Self Defence for Mental
Health Professionals
Graham Martin,
Ed Heffernan,
James Scott,
Rod Martin,
Malwina Martin,
Sarah George
Li Tieh Kuai (Iron Crutch Li), most ancient of the 8 ‘Immortals’
Born 2nd Century AD (Han Dynasty)
Disclaimer
• Today I am not trying to teach Karate; the
focus is on quick and dirty ways of
defending yourself, prior to running away.
• None of what we work on today should be
too physically arduous; we will protect you
from injury; we want you to be able to
enjoy the rest of your Congress.
• However, we cannot accept liability for any
loss or any personal injury
We live in dangerous times
• Before Grade 1, the average child has seen over 8,000
murders on television and over 100,000 violent acts. By
schoolies week, the numbers will double (American
Academy of Child and Adolescents Psychiatry, 1995)
• An average TV program contains 5 acts of violence per
hour, the average kid’s program shows 25 per hour.
(Center for Media & Public Affairs)
• Lyrics from Michael Mather (Eminem) talk about
sticking nails through eyelids and slitting parents’
throats.
• Children have access to video games like Doom, Diablo,
and Kingpin (“multiplayer gang bang death” and “see the
damage done including exit wounds”)
Team Sports may not help much
Why I wanted to do this
presentation
• We have a responsibility to ourselves and to
others to have reflected on our experience
and prepared for the future as well as we can.
• Christopher L.
• Mary K.
• Dr. Nandadevi Chandraratnam, who died on 3rd
December 1992
• Dr. Margaret Tobin, who died on 15th October
2002
Factoid
• Health care workers experience close
to 40% of non-fatal assaults on
employees in the United States.
Victims of Patient Assault
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Physicians
Nurses
Social workers and other allied health personnel
Other patients
Visitors
Emergency team members
Administrators
Police
Staff in Corrections
Brasic JR, Ainsworth J: Clinical safety in neurology. eMedicine Neurology Journal [serial online].
2005 . Available at http://www.emedicine.com/neuro/topic713.htm.
Crilly, et al.: Violence towards emergency department nurses by patients. Accid Emerg Nurs 2004;
12: 67-73
Staff members who have developed a
systematic approach to the treatment,
understanding and management of
assaultative behaviour are less likely to
injure or be injured during an assaultative
incident than those who haven’t.
Gun Deaths in Australia
Categories of
Workplace Violence (US)
• Type I- Stranger vs. Employee (example:armed robbery)
Accounts for 60%
• Type II- Client vs. Employee
(example: social worker attacked by client)
Accounts for 30%
• Type III- Employee vs. Employee
Accounts for 10% of workplace attacks and/or homicides
Small Group Workshop
Exercise
Your Personal Experience
Is there a profile?
Dr. Tobin’s killer
(prevention may not have been possible)
• “In his closing argument in the SA Supreme Court,
Prosecutor Peter Brebner said there was too much
evidence linking Jean Eric Gassy with the victim
for it to be discounted as a coincidence. Gassy
owned pistols like the one used…. And Gassy had
travelled to Adelaide in October 2002…. Gassy
also harboured resentment towards Dr Tobin for
the role she played in having him deregistered in
1997…. Gassy, 48, was diagnosed as suffering a
delusional disorder prior to his deregistration ”
(The Age)
“I remember the time
he gave to my Dad.
He would come around
at the drop of a hat.
He was a marvelous GP…
apart from the fact that
he killed my father”
Quote from Christopher Rudo son of a victim killed by mass
murderer Dr Harold Shipman
Dr. Chandra’s killer
(prevention may have been possible)
• "There is no doubt that Mr. Tzeegankoff has a
history of impulsive behaviour with violence which
ante-dates the onset of his psychotic illness in the
mid 1980’s. The psychotic illness has at times been
difficult to delineate, but on balance it would
appear that he has a paranoid schizophrenic
illness.” (Prof. Robert Goldney)
• “There is little evidence before me about whether
there was a specific treatment plan formulated in
relation to his illness.” (Coroner Wayne Chivell)
Principle 1
Most criminal violence is not committed by the
mentally ill
• most mentally ill are not violent
• violence committed by the mentally ill may be
due to reasons not directly related to their
psychiatric impairment
The next 5 slides courtesy of Dr. Ed Heffernan
Principle 2
Mental illness alone is a modest risk factor for
violence
• mental illness COMORBID with substance
abuse and personality pathology
dramatically increases risk
• more disorders = higher risk
• subs abuse > psychosis > neurotic
Principle 3
Shared risk factors
• predictors of violent recidivism in any
mental illness are strikingly similar to those
of offenders without illness
• violence committed by the mentally ill may be
due to reasons not directly related to
psychiatric impairment
– Hx of violence
– Hx of criminality
– Younger age, male, lower SES
– substance use
Principle 4
Victims are more like to be known
That is:
• more likely to be family or
acquaintances
Principle 5
Active symptoms increase risk
• individuals with mental illness alone are most
likely to be violent when acutely unwell
• non-compliance with therapy may be a
factor
Relevant History to alert you
• Previous history of violence to self or
others
• History of family violence
• Substance abuse and/or dependence
• Antisocial personality disorder
• Borderline personality disorder
• Bipolar disorder
• Dementia
• Head injury (with history of disinhibition)
• Impulsivity
• low frustration tolerance
• inability to tolerate criticism
Relevant History (2)
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Male gender
Single
Learning disability or Intellectual Disability
History of physical and/or sexual abuse
Violence at home
Lower socioeconomic status
Lower income
Homelessness
Poor social networks
Sex offender
Fire setting and other history of
Delinquency (eg torture of animals)
Current Status which may be
important
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Acute confusional state
Acute organic psychosis
Alcohol intoxication
Delirium
Delusional
Grandiose
Agitation
Anger
Factors increasing your
suspicion of likely violence
• Deep belief that they are the victim of the organization
• Self centered moral righteousness
• Access to guns and other lethal weapons
• Participation in gangs
• Tattoos and old scars
• Recklessness or Risk-taking
• Verbalization of command auditory hallucinations
to perform violence
• Verbalization of intent to kill
• Verbalization of plan to take revenge
Assessing for +ve history
• Brief Psychiatric Rating Scale (BPRS)
and Gorham, 1962)
(Overall
– Hostility Scale
(hostility, suspiciousness, and uncooperativeness)
– Negative Symptom Scale
(flat affect, emotional withdrawal, and motor retardation)
– Positive Symptom Scale
(concept disorganization, hallucinatory behavior, and
unusual thoughts)
Empathy Tasks (Abu-Akel and Abushua’leh, 2004)
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• Modified Overt Aggression Scale (Kay et al, 1988)
• Maudsley Violence Questionnaire (Walker, 2005)
Times when things can go wrong
• Seasonal variations (High Summer, Early
Spring and Deep Winter)
• Temporal variation (eg, evenings, nights,
weekends)
• Staff variation (eg, students, new staff,
temp staff)
• Nursing unit variation (eg, admission,
maximum security, violent patients)
• Copycat or Clustering Effects (Impact of
Media or Local Events)
Triggers for Violent Episodes
• Job loss
• Relationship
Breakdown
• Long wait to be
assessed
• Anxiety
• Fear
• Frustration
• Hunger
• Noise
• Pain
• Sleep deprivation
• Denial of patient
request for admission
• Involuntary
hospitalization
• Disrespect, actual or
imagined
• Lack of privacy
Contexts Associated with Violence
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Absence of escape routes
Inadequate staff
Malfunctioning equipment
Portable furniture
Portable objects
Unobserved patients
Untrained protective services
Know your environment
Exercise: Draw your rooms or where you work.
Where could you get trapped?
Where are the escape routes?
How do you let people know you are in trouble?
Signs of Impending Violence
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Flushed facies
Hostility
Impulsivity
Loud outbursts
Name calling
Obscene or Profane language
Opening and closing the fist
Pacing
Pointing
Pulling out a weapon
Signs of Impending Violence
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Tension
Restlessness
Smell of alcohol on breath
Pushing furniture
Staring or widened eyes
Sudden movements
Slamming or throwing objects
Uncooperativeness
Sometimes you are certain
you can manage
Other times you just know
you are in trouble
Assessing Risk
• Take all threats of violence seriously.
• If you feel apprehensive, tense or afraid in a
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clinical situation, then follow your instincts
and guard your personal safety. Take steps to
either remove yourself or get help.
Experienced clinicians follow their gut
reactions that something serious is imminent.
Create a Safety Plan
(personal or system based)
Exercise:
What will you do when you get back?
Administrative Approaches
• Make it clear to patients, clients, and employees
that violence will not be tolerated or permitted
• Establish face to face liaison with local police
and ask them to review your premises for
problems.
• Require employees to report all assaults and
threats
• Consider setting up an emergency response team
Technology to prevent violence:
Awareness, Vigilance, Communication, Action
• Closed circuit television monitoring
• Panic buttons in all clinical areas
• Two-way communication systems
Context Monitoring
• Establish a violence reporting system
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and regular review of reports
Review staff meeting reports on
safety issues
Analyze trends in illness/injury or
fatalities caused by violence
Measure improvement based on
lowered frequency and severity of
violence
Staff Training and Education
• Ensure that all staff are aware of potential
security hazards and ways of protecting
themselves
• Train in recognition of risk factors that cause or
contribute to assaults, and
• Early recognition of escalating behavior or warning
signs
• Workplace violence prevention policy:
– Ways to prevent volatile situations
– Standard response action plan for violent situations
– Location and operation of safety devices
Tips: Staff Protection
• Tuck ties in shirt.
• Don’t wear necklaces or earrings.
• Don’t divulge personal information
about yourself.
• Give yourself access to exit.
Tips: Alternative Devices
• Name badges can be on breakaway clips. Don’t use aroundyour-neck lanyards.
• Stethoscopes can be clipped to
the belt instead of around the
neck.
• Scissors can be used as a
weapon. Be aware of where they
are in relation to your patient.
Prevention is better than
something unexpected and
nasty happening
Personal Strategies to avoid
violence
• Do not interview or examine patients in your home.
• Do not interview dangerous patients in offices without a
security guard.
• Install windows in the doors of examination rooms.
• Avoid furniture that can block exits from rooms.
• Equip examination rooms, offices, and nursing stations
with panic buttons.
IN THE FUTURE WE MAY HAVE TO CONSIDER:
• Requiring patients (and ? even staff) to pass through
metal detectors before entering clinical areas.
Defusing Techniques
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Attend to client before things get out of hand
Walk/Stand confidently
Maintain eye contact
Avoid arguing or defending previous actions
• Avoid threatening body language (don’t stand
with arms crossed).
Defusing Techniques (2)
• Calmly but firmly state the limits.
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Communicate information about any delays etc.
Give some choices.
Seek a family member or friend to support
If situation continues to escalate, with louder,
more agitated verbalizations, reduce
stimulation from setting…eg. bring from waiting
room to exam room.
Your Personal Safety Depends
On….
Two Rules!
1. React quickly.
2. Make a decision.
Two Questions!
1. My situation?
2. Best options available?
Two Objectives!
1. Survive.
2. Escape.
Acting in Self Defence
Confronting an Attacker
• You are walking in a
dark alley when you find
yourself in a bad
situation. Standing in
front of you is a male
figure. Without
warning he moves
quickly towards you.
• What do you do??
Confronting an Attacker
• Recent studies show that females who
fight back are less likely to be killed or
seriously hurt.
• A majority of attackers are seeking an
easy target. The harder you make it for
them, the better chance you have to
survive.
Fighting Back
• Everything you do should be setting up to
allow you to escape (ie run away)
• It’s not what you can do that’s important,
but what you are willing to do.
Behaviour to Abort Violence
• Keep an attacker in your visual field.
• Maintain eye contact
• Do not turn your back on an attacker.
• Make sure that an attacker does not invade
your personal space within 4 to 6 feet
• Be prepared, but not provocative
Short Video
Taken from 100 Techniques of
Self Defence, these 2 segments
can give you some ideas
RESPONSE
Question:
When we are responding to a person
who is threatening or attempting to
injure, will we be able to match our
response to the level of injury
threatened?
Definition of Reasonable Force:
“A reasonable amount of force is just
enough force for effective protection
of self and others and no more than is
absolutely necessary”
(Smith, P., 2004. P.A.R.T. Trainers Manual)
Selecting a self defense
strategy
• What is my goal?
• If you decide to fight back,
what is the best technique
for you?
Selecting a self defense
strategy
• Am I willing to get physical?
• Can I bring myself to hit
someone?
• Could I deliberately and
knowingly cause damage?
What might you need to know?
• Martial Arts and self-defense are not
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synonymous.
Traditional martial arts have skills that
are not designed, nor are they realistic
for a self-defense situation.
The idea that someone can do a high kick
to a person’s face on an icy street is not
realistic.
In this workshop we seek to teach what
is simple, direct, and uses gross motor
skill moves.
Key Points to Fighting Back
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Don’t panic
Don’t freeze-up, react quickly
Do start yelling, make lots of noise !
Commit and go hard
Recognize and utilize escape opportunities
Do whatever it takes!
Key Points to Fighting Back
Never
ever
give
up!
Active Demonstrations
1.
Someone pointing and shouting abuse
• Maintain eye contact
• Move sideways on
• Keep hands up, but do not provoke
ESCAPE….
Active Demonstrations
2.
The Wrist Grab
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Pull away (reinforced)
Offer food
Wave at your Mum
Pull arm across body and push shoulder
ESCAPE….
Active Demonstrations
3.
The lapel grab (single hand)
• Same hand over top to cover, grab and turn
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hand over
Try the same thing with pressure on elbow
Turn in and ‘push’ under jaw
ESCAPE….
Active Demonstrations
4.
The Lapel Grab (2 hands)
• Bowling Arm
• Goal Umpire
• Strike to Brachio-Radialis
ESCAPE….
Active Demonstrations
5. On being strangled from in front
• Grab hands (natural) and turn to side
• If up against a wall sweep with 1 arm and
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twist
Turn and push away (or strike to throat)
Hit to ear or ears with cupped hand
Knee
ESCAPE….
Active Demonstrations
6. The Hay Maker Punch
• Cover up
• Wave at your Mum
• Body weight Dinosaur
ESCAPE….
Active Demonstrations
7. The Strangle from Behind
• Head Butt
• Twist head to give an airway, grab the
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hand, strike and pull your head through…
Groin Strike
The Wrist Grab
ESCAPE….
Active Demonstrations
8.
Bear Hug
• Breathe in, Drop down
• Bum Strike
• Strike to the Groin
ESCAPE….
Active Demonstrations
9.
On the Ground
• Hands on head and roll away
• Strike to the groin
• Kicking with legs
ESCAPE….
Active Demonstrations
10 The attack with a knife
No Illusions - this is hard….
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Cover up an arm and try to block
Groin kick
Grabbing the wrist
Escape….
Active Demonstrations
11 The attack with a gun
It’s all too late
Chance
[ESCAPE….]
Confronting an Attacker
• You are walking in a dark
alley when you find yourself
in a bad situation. Standing
in front of you is a male
figure. Without warning he
moves quickly towards you.
• Did you change what
you might do??
After the Event
After something horrible
happens….
Adverse Consequences of
Violence
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Feeling upset
Feeling irritable
Headache
Anger
Blaming self
Fear of caring for
isolated patients
• Insecurity
• Refusal to identify
self to patients
• Lost time from
work
• Career change
• Low worker morale
• Poor job
satisfaction
• Poor worker
retention
Coping and Survival Strategies
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Denial
Hiding
Calling police
Seeking advice or help from others
Fighting back / self-defense
Leaving
Self-medicating
Post-Incident Response
• Provide comprehensive treatment for
victimized employees and employees
who may be traumatized by
witnessing a workplace violence
incident
• Critical incident stress debriefing
• Trauma-crisis counseling
• Employee assistance programs to assist victims