Dangerous Clients: Assessment and Work
Richard Niolon, Ph.D. 5/06

Assessing Risk for Violence In assessing risk for violence, it is important to place violence in a context. Some points to remember include: most anyone, under the right circumstances, can become violent most of the time, violence is the response of a person who feels that all other options are exhausted, and there is nothing to gain by restraining themselves and nothing to lose by becoming violent the reasoning and self-control that hinder the person from choosing this "last response" are likely to be weakened by substance use, mental illness (ranging from severe depression to delusional thinking), and severe stress this "last response" is often accompanied by a strong feeling of helplessness and powerlessness, and violence is seen as a way to increase control and influence in the situation when helplessness is not the predominant emotion, fear of harm or exploitation is the next most likely one Weinger (2001) reports that health care and social service staff are more likely to experience assault than any other field, according to a 1996 OSHA study. She cites other research indicating about one in four social workers has been assaulted. While only 30% sustained a physical injury, and only 10% rate the injury as more than moderate, the impact is more widespread. While one study showed only 23% of social workers had been assaulted, a third had a weapon brought to their workplace (NASWMA), two thirds knew a coworker who had been assaulted, and three fourths have been verbally abused (NASWMA). Thus, looking only at physically serious assault minimizes the impact of client violence. A short mnemonic to remember is:   T Thoughts of harming another   M Means to harm another   A Access to means to harm another   P Pervasive thoughts of causing harm to another   P Plans to harm another A more detailed assessment should include the following:
	1) Do they have a history of violent behavior? Have they ever seriously harmed another person? When assessing risk for violence, past violent behavior is the best predictor of future violent behavior. Ask the client in a neutral manner if they have ever harmed others, how recently, and how serious the harm was… if they have threatened harm, how recently, and how serious the threats were… if they have harmed objects (kicking chairs, slamming doors, breaking treasured possessions), how recently, and how serious the damage was… with each ask about the circumstances and be listening for the degree of personal responsibility the person takes for events ask about past military and firearms training, arrests and other police involvement, court ordered treatment, and impulsive behaviors like reckless driving ask about childhood history of family violence (this can mean being abused or witnessing abuse) and police involvement in the family; how did extended family respond? Keep in mind that stereotypically, men engage in more violence. However, women are engaging in more and more violence, even if it is not as lethal, and so be careful not to underestimate a woman's risk for violence. Similarly, stereotypes and prejudices often include that black men are more violent than Caucasian men, and so be careful not to overestimate a minority male's risk for violence. 2) Does the client want help to manage the aggressive impulses? If the client recognizes their anger is a problem, this makes it easier to intervene and easier to help them learn alternate controls and responses. Remember to that having thoughts of harming someone and having the intention and motivation are two different issues. Thoughts of harm occur to all of us, but intention refers to the desire to act on those thoughts and motivation refers to some payoff expected by acting on those thoughts. Assess carefully. 3) Are there signs of agitation and losing control? Area Signs General Body Language look for restlessness and shifting around (or pacing around the room), muscle tension or tremors, jerky and abrupt movements, general puffing of the chest (as if to look larger and more threatening), nondirectly aggressive gestures (like pounding the table with a fist), and directly aggressive gestures (shaking a fist at someone); one technique involves watching the client breathe, breathing at the same rate they do, and observing whether you feel "keyed up" as a result Facial Cues look for muscle tension in the face, lowering the eyebrows (as if to make the forehead look bigger), flared nostrils (as if to take in more oxygen for quick response), flushed color (perhaps indicating the sense of embarrassment and shame), and raised lower eyelids (as if decreasing the eye's exposure - if you don't what know what this means, Gottman suggests thinking of Clint Eastwood's face just before he is about to shoot someone) Paraverbal Speech Cues listen for unusual stuttering, changes in the normal octave (a higher or lower pitch than normal), pressured speech, and more "filler" speech (the ah.., oh…, uhm…, well… speech that fills in between thoughts) Verbal Speech Cues listen for sarcasm, challenging and angry statements, cursing, direct threats as well as expressing disorganized, grandiose, or tangential thoughts Distress look for abrupt changes in emotions, disorientation, persecutory ideas and suspicions, perseveration on negative events and angry thoughts, feelings of hopelessness and "being at the end of the rope," and uncooperative behavior Intoxication uncoordinated movements and gait, slurred speech, tremors, smell of alcohol, dilated pupils, flushed face, apparent loss of visual focus, changes in alertness 4) Is there a high level of distress? inquire about current stressors such as recent deaths or anniversaries of deaths, changes in living situation, breakups and divorce, unemployment -- on these last two issues, ask about employment history and listen for patterns of conflicts with peers/supervisors and abrupt termination/quitting; ask about relationship history and listen for patterns of conflict, level of responsibility assumed versus level of blame on others, and difficulties with trust and intimacy assess personality by asking about holding grudges, a sense of persecution, and enemies in their life inquire about social support; this is more than whether they have support, and includes the kind of support - spouses and therapists in the support network decrease risk for violence, while antisocial peers and gang members increase risk of violence gather a thorough substance abuse history, and especially inquire about violence under the influence of substances gather a thorough psychiatric history, including voluntary and mandated treatment, medications and adherence to them, and the client's view of how well mental health services work and of service providers
Assessing the Environment Examine the treatment environment, and note: are there possible weapons around, like objects that can be thrown (pictures, ashtrays, books…)? are you dressed in ways that can lead to harm, such as wearing a tie, dangling earrings, or necklace? are there emergency procedures in place to handle violent clients? are clients seen after hours without adequate support staff to carry out emergency procedures? can the client remain between you and the door, and block your exit? is the environment "warm" and inviting, or "cold" and intimidating? A physical attack often can be prevented with the following steps: Remain calm at all times. That may be hard to do, but make the effort to speak in a soft and gentle voice. Validate their feelings as much as you can in short and succinct statements. This may require raising and/or validating their experiences of prejudice or unfairness. Mirroring their body posture, empathic nods, and attentiveness as they talk may be all that's needed. Avoid power struggles; this may mean that you refuse to discuss certain topics, or that you bring others in to discuss these topics with you. Pay attention to your own feelings and try to remain as relaxed as possible. Move slowly, and breathe slowly and deeply to keep your cool. Do not turn your back to the person, and be do not stand in their "personal space"; remember, when they are angry, their definition of "personal space" my be more than they normally need. Try to stand at a 45 degree angle to them. Try to isolate the patient. This can be done by asking the patient to come to an office to discuss the problem, or asking all nonprofessionals in the area to move away. (This move keeps arousing stimuli from reaching the patient and protects others). Have someone standby for help. Have a prior plan worked out with office staff for intervening with reinforcement of security guards or police if escalation is a concern. Try to shift the client to consider problem-solving. Encourage them to talk about what progress they have made, what would make things better now, and what help they need to achieve their goals. Allow the client to simply "vent" their anger verbally, especially if the above does not work. Do not interrupt, challenge, or confront. You may need to make the client aware of their escalating behavior. Tell them you see them becoming distressed and are concerned about them, and reiterate the limits in place, with assurance and firmness (e.g., "Mr. Smith, I understand that you are upset and I am here to help. However, we cannot allow physical violence"). You might ask them what they need to help them control their temper; they might need a "time out" to collect their thoughts, to write down their thoughts, time to walk around the block, to know specific information, to contact a person they trust to "talk them down"… Some disclosure might help to personalize you ("I understand what that's like - I come from an alcoholic family myself"), or to depersonalize you ("I realize how frustrating this is, but the decision was made by my supervisor/director and I didn't have any control over it"). Do not tell the patient that you are going to do something that you cannot do. Set firm and consistent limits that you can enforce. If limits have to be enacted, get as much help as possible. This "show of force" often prevents having to take physical action. Do not attempt physical restraints without enough help to do the job safely, unless the client is likely to harm themselves or others at that moment. If physical restraints are necessary and enough help is available, form a circle around the patient. Those at the patient's back should start the restraining process by holding his or her arms. At that point, those in front should hold the feet and everyone should pull, lifting the patient off the floor. Use the minimal amount of force necessary to restrain the patient. Restraint, if you think about it, is taking away self-control from a person who is feeling little control overall, and so the intervention itself may make the situation seem worse. Afterwards… There are a number of options available: refer for medication evaluation help identify personal and community resources to help them cope encourage taking responsibility and emphasize appropriate choices clarify connection between actions and consequences initiate anger management counseling or refer to an anger management group teach assertive communication, relaxation skills, and greater awareness of personal "triggers," emotional state, and cue to increasing tension encourage physical exercise to discharge body tension Home Visits While in the past it has mainly been social workers and nurses for example seeing clients in their homes, more and more, counseling and therapy is provided in the homes as well. Further, psychologists evaluating clients may go "on site" and meet clients at agencies, at schools, or in client homes. Several tips for safety include: thoroughly review the client file beforehand to determine whether there is any significant risk of violence examine your route to the meeting and assess the safety of the area; part of this is some kind of "objective" assessment of the area, and part of this is a "subjective" assessment of your comfort there examine the meeting space in advance, and assess the environment (see above) enlist the aid of another staff member, and either have them "check in" periodically with you, or expect periodic "check ins" from you to report on your progress; one way is to have them call you and you step away to handle the call, allowing the two of you to speak outside of the client's hearing about any safety issues dress appropriately - slightly better than the client perhaps, but not in "flashy" clothes that draw attention to the power difference between you and the client Resources Weinger, Susan (2001). Security Risk: Preventing Client Violence Against Social Workers. Washington DC: NASW Press. DangerousBehaviors.com How to Treat Angry, Hostile or Violent Clients by Cardwell C. Nuckols, PhD Safety issues for counselors who work with violent clients