PROTECTING THE RIGHTS OF THERAPISTS WITH DIFFICULT AND
THREATENING CLIENTS: ETHICAL AND LEGAL CONSIDERATIONS
Florida Psychological Association (3 HOURS)
Abridged Powerpoint from seminar originally presented by:
Presented by Ernest J. Bordini, Ph.D. & Robert Henley Woody, Ph. D., Sc. D., J. D., ABPP
July 14, 2006 -- Sarasota, Florida
PROTECTING THE RIGHTS OF THERAPISTS
WITH DIFFICULT AND THREATENING CLIENTS:
ETHICAL AND LEGAL CONSIDERATIONS (3 HOURS)
Presented by July 14, 2006 -- Sarasota, Florida
Presenters:
Robert Henley Woody, Ph. D., Sc. D., J. D., ABPP
Ernest J. Bordini, Ph. D. (Clinical Psychology Associates of
North Central Florida, P.A., Gainesville, FL)
Tony Galietti
WORKPLACE VIOLENCE
Workplace Homicide Trends
• Workplace homicides 1993 through 2002 declined from 1,074
workplace homicides in 1993 to 609 in 2002 - a 43% decline.
• This decline did not, however, occur uniformly across all
demographic and occupational categories.
• Within that time period, health service industry homicides did not
decline 14 in 1993 vs. 13 in 2002.
• Source: Census of Fatal Occupational Injuries (CFOI)
•
The Bureau of Labor Statistics’ Census of Fatal Occupational
Injuries (CFOI) reported an average of just under 800 homicides per
year between 1992 and 2006. The largest number of homicides in
one year (n=1080) occurred in 1994, while the lowest number
(n=540) occurred in 2006.
Workplace Homicide Trends
• Victimization rate for mental health professionals and custodial
workers was 6.82 per 100 workers compared to a rate of 1.26 per
100 workers across all occupations combined (Durhart 2001).
• Non-fatal assaults on health care workers includes assaults bruises,
lacerations, broken bones and concussions but those reported to the
Bureau of Labor Statistics (BLS) only include injuries severe enough
to result in lost time from work.
• References: Duhart, D.T. (2001). Violence in the workplace, 199399 (No. December 2001, NCJ 190076). Washington, DC: U.S.
Department of Justice, Office of Justice Programs.
ABC7 Newsline:
Psychologist Gunned Down In
Vallejo Office
• Nov. 2, 2005 Was it a patient who
murdered an East Bay psychologist?
Vallejo police are planning to look
through his patient files after the doctor
was gunned down after a long day of
counseling. It's a theory Vallejo police confirm they're pursuing,
after the 64-year-old Polonsky was gunned down in his office
Tuesday night.
• A lone gunman walked up to Polonsky's second floor office past a
waiting patient and shot the doctor in the chest in the hallway.
• Dr. Polonsky provided family, couples and individual therapy in
Vallejo for 25 years.
•ABC7 Talks To Victim's Sons
• Reform school teens charged in
counselor's death
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Tuesday, November 11, 2003 - By Barbara White Stack and
Patrick Hernan, Pittsburgh Post-Gazette
• Two teenagers at a Mercer
County reform school yesterday were
accused of strangling a school
counselor, whose legs and hands
had been tied and a sheet fastened
around his neck and head, and
taking his truck to Pittsburgh.
Assaults in the Health Care Sector
• Average of 1.7 million episodes/yr. of victimization at
work per year 1993-1999 (Department of Justice National Crime
Victimization Survey (NCVS), Durhart, 2001).
• The health care sector continues to lead all other
industry sectors in incidence of nonfatal workplace
assaults. In 2000, 48% of all nonfatal injuries from violent
acts against workers occurred in the health care sector
(Bureau of Labor Statistics BLS, 2001).
• Nurses, nurse's aides and orderlies suffer the highest
proportion of these injuries.
Non-Fatal Victimizations
I
ncidence rates for nonfatal assaults
and violent acts by industry, 2000
Incidence rate per 10,000 full-time workers
Source: U.S. Department of Labor, Bureau
of Labor Statistics. (2001). Survey of
Occupational Injuries and Illnesses, 2000.
Violent Crime against Mental Health Workers
Violent crime for all occupations is 12.6
per 1,000 workers.
• The average annual rate for physicians
is 16.2;
• for nurses,21.9;
• for mental health professionals, 68.2;
• for mental health custodial workers, 69.
Factors Associated with Workplace
Violence in Health Care Settings OSHA, 2004
•
The prevalence of handguns and other
weapons among patients, their families
or friends;
•
The increasing use of hospitals by police
and the criminal justice system for
criminal holds and the care of acutely
disturbed, violent individuals;
•
The increasing number of acute and
chronic mentally ill patients being
released from hospitals without follow-up
care
•
The availability of drugs or money at
hospitals, clinics and pharmacies,
making them likely robbery targets;
•
Factors such as the unrestricted
movement of the public in clinics and
hospitals and long waits in emergency or
clinic areas that lead to client frustration
over an inability to obtain needed
services promptly;
•
The increasing presence of gang
members, drug or alcohol abusers,
trauma patients or distraught family
members;
•
Low staffing levels during times of
increased activity such as mealtimes,
visiting times and when staff are
transporting patients;
•
Isolated work with clients during
examinations or treatment;
•
Solo work, often in remote locations with
no backup or way to get assistance, such
as communication devices or alarm
systems (this is particularly true in highcrime settings);
•
Lack of staff training in recognizing and
managing escalating hostile and
assaultive behavior; and
•
Poorly lit parking areas.
Workplace Violence in Health Care Settings
OSHA, 2004
• Elements of an effective violence
prevention program
• Management commitment and employee involvement;
•
Worksite analysis;
•
Hazard prevention and control;
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Safety and health training; and
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Recordkeeping and program evaluation.
De-institutionalization means higher
risk patients are being seen outpatient
De-institutionalization means higher
risk patients are being seen outpatient
“Even patients estimated to be at high risk
of violence to others may be discharged in
a few weeks, or increasingly, in a few
days, assuming that they are ever
hospitalized in the first place”
Monahan, J., Bonnie, R., Appelbaum, P. S., Hyde, P. S., Steadman,
H. J., & Swartz, M. S. (2001). Mandated community treatment:
Beyond outpatient commitment. Psychiatric Services, 52, 1198–
1205.
What do most therapists consider
in assessing violence risk?
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history of violence (66%)
Medication noncompliance (33%)
substance abuse (28%)
poor anger control (21%)
• Eric B. Elbogen, Matthew T. Huss, Alan J. Tomkins, Mario J.
Scalora Clinical Decision Making About Psychopathy and
Violence Risk Assessment in Public Sector Mental Health
Settings Psychological Services 2005, 2(2) 133–141
Kevin S. Douglas, Jennifer L. Skeem VIOLENCE RISK ASSESSMENT
Getting Specific About Being Dynamic
Psychology Public Policy, and Law 2005, Vol. 11, No. 3 347–383
A causal dynamic risk factor is a variable that has
been shown to:
1. precede and increase the likelihood of violence
(i.e., be a risk factor);
2. change spontaneously or through intervention
(i.e., be a dynamic factor);
3. predict changes in the likelihood of violence
when altered (i.e., be a causal dynamic risk
factor).
Evolution of Study of Static Factors to
Dynamic Risk Factors for Violence
Proposed Dynamic Risk Factors
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Impulsiveness
Negative affectivity
Anger
Negative mood
Psychosis
Antisocial attitudes
Substance use and related problems
Interpersonal relationships
Treatment alliance and adherence
Treatment and medication compliance
Treatment–provider alliance
• Kevin S. Douglas, Jennifer L. Skeem VIOLENCE RISK
ASSESSMENT - Getting Specific About Being Dynamic
Psychology, Public Policy, and Law 2005, Vol. 11, No. 3, 347–383
Screening for Domestic Violence: Recommendations Based
on a Practice Survey
Sarah L. Samuelson and Clark D. Campbell
Professional Psychology: Research and Practice 2005, Vol. 36, No. 3, 276–282
• Steps That Psychologists Can Take to Assist Victims of Domestic
Violence
• Decide to implement a screening protocol.
• Obtain more training as needed. Previous training may be
insufficient
• or outdated.
• Establish links with community resources prior to screening
• implementation.
• Obtain information regarding hotline numbers, local shelters,
domestic
• violence therapy groups, law enforcement, legal aid, advocacy
• groups, educational and financial services, and food and housing
• assistance.
Screening for Domestic Violence: Recommendations Based
on a Practice Survey
Sarah L. Samuelson and Clark D. Campbell
Professional Psychology: Research and Practice 2005, Vol. 36, No. 3, 276–282
• Maintain a supply of domestic violence literature to offer
to clients.
• Screen all adolescent and adult clients for domestic
violence at the time
• of intake.
• Also include questions regarding personal safety on
client completed
• intake forms.
• Screen in privacy and maintain confidentiality.
• Screen couples individually. Emphasize that this is a
standard
• component of the intake process.
• Validate identified victims’ experiences.
Screening for Domestic Violence: Recommendations Based
on a Practice Survey
Sarah L. Samuelson and Clark D. Campbell
Professional Psychology: Research and Practice 2005, Vol. 36, No. 3, 276–282
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Acknowledge that many women experience domestic violence, that
domestic violence is illegal and inappropriate, that it results in
physical and psychological damage, and that a variety of resources
are available for victims.
Assess identified victims’ level of safety.
What threats have been made to the client?
How accessible is the client to the abuser at this time?
Is the client requesting immediate protection by law enforcement or
the safety of a shelter?
If the client is not in imminent danger, has she devised a plan to
protect herself and any children if the danger escalates?
Does the client know how to access community resources if she feels
unsafe?
How can employees protect
themselves?
• Nothing can guarantee that an employee will not become
a victim of workplace violence. These steps, however,
can help reduce the odds:
• Learn how to recognize, avoid, or diffuse potentially
violent situations by attending personal safety training
programs.
• Alert supervisors to any concerns about safety or
security and report all incidents immediately in writing.
• Avoid traveling alone into unfamiliar locations or
situations whenever possible.
• Carry only minimal money and required identification into
community settings.
WHAT IS DISRUPTIVE, THREATENING,
ASSAULTIVE, OR VIOLENT BEHAVIOR?
• Violent behavior includes any physical
assault, with or without weapons; behavior
that a reasonable person would interpret
as being potentially violent such throwing
things at someone or in their general
direction, pounding on a desk or door in a
threatening manner, or threats to inflict
physical harm such as direct or implied
threats to hit, shoot, stab, or physically
harm someone.
WHAT IS DISRUPTIVE, THREATENING,
ASSAULTIVE, OR VIOLENT BEHAVIOR?
• Disruptive behavior disturbs, interferes with or prevents
normal work functions or activities. Examples include
yelling, using profanity, waving arms or fists, or verbally
abusing others.
• Threatening behavior includes oral or written threats to
people or property, and can include indirect or even
vague threats that imply violent action or retaliation. This
involves statements that a reasonable person could
believe was a threat.
• A specific threat to someone’s safety or well-being
with the apparent ability to carry it out is legally
considered an assault and may be subject to criminal
investigation and prosecution.
When faced with an escalating
individual
Avoid yelling, name calling, sarcasm, or other behaviors
-These are disrespectful can go a long was in reducing
the intensity of a conflict or problem.
Being firm is not the same as being loud.
Speaking softer and slower is better.
Keeping hands relaxed and avoiding threatening
stances, gestures or postures.
When dealing with an angry individual, don’t crowd,
leave space.
When faced with an escalating
individual (no threat or weapons)
Respond quietly and calmly. Try to de-escalate the
situation.
Do not take the behavior personally.
Ask questions, display respectful concern.
Indicate you are taking the person seriously.
Communicate understanding by calmly and clearly
summarizing what the person is telling you.
Dealing with escalation or disruption
(no weapons, threat, ctd.)
•
Consider offering an apology, even if you've done nothing wrong. This may
calm the person now. Try to establish mutual cooperation in solving the
problem. Try to establish some areas of agreement.
•
If this does not stop the disruption, and in your judgment the person is
upset, but not a threat or dangerous, set some boundaries or limits and
seek any necessary assistance:
•
Calmly and firmly set limits by directing the person to lower their voice, or
stop engaging in whatever disruptive behavior they may be doing, with the
message that this will make it easier for you to try to help them or help to
resolve the problem.
•
If the behavior persists warn the individual that appropriate action may
follow, such as calling for some for of assistance from other staff that may
be available, superiors, or if necessary law enforcement. Ask them to leave
or follow up with getting assistance if they do not.
If the person seems Dangerous:
• Try to reduce any audience and find a quiet place to talk, but do not
leave yourself alone with the individual.
• Maintain a safe distance, do not turn your back, and do not place the
individual between you and a safe exit. If seated, sit near the door
and make sure someone is nearby if needed.
• Do not confront the individual. Let the person speak and as above,
try to summarize what their concern is in a neutral and calm manner.
Never be sarcastic or make the person feel they have been
demeaned. Try to help them “save face” if possible.
• NEVER close in our touch the individual yourself to try to remove
him/her from the area.
If the person seems Dangerous:
• Signal as quietly and unobtrusively as you can for help. In high-risk
areas it may be helpful to have worked out pre-arranged signals or
codes with co-workers. If you need help, the co-worker should alert
your supervisor and/or the police if necessary.
• Do not mention discipline or the police if you fear an angry or violent
response.
• If the situation becomes more heated or you fear violence will occur,
find a way to excuse yourself and to leave the room or area for help.
• Be aware of any weapons.
What if there is an assault in
progress?
• IN AN EMERGENCY OR IF THERE IS VIOLENCE IN PROGRESS
• For violent incidents or specific threats of imminent violence, call 91-1. If possible use a phone out of sight/hearing of the individual.
Follow instructions.
• Do not attempt to intervene physically or deal with the situation
yourself. It is critical that the police take charge of any incident that
can or does involve physical harm.
• Get yourself and others to safety as quickly as possible.
• If possible, keep a line open to police until they arrive.
• While most of these involve institutional
settings, what if a stalker or violent patient
attacks at your office? Follows you?
• Or
• Learns where you live?
Dr. Jim Trent Continues to Recover - by
Ellen Slicker, PhD and David C. Mathis, EdD
•
We were all shocked and saddened to learn of one of our
professional colleagues being a victim of violence. On January 20,
2001, Jim Trent, PhD, Licensed Psychologist, was shot at his home
by an individual he had recently evaluated for “Fitness for Duty.” Dr.
Trent innocently opened the door for who he thought was one of his
son’s friends. Instead, the man raised a firearm and shot three
times.
• Dr. Trent was struck twice; once in the right chest and once in his
temple. The perpetrator of the shooting, who may have been under
some chemical influence, sped away from the crime at an excessive
rate of speed, ultimately crashing into a tree, which killed him
instantly.
Initially, Dr. Trent had severe aphasia, but made rapid improvement.
Lately his progress has reached somewhat of a plateau that is at
times frustrating to him. He receives physical therapy and speech
therapy twice a week.
Dr. Jim Trent Continues to Recover - by
Ellen Slicker, PhD and David C. Mathis, EdD
• While he had previously highly valued the ability to
preserve normalcy in his life, he now places a greater
emphasis upon protecting the privacy for himself and his
family. Another area that he has examined is the type of
clinical work he is accepting. Dr. Trent believes that
psychologists should recognize and exercise their own
choices rather than feeling compelled to “help” everyone.
Especially for psychologists in private practice, it is
important to recognize limits of resources when dealing
with difficult clients.
A full recovery is expected for Dr. Trent although he told
his wife that he won’t be doing any more “Fitness for
Duty” evaluations in the future.
Dr. Trent and his family greatly appreciate the support
they have received from the community.
If threatened called 911 –
………….then what?
Psychological Aspects of Firearm Safety
•"Criminals are afraid of only two things: Big dogs and guns. They stay away
from cops because cops have both." - Ayoob
•“Grrrrrr….” - Rocky