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.

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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 byPresented by
Ernest J. Bordini, Ph.D. Robert Henley Woody,
Ph. D., Sc. D., J. D., ABPP July 14, 2006 --
Sarasota, Florida
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PROTECTING THE RIGHTS OF THERAPISTSWITH
DIFFICULT AND THREATENING CLIENTSETHICAL 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

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WORKPLACE VIOLENCE
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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 (n1080) occurred in 1994, while the lowest
  number (n540) occurred in 2006.

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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, 1993-99 (No. December 2001, NCJ
  190076). Washington, DC U.S. Department of
  Justice, Office of Justice Programs.

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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

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• Reform school teens charged in counselor's death
• 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.

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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.

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Non-Fatal Victimizations
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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.
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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.

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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 high-crime settings)
• Lack of staff training in recognizing and
  managing escalating hostile and assaultive
  behavior and
• Poorly lit parking areas.

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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
• Safety and health training and
• Recordkeeping and program evaluation.

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De-institutionalization means higher risk
patients are being seen outpatient

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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,
  11981205.

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What do most therapists consider in assessing
violence risk?

• 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)
  133141

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Kevin S. Douglas, Jennifer L. Skeem VIOLENCE
RISK ASSESSMENT Getting Specific About Being
Dynamic Psychology Public Policy, and Law 2005,
Vol. 11, No. 3 347383

• A causal dynamic risk factor is a variable that
  has been shown to
• precede and increase the likelihood of violence
  (i.e., be a risk factor)
• 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).

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Evolution of Study of Static Factors to Dynamic
Risk Factors for Violence

• Proposed Dynamic Risk Factors
• Impulsiveness
• Negative affectivity
• Anger
• Negative mood
• Psychosis
• Antisocial attitudes
• Substance use and related problems
• Interpersonal relationships
• Treatment alliance and adherence
• Treatment and medication compliance
• Treatmentprovider 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, 347383

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Screening for Domestic Violence Recommendations
Basedon a Practice SurveySarah L. Samuelson and
Clark D. CampbellProfessional Psychology
Research and Practice 2005, Vol. 36, No. 3,
276282

• 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.

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Screening for Domestic Violence Recommendations
Basedon a Practice SurveySarah L. Samuelson and
Clark D. CampbellProfessional Psychology
Research and Practice 2005, Vol. 36, No. 3,
276282

• 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.

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Screening for Domestic Violence Recommendations
Basedon a Practice SurveySarah L. Samuelson and
Clark D. CampbellProfessional Psychology
Research and Practice 2005, Vol. 36, No. 3,
276282

• 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?

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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.

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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.

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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 someones 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.

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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, dont
  crowd, leave space.

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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.

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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.

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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.

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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.

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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 9-1-1. 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.

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• 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?

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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 sons 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.

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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 wont 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.

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If threatened called 911 .then what?

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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

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