Wk5CH14

CHAPTER 14: Violent Behavior in Institutions There have not been a lot of statistics published lately on what kinds of violent assaults human services workers experience, and happily overall violent crime in the United States is down in the last 5 years. Of 13,636 murders in the United States in 2009, only 10 occurred in institutions, according to the FBI’s 2009 Uniform Crime Report. Good news indeed, except to the 10 people who were murdered and their loved ones and the thousands of others who were assaulted. Thus, to think that violence against caring and sharing human service workers has never existed or doesn’t still exist is to be gravely mistaken (Flannery, 2009; Gabe & Elston, 2009; Slovenko, 2006). From 1996 to 2000 there were 69 homicides in the health services industry in the United States, and none of these people were killed at the post office! However, the vast majority of workplace violence is composed of nonfatal assaults. In 2000, 48 percent of all nonfatal injuries from occupational assaults in the United States occurred in health care and social services (U.S. Department of Labor, Bureau of Labor Statistics, 2001, 2002). For mental health workers in particular, the average number of assaults was 68.2 per 1000 (U.S. Department of Justice, Bureau of Justice Statistics, 2001). These results were chilling enough that the Federal Bureau of Investigation sponsored a workplace symposium on violence in 2002. (To put those statistics in terms that tell you how dangerous the mental health services can be, you would be as likely to be assaulted as if you worked in a convenience/liquor store (68.4/1000). Besides law enforcement and corrections occupations, only bartending is more likely to get you assaulted (91.3/1000) (U.S. Department of Justice, Bureau of Justice Statistics, 1998)! A best estimate is that the chance of human services workers being assaulted on the job during their lifetime is approximately 50 percent (Turns & Blumenreich, 1993, p. 5). Newhill’s (2003, pp. 35–54) comprehensive review of violence studies on social workers in the United States found that between 20 and 50 percent of the professionals studied reported that they had been assaulted. Other countries such as the United Kingdom (Brown, Bute, & Ford, 1986; Leadbetter, 1993; Rowett, 1986), Canada (MacDonald & Sirotich, 2001), Israel (Guterman, Jayaratme, & Bargal, 1996), and Australia (Koritsas, Coles, & Boyle, 2010) confirm a high incidence of violence and threatened violence against human service workers. Perhaps more ominous is the notion of threat. Newell found in her own study that social workers who do not suffer an assault may experience destruction of property or verbal threats. Those threats are not taken lightly given the violent histories of many of the clients with whom they are dealing (Newhill, 2003, pp. 46–47). Constantly wondering whether an emotionally disturbed or mentally ill client will make good on his or her threats every time a human service worker walks out of the office is not the way to have a fulfilling and rewarding work experience. In summary, the foregoing statistics should tell you one thing: Although you may believe that you are some combination of Jane Addams, Carl Rogers, and Mother Teresa ministering charitably and caringly to the disenfranchised and outcast, your clients may have a different idea (Newhill, 2003, p. 206)! Why is this so? Precipitating Factors A variety of hazards now put human services professionals more at risk of being victims of violent behavior than they have been in the past. This problem has become so pervasive that the American Psychological Association formed a task force to report on education and training in dealing with behavioral emergencies (American Psychological Association, 2000). They found in a survey of the literature that between 35 and 50 percent of psychologists in clinical practice had reported being assaulted. The threat has become so compelling that the American Psychological Association (2002) incorporated in their ethical standards a section to specifically address psychologists’ freedom to terminate therapy if they feel threatened or endangered. The social work profession has become very interested in violence because social workers are invariably in the line of fire as frontline workers attempting to deal with some of the most economically, socially, and emotionally disenfranchised individuals in the human service business. Interestingly, the counseling profession has not seemed as concerned, although high school counselors in particular are in the line of fire with one of the most volatile and violence-prone age groups there is. The amount of violence that now occurs in K–12 schools in the United States is approaching epidemic levels. Substance Abuse. Probably the most noteworthy trend in the upsurge of violence has been the increasing numbers of substance abuse clients (Blumenreich, 1993b, pp. 23–24; Occupational Safety and Health Administration, 2003; Monahan et al., 2001; Turns & Blumenreich, 1993, p. 7). Intoxication’s disinhibiting effect (McNeil, 2009) appears to directly influence violence, particularly in those individuals who are aggressive and impulsive (Chermack, Fuller, & Blow, 2000) and those with diagnosed major mental disorders (RachBeisel, Scott, & Dixon, 1099). Deinstitutionalization. Since the “least restrictive environment” movement and subsequent deinstitutionalization of patients in the 1970s, day care centers, halfway houses, and shelters have filled the gap left when the warehousing facilities of state mental institutions were emptied. Lack of facilities for transients, shortage of staff, lack of follow-up care, and inability to monitor medication closely have created a fertile breeding ground for clients to regress to their previous pathological states (Occupational Safety and Health Administration, 2003; Weinger, 2001, p. 4). Mental Illness. The role of mental illness in violent behavior has been hotly debated. To say that all mentally ill people will become violent is patently ludicrous. However, there is some clear evidence that a subset of mentally ill people will and do become violent (McNeil, 2009; Newhill, 2003, pp. 96–104). Delusions (schizophrenics), hallucinations (multiple disorders), and violent fantasies (sex offenders, multiple murderers) are all cues to possible violence in the mentally ill. Organic issues such as internal head injuries, brain diseases, and dementia all have the potential for increased violence (McNeil, 2009; Monahan et al., 2001; Tardiff, 2003). The personality disorders are rife with the kinds of mental disorders that may become violent. Many of the personality disorders are marked by anger control issues, impulsivity, and inability to regulate or control emotions (Newhill, 2003, pp. 99–104). Most particularly, those persons diagnosed with antisocial personality disorders and those with explosive personality disorders are prime candidates for acute onset of anger and violence (McNeil, 2009). Furthermore, because society and the judicial system have become increasingly aware of the role that mental illness plays in crime, a number of people who would formerly have been incarcerated are now remanded to mental health facilities (Occupational Safety and Health Administration, 2003). Also, because of prison overcrowding, potentially violent people are released on early parole. Farmed out to halfway houses that are also understaffed, and assigned to parole officers who have tremendous caseloads, parolees do not always get the follow-up care and supervision they need. Police now routinely use hospitals for criminal holds on acutely disturbed, violent individuals. Thus, human services workers are now being asked to deal with a wider variety of felons than before (Hartel, 1993; Occupational Safety and Health Administration, 2003; Walker & Seifert, 1994). Gender. The stereotypical notion that males are more aggressive is becoming dated (Weinger, 2001, p. 7). While young males account for the majority of assaults, women are catching up. In regard to equal opportunity violence, Lam, McNeil, and Binder (2000) found that females were as likely to assault staff on a locked inpatient unit as were their male counterparts. Ryan and her associates (2004) found in their study of assaults on staff by youths that gender did not differentiate between who would and would not assault staff. Gangs. Gang violence can be found in settings ranging from emergency rooms to juvenile detention facilities. Gang members’ extreme violence, either as a rite of passage into the gang or in retaliation for offenses against them, is without fear or remorse regarding any person, time, or place (Kinney, 1995, pp. 168–169; Occupational Safety and Health Administration, 2003). Required Reporting. The development of child and elder abuse reporting laws and domestic violence laws have made human service workers into something other than Florence Nightingale in the eyes of those who come into conflict with the social services and legal systems. Most of the time field staff such as social workers for human service agencies and school counselors and school psychologists become the objects of offenders’ ire (Weinger, 2001, p. 5). Elderly. The increase in the number of elderly people now institutionalized in nursing homes and hospitals has created a whole new population of potentially violent individuals. Casually dismissed as infirm and incapable of rendering harm to anyone, geriatric patients commit a disproportionate percentage of violent behavior against human services workers. The assumption that elderly clients are passive recipients of care is misguided. Study after study indicates this clientele to be at risk for behaving violently (Astroem et al., 2002; Daugherty et al., 1992; Gates, Fitzwater, & Succop, 2005; Hillman et al., 2005; Mentes & Ferrario, 1989; Ochitill & Kreiger, 1982; Petrie, 1984, p. 107; Petrie, Lawson, & Hollender, 1982; Snyder, Chen, & Vacha-Haase, 2007; Weinstock et al., 2008). Institutional Culpability By their very nature, most care providers are readily accessible to clientele and have minimal security checks. Often unrestricted movement throughout a facility may be gained by agitated and distraught family members, gang members, boyfriends and girlfriends, and clients who are frustrated over long waits and seeming lack of service. Care providers are also easy prey to any-one who walks in off the street with intentions other than seeking services and may believe drugs or money is readily available (Occupational Safety and Health Administration, 2003; Turner, 1984, pp. v–vi). Security training and security devices cost time and money. Administrators trained solely in handling the financial, logistical, and personnel functions of institutions with the responsibility of maintaining adequate patient care are unaware of what it takes to provide an adequately secure environment for their staff (Dyer, Murrell, & Wright, 1984). Physical features of mental health facilities built to deemphasize security and confinement as a reaction to the “snake pit” mental hospitals of old have paradoxically put the human services workers at greater risk (Turns, 1993). Emotionally “cold and uncaring” settings, unclear staff roles, poorly structured activities, downsizing of staff, and unpredictable schedules are all stress elevators for the potentially violent client (Blumenreich, 1993a, pp. 38–39; Occupational Safety and Health Administration, 2003). Assessment of potential for violent behavior should be mandatory in institutions and clinical facilities that deal with the mentally ill and emotionally disturbed (McNeil, 2009). Instruments are now available that, combined with clinical judgment, do a good job of predicting violent behavior if—and that is a big if—institutions will use them. Universities and Their Counseling Centers We have been particularly concerned with safety issues at many university counseling centers we have toured and two we have worked in. In an effort to be open, warm, and accessible, the university counseling center typically has no choke point that controls access to counseling offices. Students are free to roam about the center. Yet many of the offices are separated from the reception area and are extremely isolated. Even if there are visual, sound, and code alarms, the reaction time for help to arrive will be slow, giving a perpetrator time and ease of egress to escape. Career counseling, academic advising, and personal counseling clients in the university counseling center may all be mixed together in a very egalitarian environment, but it is a situation that has security risks. As evidenced by Seung-hui Cho’s rampage at Virginia Tech in April 2007, some of the individuals who frequent the university counseling center may not be there just because they are homesick (Grayson & Meilman, 2006; Myer, James, & Moulton, 2011). Numerous studies indicate that university counseling centers are dealing with more severe psychopathology than they have in the past (Benton et al., 2003; Bishop, 2006; Erdur-Baker et al., 2006; Pledge et al., 1998) and that more students are on psychotropic medication (Schwartz, 2006). More than 1 in 10 students sought counseling center services in 2009, which is the highest percentage ever found in the long-running National Survey of Counseling Center Directors. Further, about 48 percent of the students seen in those counseling centers has severe psychological problems (Munsey, 2010). Those shifts appear to be true not only in the United States but in the United Kingdom as well (Waller et al., 2005). Are those changes due to the general population in the United States becoming more pathological, or is the on-campus population changing because of the Rehabilitation Act of 1973 and the Americans With Disabilities Act of 1990, which made college campuses more receptive and accommodating to people with existing mental illnesses? This question has become so important that the Journal of College Counseling devoted its Fall 2005 issue to the topic of severe and persistent mental illness on college campuses (Beamish, 2005). The implications for safety issues overall in the university as an institution are sobering. One recent study (Kelly & Torres, 2006) found that women students felt a “chilly campus climate” that had nothing to do with the weather and everything to do with their perception of being unsafe on campus. This issue is even more compelling in regard to “chilly” safety considerations in university counseling centers. It is interesting to note that extended searches for any studies analyzing safety issues in university counseling centers turned up no hits. Rudd’s (2004) summary analysis of why college counseling centers are looking more and more like community mental health clinics is sobering. Counseling centers and universities that do not become proactive in tightening their security, notification, and oversight procedures will put their general populations at risk. Rudd contends that if university administrations have not already identified a risk management officer to place in the counseling center, they will soon have to do so. In 40 years of counseling in some tough public schools, a state mental hospital, and a federal penitentiary, and meeting lots of disgruntled and unhappy customers with Memphis Police Department Crisis Intervention Team officers, we have yet to meet more severely mentally ill and emotionally disturbed individuals who were not incarcerated for their own safety than we have in a university counseling center. The only three colleagues we have known who were killed in the line of duty died from assaults inflicted on them by clients at the college counseling centers where they worked. Given our history and background, we may clearly have a bias. However, we do not think the murderous assault at Virginia Tech in April 2007 was happenstance. Subjective evidence tells us that many of our colleagues in counseling centers around the country still wear rose-colored glasses when it comes to truly appreciating the potentially dangerous people who find their way to a college counseling center and the lack of security that characterizes those centers. Combining those two variables results in a lethal formula. Denial Because of the negative publicity that accrues from violent incidents, institutions are loath to admit that they occur (Lanza, 1985), and it appears that such episodes go largely unreported (California Occupational Safety and Health Administration, 1998, p. 3; Hartel, 1993; Occupational Safety and Health Administration, 2003). Indeed, the reticence of colleges and universities to report campus crime for fear of bad publicity was in large part responsible for the Crime Awareness and Campus Security Act of 1990, known as the Clery Act for Jeanne Clery, a 19-year-old Lehigh University freshman who was raped and murdered in her campus residence hall in 1986. A recent study conducted to determine whether parents were aware of the Clery Act and how to find information on crime statistics found their knowledge of the act to be low (Janosik, 2004). It seems somewhat ironic that the study was carried out at Virginia Tech. One can only wonder if the results of that study would be different today. Understaffing, overwork, poorly maintained physical environment, poorly educated nonprofessional staff, high staff turnover, absenteeism, on-the-job accidents, poor or incomplete communication between administration and staff, lack of staff training in recognizing and managing escalating hostile and assaultive behavior, and lack of a unifying treatment philosophy allow frustration to build within the staff and disrupt the treatment routine. As the staff transfer their frustration to the clients, the clients in turn become more threatened and start testing the limits of what will be tolerated. When staff attempt to impose behavioral limits under these erratic conditions, the outcome is often violent behavior by clients (Blair, 1991; Jensen & Absher, 1994; Occupational Safety and Health Administration, 2003; Piercy, 1984, pp. 141–142). Finally, secondary victimization occurs when, after an injury by an assaultive client, there is the underlying belief that “It wasn’t handled right by the worker” (Turns, 1993, p. 131). Thus, not only does the human services worker suffer physical assault and all the psychological ramifications that go with it, but he or she also becomes a scapegoat for an administration unable to handle the increased violence (Newhill, 2003, p. 209). Staff Culpability Staff members are also culpable. A prevailing philosophy is that because human services workers are caring, well-intentioned people, recipients of their services will act in reciprocal ways toward them (Newhill, 2003, p. 13; Turner, 1984, p. vii). The ostrichlike assumption that “It can’t happen to me, and besides, there are so few violent incidents that I really don’t need to be concerned” is fallacious (Dyer, Murrell, & Wright, 1984, p. 1). Madden, Lion, and Penna (1976) interviewed psychiatrists who had been assaulted and found that more than half could have predicted the assault if they had not been in denial and thought themselves immune from the threat. From the client’s viewpoint, becoming violent is invariably seen as a consequence of being provoked by the worker in some way (Rada, 1981; Ryan et al., 2004). Paradoxically, most staff members have little idea what they or the institution do that is provocative. For many clients, treatment may be perceived as coercive, threatening, or frightening. When a client feels little control over treatment conducted by an authoritarian staff, the client may feel the only option is to aggressively act out (Blair, 1991). Furthermore, if the staff treatment philosophy includes limit setting such as use of restraints, seclusion, medication, locked units, and assaults as “part of the territory” (Occupational Safety and Health Administration, 2003), then a self-fulfilling prophecy is likely to develop, with violent acting out as the norm and the only way to get attention. Conversely, a staff’s failure to set limits in regard to appropriate behavior in a positive, firm, fair, and empathic manner, as opposed to dictatorially taking away privileges without defining how those might be lost or explaining how they can be regained, increases the potential for violence (Blair & New, 1991). The attitude of staff toward clients also plays a part in who gets assaulted. Staff members who are burned out are more likely to be assaulted than those who are not (Isaksson et al., 2008). Experience also makes a difference. The great majority of assaults occur to people like you who are reading this sentence—that is, rookies in the field who don’t know the lay of the land (Flannery et al., 2011). Guy, Brown, and Poelstra (1990) found, in a national study of psychologists who had been assaulted, that 46 percent of all assaults involved students or trainees and that the incidence of assaults decreased the more years of experience workers had. So, you might want to personalize the contents of this chapter a little more than usual. Legal Liability Although health-care providers may be the victims of assaults, they may also become legally liable for their actions, no matter how well intended those actions may be (Monahan, 1984). Such liability extends to the institutions and directors of those institutions, who may fall under a heading of “vicarious” civil and criminal liability (Dyer, Murrell, & Wright, 1984, p. 23). As paradoxical as it may seem, assaultive clients have held institutions and their employees liable for failure of “duty of care owed” to those selfsame clients (Belak & Busse, 1993, pp. 137–143). Numerous successful lawsuits also have been brought against health-care providers for failure to properly diagnose, treat, and control violent clients or protect third parties from assaultive behavior (Felthous, 1987). Workplace violence has become so serious that the Centers for Disease Control has declared workplace violence a national health problem (National Institute for Occupational Safety and Health, 1992), and the federal Occupational Safety and Health Administration (OSHA) has come to the conclusion that workplace violence can no longer be tolerated (California Occupational Safety and Health Administration, 1998, p. 5). OSHA has recently started issuing citations to employers who fail to adequately protect their employees from violence in the workplace. One of the better predictors of who will or will not be at risk to become violent is the pooled clinical judgment of human services workers who have come into contact with the clients (Douglas, Ogloff, & Hart, 2003; Durivage, 1989; Werner et al., 1989). One of the primary reasons that cases have been decided in favor of the plaintiff is the failure of one clinician to communicate with another clinician that a client has a history of violence and might present a future danger (Beck, 1988; Belak & Busse, 1993, p. 147). From that standpoint, the institution and worker who wish to avoid a court appearance would do well to flag records of violent acts or ideation and relay that information to other members of the treatment team for feedback and possible action (Blair, 1991; Martin et al., 1991). Dynamics of Violence in Human Services Settings The dynamics of violence in human services settings is complex. It involves not only the clients themselves, but also the human services workers and the institution. The ability to predict who will be violent, when, and under what conditions has been notoriously unreliable (American Psychiatric Association, 1974; Kirk, 1989; Monahan, 1988; Mulvey & Lidz, 1984; Palmstierna & Wistedt, 1990; Sloore, 1988). Predictions are especially likely to be wrong when crisis workers have little back-ground information on clients and may not have time to make more than an “eyeball” assessment of the situation before they have to act. Yet data do exist to present general profiles of clients who are more likely than others to become violent, given the right constellation of conditions. To that end, accurate behavioral information is the central core in assessment for violent behavior. Cawood and Corcoran (2009, p. 17) propose that the depth and accuracy of behavioral information obtained are directly correlated to the quality and accuracy of assessment of who may become violent, where, and under what conditions. Violence Potential Assessment Instruments The HCR-20 (Webster et al., 1997) is a violence risk assessment rating device that asks clinicians to rate clients on 20 variables based on a variety of questions concerning clients’ history of violence, clinical mental health status, self-management, and degree of risk upon return to society. The ratings show good reliability in predicting who among forensic psychiatric clients will become violent both in the long term (Douglas, Ogloff, & Hart, 2003) and in the short term (McNeil et al., 2003), although it fared poorly when assessing incarcerated females in regard to who might commit a violent crime and had an inverse ability to predict which females had been convicted for murder (Warren et al., 2005)! The Violence Screening Checklist–Revised (VSC-R) includes checkoff items that review history of physical attacks and fear-inducing/threat behavior during the first 2 weeks of hospital admission, presence or absence of suicidal behavior, schizophrenic or manic diagnosis, and male gender (McNeil & Binder, 1994). This instrument appears to be highly reliable, particularly in regard to the first few days of hospital admission (McNeil et al., 2003). The Broset Violence Checklist (BVC; Linaker & Busch-Iversen, 1995) checks for the presence or absence of six factors that are frequently seen as a prelude to violent incidents on acute psychiatric wards: confusion, irritability, boisterous acting out, verbal threats, physical threats, and attacks on objects. This device has been shown to have good predictive validity during 24-hour follow-ups if two or more of these items are checked. A large-scale study of geriatric patients who were violent as opposed to those who were not found the BVC to be a good predictor of violent episodes and a good discriminator between those who would and would not become violent (Almvik, Woods, & Rasmussen, 2007). The Dynamic Appraisal of Situational Aggression (DYAS) checks for immediate risk of violence and is also a treatment plan aid that helps in reducing the risk of violence. When combined with professional observation, the DYAS was found to be a better predictor than clinical judgments alone (Ogloff & Daffern, 2006). While all of these instruments would seem to do a good job of predicting both short- and long-term violence risk in psychiatric populations, the problem is still predicting when it is happening “RIGHT NOW!” and doing something about it. From that standpoint, knowing the verbal and physical cues and using interocular and auditory analysis (eyeballing and listening) are still the best bet for staying out of harm’s way. Bases for Violence Keeping in mind the terms “general profiles” and “right conditions,” the following bases for profiling violence are “best bet” predictors of “RIGHT NOW!” There are biological, psychological, and social bases for violence. Biologically, low intelligence, hormonal imbalances, organic brain disorders, neurological and systemic changes of a psychiatric nature, disease, chemicals, intense and chronic pain, or traumatic head injury may lead to more violence-prone behavior (Fishbain et al., 2000; Hamstra, 1986; Heilbrun, 1990; Heilbrun & Heilbrun, 1989; McNeil, 2009; Newhill, 2003, pp. 107–108). Psychologically, specific situational problems, certain functional psychoses, and character disorders are predisposing to violence (Greenfield, McNeil, & Binder, 1989; Heilbrun, 1990; Heilbrun & Heilbrun, 1989; Klassen & O’Connor, 1988; McNeil, 2009; Newhill, 2003, pp. 94–106). Socially, modeling the violent behavioral norms of family, peers, homelessness, lack of social support, relationship with potential victims, and the milieu within which one lives can exacerbate violent tendencies (McNeil, 2009; Nisbett, 1993; Tardiff, 1984a, p. 45; Wood & Khuri, 1984, p. 60). Finally, specific on-site physical environmental stressors such as heat, bad lighting and décor, crowding, noise, conflict, and poor communication can trigger violence (Anderson, 2001; Jensen & Absher, 1994; Newhill, 2003, p. 190; Vaaler, Morken, & Linaker, 2005). When all these ingredients are mixed together, the results start to resemble the kinds of people and environments with which the crisis worker is likely to come in contact (Tardiff, 1984a, p. 45). Age. Males between the ages of 15 and 30 tend to be the most violent subgroup (Blumenreich, 1993a, p. 36; Fareta, 1981; Kroll & Mackenzie, 1983; Shah, Fineberg, & James, 1991). Next come elderly clients, who are disproportionately represented in the population that may become violent (Astroem et al., 2002; Hindley & Gordon, 2000; Petrie, 1984, p. 107). Crisis workers tend to dismiss this group as being harmless, but in a study of 200 cases of assault at the Cincinnati Veterans Administration Medical Center, Jones (1985) discovered that 58.5 percent of the assaults took place in the geriatric facility. This statistic is noteworthy because the institution also had a large psychotic and substance-abusing population. Substance Abuse. There is probably no psychotropic drug, either legal or illegal, that does not correlate with violence when it is abused. Whether the abuser is going on a meth high, coming off Valium, or experiencing the withdrawal of heroin, violence and drug use have a strong relationship (Blumenreich, 1993b, p. 24; Piercy, 1984, pp. 131–135; Rada, 1981; Simonds & Kashani, 1980). The foregoing statement most certainly includes alcohol. Alcohol has been associated with more than half of reported cases of violence in emergency rooms and one-fourth of reported cases in psychiatric institutions (Bach y Rita, Lion, & Climent, 1971). The potential for violence is further increased when individuals who have a history of psychosis engage in alcohol or drug use (Klassen & O’Connor, 1988; Yesavage & Zarcone, 1983). Predisposing History of Violence. A history of serious violence, homicide, sexual attacks, assault, or threat of assault with a deadly weapon is one of the best predictors of future violence (California Occupational Safety and Health Administration, 1998, p. 3; Fareta, 1981; Monahan, 1981). Any background that includes contact with the criminal justice system for aggravated felonies, weapons possession, threats against prospective victims, or a history of assaultive behavior while hospitalized should automatically put the human services worker on notice to be extremely cautious with the client (Blumenreich, 1993a, p. 37; Klassen & O’Connor, 1988). Of all the predisposing clues for violent behavior, probably there is none better than being brought to a facility for violent behavior as a part of emotional disturbance or mental illness. Psychological Disturbance. A variety of mental disorders may be predisposing to violence: the antisocial personality type who has a history of violent behavior, emotional callousness, impulsivity, and manipulative behavior; the borderline personality who lacks adequate ego strength to control intense emotional drives and repeatedly exhibits emotional outbursts; the paranoid who is on guard against and constantly anticipating external threat; the manic who has elevated moods, hyperactivity, and excessive involvement in activities that may have painful consequences; the explosive personality who has sudden escalating periods of anger; the schizophrenic who is actively hallucinating and has bizarre or grandiose delusions; the panic attack victim who is fearful, dissociative, and has extreme fight-or-flight reactions; and the depressed suicidal ideator who is hopeless, agitated, and acting out suicidal plans (Blumenreich, 1993b, pp. 21–22; Grassi et al., 2001; Greenfield, McNeil, & Binder, 1989; Heilbrun, 1990; Heilbrun & Heilbrun, 1989; Klassen & O’Connor, 1988; McNeil, 2009; Murdach, 1993; Newhill, 2003, pp. 96–104). Social Stressors. Loss of a job, job stress, breakup of a relationship, a past history of physical or sexual abuse, and financial reversals are a few of the social stressors that cause acute frustration and rage in an out-of-control social environment that leads to violence (Blumenreich, 1993a, p. 370; Munoz et al., 2000). Family History. A history of violence within the family is often carried into other environments. An early childhood characterized by an unstable and violent home is an excellent model for future violence (Wood & Khuri, 1984, pp. 65–66). A history of social isolation or lack of family and environmental support also may heighten the potential for violence (Heilbrun & Heilbrun, 1989; Munoz et al., 2000). A nasty predictor of future criminal and violent behavior is cruelty to animals (Felthous & Kellert, 1986; Hellman & Blackman, 1966). It doesn’t take too much imagination to predict that children who set cats on fire or do other cruel things to pets are capable of a lot of violence as they become adults. Predisposing family histories of witnessing family violence, being abused, enduring excessive physical punishment, abandonment, deprivation, and neglect, as explicated in the chapter on partner abuse, are all predisposing to adult aggression (Eddy, 1998). Work History. A history of fractiousness and problems at a worksite is another correlate with violence (Newhill, 2003, pp. 110–111). Being fired at the post office is not the only situation in which workers exact revenge. Job loss and economic instability easily translate into paranoid “they did me wrong” thinking, which can then transfer over to social workers in unemployment offices and vocational counselors at employment services. Time. In relation to a person’s admission and tenure in a facility, time is critical. Admission on Friday or Saturday night during “party hours” significantly increases the potential for violence. In geriatric and mental hospitals, the evening hours, with the onset of darkness, change of shift, and decrease in staff, often lead to client disorientation and states of confusion (Occupational Safety and Health Administration, 2003). The effects of this time period have become so notorious that they have been labeled the sundown syndrome (Piercy, 1984, p. 139). Mealtime, toileting, and bathing are also prime times for violent outbursts (Barrick et al., 2008; Jones, 1985). Patients in both general and forensic psychiatric hospitals are more likely to be violent immediately after admission to the hospital (McNeil et al., 1991). McNeil, Binder, and Greenfield (1988) found that recent violent acts in the community are highly associated with violent acts in the first 72 hours of inpatient care. For most patients committed involuntarily, the possibility of assault is significantly increased during the first 10 to 20 days after admission, and for paranoids it remains high during their first 45 days (Rofman, Askinazi, & Fant, 1980). Presence of Interactive Participants. Violent behavior may be contingent on those who bring the person to the institution (Occupational Safety and Health Administration, 2003). Family members or friends who bring patients in for treatment often interact in a volatile manner with admitting staff, particularly if the staff are seen as abrasive and callous (Ruben, Wolkon, & Yamamoto, 1980) and treat either the patient or support persons in a curt or uncaring manner (Wood & Khuri, 1984, p. 58). Arguments that may occur between the client and support persons are easily transferred to staff. Furthermore, when admonitions by distraught or intoxicated supporters to “fix” the client are not given immediate attention, they or the client may express grievances against the institution and staff by acting out. Any client who is accompanied to the institution by a police officer should be viewed as potentially violent (Kurlowicz, 1990; McNeil et al., 1991; Piercy, 1984, pp. 140–141). Motoric Cues. Close observation by the human services worker of physical cues will often give clues to emergent states predisposing to physical violence (Kurlowicz, 1990; Petrie, 1984, p. 115; Weinger, 2001, p. 24). Early warning signs include tense muscles; bulging, darting eye movements; staring or completely avoiding eye contact; closed, defensive body posture; twitching muscles, fingers, and eyelids; body tremors; and disheveled appearance (Tardiff, 1989, p. 98; Wood & Khuri, 1984, p. 77). If the client is pacing back and forth, alternately approaching and then retreating from the worker, this may be a sign that the individual is gathering courage for an assault (Dang, 1990). The agitated client may have an expanded sense of personal space up to 8 feet in radius, instead of 3 to 4 feet, and may be extremely sensitive to any intrusion into that space (Moran, 1984, pp. 244–246). A number of verbal cues are precursors to violent action by the client. Heightened voice pitch, volume, and rapidity of speech may occur, particularly if the client has been using amphetamines or other psychostimulants. Confused speech content can reflect confused thought and psychotic breaks. Clients may use profanity or verbally threaten significant others, the worker, or the world in general. Note that there is a high correlation between threats of violence and acting on those threats. The more specific the threat is to the person, method, and time, the more seriously the threat should be taken (Blumenreich, 1993a, p. 37; Tardiff, 1989, p. 99). Multiple Indicators. The more the foregoing indicators are combined, the higher the potential for violence becomes (Klassen & O’Connor, 1988). Tardiff (1989) indicates that, if possible, the human services worker should attempt to assess all these factors; if they are present, the worker should clearly note the potential for violence on an intake form (p. 97) or on one of the violence prediction instruments previously mentioned. Tardiff further proposes that whether or not this information is available, one of the better verbal assessment techniques is to ask, “Have you ever lost your temper [in a violent manner]?” If the answer is “Yes!” the worker should proceed to ask how, when, and where this happened, and then perform an assessment much like that for suicide (p. 98). If any of the foregoing factors are apparent or are stated by the client, no matter how calm the client may appear to be, then a triage assessment of 10 on the interpersonal behavioral dimension should be made, the client’s record should be flagged, and caution should be used in regard to the potential of the client to harm self or others. Does this mean you should not go into the human services business and go into something less stressful, like hauling explosives? Your authors would propose not, because about 85 to 90 percent of violence is preventable (Mack et al., 1988). The rest of this chapter will attempt to demonstrate how that percentage can be achieved. Intervention Strategies Because the institution itself plays such a large part in the who, what, why, how, and when of treatment, it may be viewed as an equal and contributing partner in resolving problems with clients disposed to becoming physically and verbally assaultive. No two institutions are alike with respect to a number of variables that affect what the institution can do about the problem of violence. Yet when confronting clients who may be distraught, angry, fearful, and experiencing disequilibrium, all institutions have a common core of problems. Given the financial, legal, treatment, organizational, and philosophical limits idiosyncratic to each setting, the following intervention strategies should be viewed as a best “general” approach. Security Planning No antiviolence program can be accomplished without the commitment and involvement of top management such that everybody in the institution or agency understands that preventing violence is an absolute top priority (Barret, Riggar, & Flowers, 1997; California Occupational Safety and Health Administration, 1998, p. 6; Newhill, 2003; Weinger, 2001). The five main components of any effective safety and health program also apply to the prevention of workplace violence. These components are management commitment and employee involvement, worksite analysis, hazard prevention and control, safety and health training, and record keeping and program evaluation (Occupational Safety and Health Administration, 2003). Commitment and Involvement One of the first steps in preventing violence is understanding what precautions the institution has taken to ensure the safety of clients and staff. Management commitment and employee involvement in a safe workplace are critical (Occupational Safety and Health Administration, 2003). The institution should have a zero tolerance policy for violence for both clients and providers. It should assign clear responsibility to all staff members so that they know what is expected of them, along with adequate resources to carry out those responsibilities and make them accountable for doing so. Certain precautions can be taken to ensure that workers are not put at extreme risk by their clientele. First and foremost, management should conduct a security management analysis with experts in the security field (Ishimoto, 1984, p. 211; Kinney, 1995, pp. 47–50). Kinney (1995) urges that management recognize that the people with the most knowledge are the frontline workers who deal with the institution’s clientele on a day-in, day-out basis, even though management may not want to hear from these workers for fear of what they might say. There should be channels for employees to bring their concerns to management and receive feedback without fear of reprisal or censure (Occupational Safety and Health Administration, 2003). Worksite Analysis A worksite analysis involves taking a step-by-step approach to addressing potential hazards, focusing on areas in which they may develop, and reviewing procedures put in place to curtail violence (Occupational Safety and Health Administration, 2003). There is a condensed security analysis questionnaire from Kinney (1995, pp. 211–216) and Ishimoto (1984, pp. 211–216) in the website exercises for this chapter, and you are invited to peruse the rather lengthy list of questions. This questionnaire analyzes and tracks records, generates screening surveys, and reviews workplace security (Occupational Safety and Health Administration, 2003). If such a survey is not taken, not only does the facility risk outbreaks of violence but the staff will perceive management as not being greatly concerned about what happens to them (Lewellyn, 1985). Once the results of the survey are compiled, the organization should institute planning in hazard prevention and control. Hazard Prevention and Control All staff should have input into these questions, and a comprehensive security plan should be worked out and disseminated (California Occupational Safety and Health Administration, 1998, p. 8; Occupational Safety and Health Administration, 2003). Such a plan should be comprehensive and simple, detailing who is responsible for what, under which conditions. The plan should cover the entire domain of the institution, starting with the parking lot, moving through the front door to admissions, and proceeding through the building to encompass day treatment facilities, staff offices, food services, pharmaceutical dispensaries, and client rooms (Ishimoto, 1984, pp. 209–223). Although the administration may view the initial costs in time and money for this service as burdensome, net cost will be minimal if this action avoids just one lawsuit by a client or staff member (Moran, 1984, p. 249). Threat Assessment Teams. While consultants with different areas of expertise in violence containment may be helpful, planning should start by forming a threat team composed of a cross section of the staff and by naming a violence prevention coordinator. The duties of this team and coordinator will be to (1) outline the scope and activities of a threat management policy; (2) issue a clear and publicized statement against violence, even if the statement simply says, “This organization will not tolerate violence and aggression either from within or from outside the organization”; (3) identify a location and person for reporting threats; (4) determine when threats are serious enough to convene the team; (5) set training for all staff; and (6) establish a protocol for violence reduction that addresses unacceptable types of behavior as well as appropriate sanctions for that behavior (Kinney, 1995, pp. 73–80; Myer, James, & Moulton, 2011; Newhill, 2003, pp. 189–199; Nicoletti & Spooner, 1996; Weinger, 2001, p. 53). Establishment of a threat assessment team is particularly critical on a college campus (Myer, James, & Moulton, 2011, pp. 256–267). Virginia Tech is a classic example where, for various political, logistical, legal, and ethical reasons, a silo mentality occurred and critical information was kept in separate units and never shared. It should be clearly understood that Virginia Tech was no different from any other institution in regard to the barriers erected and communication channels that were effectively blocked that could perhaps have mitigated the effects of a mass murderer before he got to the tipping point. In fact, thanks to changes in Virginia law, institutions of higher education and mental health facilities in Virginia are now better able to communicate and exert sanctions and exclusions on individuals who fail to cooperate in assessment and treatment programs than in most other states (Mandatory Treatment of Mental Health Patients, 2007; Threat Assessment Team Formation, 2008; Threat of Violence, 2008). An individual such as Seung-hui Cho may come to the attention of a variety of individuals, entities, and departments but never be so blatant and labile that he or she comes to the attention of anyone and nothing is done to proactively contain the person until a tragedy occurs. That’s why a cross section of campus representatives from housing, recreation, food services, academic departments, the counseling center, and law enforcement all need to be part of a threat assessment team that meets regularly and sifts through all incident reports that occur on campus. That threat assessment team also needs a common language such as TASSLE (Myer et al., 2007), discussed in Chapters 3 and 13, so that they have a common set of terms and behavioral anchors to use in making dispositions of individuals that come to their attention (Myer, James, & Moulton, 2011, pp. 233–270). Precautions in Dealing With the Physical Setting. Safety precautions should be taken that deal with the physical settings of the institution in which staff members are most likely to become involved in potentially violent situations with clients. Two critical areas important to all crisis workers are the admissions area and the worker’s office. The reception area or waiting room should offer a television set, reading material, and accessibility to snack areas. Availability of entertainment and food and drink gives clients and visitors an opportunity to engage in a pleasurable activity that can offset the hostile feelings that may be engendered by the problems they are facing and can defuse the stressful situation of admission (Wood & Khuri, 1984, pp. 79–80). One admonition is necessary with regard to food and drink: Clients who are extremely rebellious about entering the institution may attempt to choke themselves on food or even swallow pull tabs from metal cans. The admissions staff should carefully monitor clients if they are allowed to eat or drink (McCown, 1986). The admissions area should be clean and well kept, with furniture, carpet, and wall coverings well maintained. First impressions are lasting. If the client’s first impression of a facility is that staff have little regard or respect for the facility, the client will have little reason to respect what goes on there either (Marohn, 1982). Suffice it to say that fire engine red paint is not a decorating choice. Bright, cheery, energizing decorations should not be used any more than the somber and depressing institutional grays and greens of many mental institutions and prisons one of your authors has worked in and visited (Newhill, 2003, p. 190; Vaaler, Morken, & Linaker, 2005). Subdued painting and decorating and comfortable, relaxing furniture do a lot to alleviate anger, tension, and pent-up agitated feelings and thoughts. No sharp, movable objects, including furniture, should be available as potential weapons (McCown, 1986). Clients should be given lockers in which to put their belongings (Munsey, 2008). The area should be set up so that it is a choke point: only one way into the rest of the facility should be available from the admissions area. Video surveillance should be kept on this area to record everybody who comes in and out, along with a sign-in sheet that records everyone coming in and is checked to make sure that everyone has gone out (Annis, McClaren, & Baker, 1984, p. 30). There should, however, be another way out for workers, and a panic room where workers could secure themselves from intruders is not a bad idea (Munsey, 2008). Depending on how much security is needed, the reception area may also have electronically locked doors that separate it from the rest of the facility, identity check procedures, curved mirrors, and metal detectors (California Occupational Safety and Health Administration, 1998, p. 10; Munsey, 2008). Clients who are waiting for service should be treated in a courteous and friendly manner and updated on interview delays. Waits should be kept to a minimum (Weinger, 2001, p. 53). In that regard, is it any wonder that people become agitated and enraged in most hospital emergency rooms? The admissions worker will make the first contact with the client and will engage the person during one of the most potentially violent moments the institution is likely to encounter. The admissions worker should be highly skilled in crisis intervention techniques and should have one primary job—staying with and attending to the client being admitted! Under no circumstances should a secretary, receptionist, or any other support person who is not professionally well versed in crisis intervention or who has other tasks to perform, such as typing letters or answering the telephone, be delegated to handle this important assignment. The admissions worker should not leave the client until all admitting procedures have been accomplished and the client is safely settled (McCown, 1986). The admissions worker should also never be left in a position of isolation from the rest of the staff (Turnbull et al., 1990). Security support equipment such as a body alarm (a button-activated device that when triggered will automatically send an alarm and position fix to security), an automatic dialer preset to in-house security and 911, convex mirrors to monitor the whole waiting area, panic buttons, closed-circuit television monitoring equipment, button locks on elevators, and a metal detector at the entrance should be available. Initial interviews are critical in setting the tone for what will occur behaviorally. Therefore, the interview area should be open, yet afford privacy. At times, if the client is very agitated, other staff or indeed a police officer may need to be present (Doms, 1984, pp. 225–229; Jones, 1984; McCown, 1986; Weinger, 2001, p. 53; Wood & Khuri, 1984, pp. 79–80). Now a word about what you need to look like. The following admonition is probably politically incorrect, and we are going to sound like your overprotective father to many of you young women reading this, because we are now going to tell you what you need to wear. Low-cut necklines are all the rage right now. This is not the setting to be a slave to fashion! Some clients have real boundary problems (Newhill, 2003, p. 191), and here is not the place for their impulsivity to take over and you to wind up being sexually or physically assaulted. Put on professional work clothes that say, “I am here to help you, but I mean business!” And if you are a guy and you are into grunge and you think that looking like a punk rocker will help you relate to your clients, you probably need to go into a street ministry. Conversely, you don’t need to look as though you stepped out of GQ or Vogue magazine, but not looking like a professional conveys the impression that you aren’t. It is called face validity. If clients don’t believe you look as though you know what you are doing, you will probably not get the chance to demonstrate that you do. Personal work environments should also be safe. Desks should be set up so that they allow for separation of client and worker, even though communicating across a desk is not the most desirable counseling setup. Furniture should be heavy and difficult to move. Space should be arranged to permit both the worker and the client clear access to the door and to allow the worker to leave the room without having to confront the client or cross the client’s personal space. No potential weapons such as paperweights, letter openers, and sharpened pencils should be openly displayed or within easy reach of the client. The same personal warning devices and procedures recommended for the reception area should also be in place in workers’ offices (Jensen & Absher, 1994, 1998; Tardiff, 1984a, p. 50). The receptionist or others in the building need to be able to warn the worker if danger is imminent, and vice versa. There should be a common code word that is understood to mean a summons for immediate help. A panic button and a telephone that the worker can use to get in touch with the outside world should be available. These last two points are particularly critical because of the typical isolation of the human services worker with a client in a therapeutic setting (Jensen & Absher, 1994, 1998; Tardiff, 1984a, p. 50). Training Planning is of little consequence if no training follows. Staff who have been trained in the appropriate methods, techniques, and procedures have increased confidence in their ability to deescalate violence and have reduced assaultive behavior (Thomas, Kitchen, & Smith, 2005; Turnbull et al., 1990). Training should include both knowledge and skill building and should be ongoing, with immediate training for new members of the treatment team and continuing education for veterans (Dyer, Murrell, & Wright, 1984, pp. 12–15; Newhill, 2003, p. 207; Turnbull et al., 1990; Weinger, 2001, pp. 52–53). Every employee should understand that violence should be expected but can be avoided or reduced through preparation (Newhill, 2003, p. 206; Occupational Safety and Health Administration, 2003). Training should begin with the crisis intervention skills listed in Chapters 3 and 4 and additionally cover legal aspects, theories of aggression, reporting and recording of incidents, assessment of contextual and environmental variables, verbal defusing techniques, triggers of aggression, warning signs, use of safety and alarm devices, self-defense and restraint techniques, behavioral observation, consultation, follow-up staffing procedures, and debriefing (Blair, 1991; Kinney, 1995; Murray & Snyder, 1991; Occupational Safety and Health Administration, 2003; Turnbull et al., 1990). A critical component of training is not just talking about problems but gaining practice in solving them. There is no better way of doing this than in role-play and incident simulation situations, which can be video-taped for analysis and feedback by instructors and peers (Forster, 1994; Turnbull et al., 1990). Training should also include the people who need it most—the clients! Anti-Violence Intervention. Most approaches to anti-violence prevention involve the use of behavioral (token economies, shaping, modeling contingency contracting) or cognitive-behavioral intervention methods (reframing negative attributions, thought stopping, relaxation training, positive counterinjunctions) (Douglas, Nicholls, & Brink, 2009). The risk-needs-responsivity (RNR) model is a procedure that is taken from the corrections field. The risk component proposes that high-risk individuals get more targeted, specific, and tailored therapeutic inputs before they go critical. The needs component focuses on the dynamic risk factors that when changed reduce recidivism. This procedure has been applied to anti-violence programs with the severely mentally ill and severely emotionally disturbed. RNR usually incorporates cognitive-behavioral therapy, social skills training, anger management, and behavioral techniques that apply role rehearsal, modeling, and shaping to prosocial behavior (Douglas, Nicholls, & Brink, 2009). While not perfect by any stretch of the imagination, it appears that RNR is at least somewhat effective with severely mentally ill and severely emotionally disturbed individuals (Lovell et al., 2001; van den Brink et al., 2010; Wong, Gordon, & Gu, 2008; Yates et al., 2005) who present with very tough, intractable, and chronic issues that are generally resistant to change. Assumptions. Adequate training should endow the crisis worker with the ability to make certain assumptions and take certain precautions when dealing with potentially violent clients (Newhill, 2003, pp. 121–165; Turnbull et al., 1990; Weinger, 2001, p. 45; Zold & Schilt, 1984, pp. 98–99). 1. Assume the need to set limits and provide clear instructions with options that define what positive and negative consequences will occur. 2. Assume the client feels a number of debilitating emotions such as fear, depression, anxiety, helplessness, anger, rejection, and hopelessness, and demonstrate concern by encouraging verbal ventilation through how and when questions, showing empathic concern by restatement and reflection of the client’s feelings, and reinforcing appropriate behavior and communication of feelings. 3. Assume frustration of normal activity and boredom when the client is in residence, and provide activities to keep the client fruitfully busy. 4. Assume a threat to the client’s self-esteem, independence, and self-control, and provide choices and opportunities to help in carrying out medical and psychological activities. 5. Assume tension and arousal, and provide a calm and relaxing atmosphere, particularly in high-tension periods, by manipulating environmental variables and using a cooperative “we” approach. 6. Assume that there will be confusion, and provide a careful explanation of all procedures to be employed, being particularly sure that all staff are operating from the same frame of reference. 7. Assume responsibility, and provide for one primary staff member to act as chief caretaker and advocate of each client. 8. Assume disconnectedness and rootlessness if the client is to be institutionalized for any length of time, and provide familiarity and psychologically calming anchors associated with pleasant memories. Precautions. While providing support through the preceding proactive behaviors, the wise human services worker should observe a number of precautionary measures (Blair, 1991; Forster, 1994; Greenstone & Leviton, 1993; Moran, 1984, p. 244; Piercy, 1984, p. 143; Turnbull et al., 1990; Weinger, 2001, pp. 33–48; Wood & Khuri, 1984, p. 69). 1. Don’t deny the possibility of violence when early signs of agitation are first noticed in the client. 2. Don’t dismiss warnings from records, family and peers, authorities, or fellow workers that the client is violent. 3. Don’t become isolated with potentially violent clients unless you have made sure that enough security precautions have been taken to prevent or limit a violent outburst. 4. Don’t engage in certain behaviors that may be interpreted as aggressive, such as moving too close, staring directly into the client’s eyes for extended periods of time, pointing fingers, or displaying facial expressions and body movements that would appear threatening. 5. Don’t allow a number of the institution’s workers to interact simultaneously with the client in confusing multiple dialogues. 6. Don’t make promises that cannot be kept. 7. Don’t allow feelings of fear, anger, or hostility to interfere with self-control and professional understanding of the client’s circumstances. 8. Don’t argue, give orders, or disagree when not absolutely necessary. 9. Don’t be placating by giving in and agreeing to all the real and imagined ills the client is suffering at the hands of the institution. 10. Don’t become condescending by using childish responses that are cynical, satirical, or otherwise designed to denigrate the client. 11. Don’t let self-talk about your own importance be acted out in an officious and “know-it-all” manner. 12. Don’t raise your voice, put a sharp edge on responses, or use threats to gain compliance. 13. Conversely, don’t mumble, speak hesitantly, or use a tone of voice so low that the client has trouble understanding what you are saying. 14. Don’t argue over small points, given strong opposition from the client. 15. Don’t attempt to reason with any client who is under the influence of a mind-altering substance. 16. Don’t attempt to gain compliance based on the assumption that the client is as reasonable about things as you are. 17. Don’t keep the client waiting or leave a potentially violent client alone with freedom to move about. 18. Don’t allow a crowd to congregate as spectators to an altercation. 19. Don’t use why and what questions that put the client on the defensive. 20. Don’t allow the client to get between you and an exit. 21. Don’t dismiss increasingly vociferous client demands as merely attention-seeking, petulant, or narcissistic behavior. 22. Don’t enter a room ahead of unknown clients. Stay behind and visually “frisk” them as you go into the room. 23. Don’t remain after hours with a potentially violent client unless proper security is available. 24. Don’t fail to make contingency plans for violent incidents. Take your personal safety seriously by playing “what if this happens” scenarios in your mind and with others. 25. Most important, don’t attempt to be a hero. Outreach Precautions. In the rapidly changing world of mental health, much crisis intervention now occurs on-site (see Chapter 17, Disaster Response). Although outreach and “mobile go-out” teams give the crisis interventionist far more mobility and rapid response capability, on-site intervention also has the potential to put crisis workers in extreme danger as they operate in violent neighborhoods and households (Burry, 2002). Besides the foregoing warnings given for in-house operation, the following injunctions generated by your authors and a variety of others (Cawood & Corcoran, 2009; Greenstone & Leviton, 1993, pp. 31–33; Jensen and Absher, 1998; Newhill, 2003, pp. 199–204; Weinger, 2001, pp. 56–59) should be added to the repertoire of the crisis worker who operates outside the walls of the institution. 1. If at all possible, go with a partner, or at least have a cell phone or other means of communication to get help in a hurry. 2. Let someone else in the office know where you are going and when you will be back. 3. Check out your surroundings. Although time is of the essence in most crisis intervention, move into the situation slowly and carefully, and be fully aware of what is going on in the environment around you. 4. Plan what you are going to do before you go. Take time to gather in-depth and accurate behavioral information on the client and family. Note any incidents of violence, drug abuse, or other potentially threatening behaviors in the client’s folder before the visit. Our Crisis Intervention Team officers for the Memphis Police Department rendezvous and plan who is going to do what before they enter a hazardous situation whenever possible. You should do the same. 5. Don’t park directly in front of the place where the crisis is occurring. Check out the area as you drive by, and park just beyond it. If you have to leave in a hurry, this position allows you to leave without crossing the line of sight of a person who may be able to harm you. 6. Before knocking on a door or entering a building, listen carefully for a few seconds for clues as to what may be going on inside. 7. Never stand directly in front of a door. Knock and, as the police do, stand aside, so you are not assaulted or shot through the door. If the client hesitates in opening the door, be very wary of going inside. If you think that something is happening that is suspicious or that could be hazardous to your health, politely terminate the appointment and leave. 8. Consider what you are wearing from a safety view-point. A tie or a choke chain may make you look more professional, but it can also get you strangled. High heels are elegant, but you can’t run in them. Loose-fitting, mobile, and nonflashy clothing is the watchword. 9. Once the door is open, immediately scan the room to determine who is in it and where they are. Compare these visual data to i

f