask sensitive questions, said Foster, noting that, oftentimes, the question is perceived as more threatening by the counselor than the client and, if asked directly, they usually have no trouble answering.

Safety Tips

When counseling a population as unpredictable as those with a history of or potential for violence, the wrong move could mean much more than a therapeutic setback. Counselors who work with this population need to take precautions so they can protect themselves and still provide the necessary counseling services.

The mental health professionals interviewed for this article offered a number of safety tips that could help both novice and veteran counselors:

• Work in groups with a co-worker.
• Position your chair closest to the door so you have a clear path should you need to escape.
• Don't take foolish risks. For example, don't go to a house when a client is in crisis and talking about hurting someone. Call the police and offer your services once the situation has been diffused.
• Never meet anyone by yourself at night.
• Make sure your facility or home is well-lighted.
• Build a good relationship with the police department. You may want to ask them occasionally to swing through the parking lot.
• Establish a system with the police or a family member where you will call at a certain time and if you don't, ask that they check up on you.
• Have a standard plan for dealing with clients who become violent and make sure your co-workers know the plan.
• Know how to diffuse a violent person's emotions and de-escalate an explosive situation.
• If working in a hospital or prison, let security know you'd like them around at certain times.
• Never chase after a client who storms out of a session.

"We have to remember that as providers, we have rights, too," concluded Kirley. "No client is worth getting hurt."-