Nearly one-third of the 100 “fatalities in healthcare and social service settings that occurred in 2013 were due to assaults and violent acts” (OSHA, 2016) No matter what area you work in (community mental health, general or mental hospitals, working in client homes or in a centralized office like a crisis line) you may find yourself working with clients who are expressing thoughts or feelings of violence.
Risk Factors for Violence
A number of factors increase the chances that a client will be violent. Some of these include (James, 2008):
- Substance abuse. Active intoxication increases the chances a client will be violent. (Tomlinson, Brown, & Hoaken, 2016)
- De-institutionalization. Moving individuals into community care increases the chances they will revert to their previous state and become violent. (Torrey, 2015)
- Mental illness. Certain mental illnesses might increase the chances a person will become violent (Stuart, 2003) although the evidence is mixed. Most people with mental illness are statistically more likely to be victims than perpretrators of violence (Desmarais, et. al., 2014)
- Gender. Men are more likely to be violent than women and more likely to be victims of violence. (Kellermann & Mercy, 1992)
- Gangs. Gang violence, common in some areas, can increase the chances that youth experience violence as a perpetrator and victim (Neville, et. al., 2015)
- Elderly. As elderly clients are institutionalized, they may find themselves at increased levels of violence as perpetrators and victims. (Sandive, et. al., 2004)
Assessing Violence Risk
The Dynamic Appraisal of Situational Aggression (DASA; Ogloff & Daffern, 2006) can be used to assess the likelihood that a patient or client will become aggressive within a psychiatric inpatient environment. The DASA has 7 items that are scored 0 for absent and 1 for present within the last 24 hours.
Other useful models for assessing violence risk include the Biopsychosocial Model of Violence Risk Assessment and the Violence Risk Appraisal Guide (VRAG).
Assessing Homicide Risk
Assessing long-term homicidal risk is a task best left to clinical and forensic psychologists or social workers who have training specifically in this area. On the other hand, short-term homicide risk (such as the kind required by Tarasoff ethics) can be learned by all social service workers.
Borum & Reddy (2001) provide an article to performing these assessments, and I’ve also written an article on basic homicide risk assessment that you may refer to.
Levels of Violence Intervention
There are 3 levels of intervention related to violence, depending on the situation. These are suggested by dos Reis et al. (2013) in the youth context. Stage 1 is simple behavioural management such as listening, stage 2 involves pharmacotherapy while stage 3 involves the most significant interventions such as restraints, seclusion or antipsychotics.
A different conceptualization more useful for adult clients is as follows:
- Stage 1: Immediate intervention to prevent further escalation.
- Stage 2: To reduce symptoms that can lead to aggression
- Stage 3: Maintain safety of clients and staff
Stages of Violence Intervention (James, 2008)
- Stage 1: Education
- Stage 2: Avoidance of Conflict
- Stage 3: Appeasement
- Stage 4: Deflection
- Stage 5: Time-Out
- Stage 6: Show of Force
- Stage 7: Seclusion
- Stage 8: Restraints
- Stage 9: Sedation
Violence Intervention Training
Borum, R. & Reddy, M. (2001) Assessing violence risk in tarasoff situations: A fact-based model of inquiry. Behavioral Sciences and the Law. 19:375-385. doi: 10.1002/bsl.447
Desmarais, S. L., Van Dorn, R. A., Johnson, K. L., Grimm, K. J., Douglas, K. S., & Swartz, M. S. (2014). Community Violence Perpetration and Victimization Among Adults With Mental Illnesses. American Journal Of Public Health, 104(12), 2342-2349. doi:10.2105/AJPH.2013.301680
dosReis, S., Barnett, S., Love, R.C. & Riddle, M.A. (2003) A Guide for Managing Acute Aggressive
Behavior of Youths in Residential
and Inpatient Treatment Facilities. Psychiatric Services. 54(10). Retrieved on March 26, 2017 from http://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.54.10.1357
James, R.K. (2008) Crisis Intervention Strategies. Brooks/Cole: Belmont, CA.
Kellermann, A.L. & Mercy, J.A. (1992) Men, women, and murder: gender-specific differences in rates of fatal violence and victimization. Journal of Trauma. 33(1):1-5.
Neville, F. G., Goodall, C. A., Gavine, A. J., Williams, D. J., & Donnelly, P. D. (2015). Public health, youth violence, and perpetrator well-being. Peace And Conflict: Journal Of Peace Psychology, 21(3), 322-333. doi:10.1037/pac0000081
Occupational Safety and Health Administration (OSHA). (2012). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Retrieved on March 25, 2017 from https://www.osha.gov/Publications/osha3148.pdf
Ogloff, J. P., & Daffern, M. (2006). The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behavioral Sciences & The Law, 24(6), 799-813. doi:10.1002/bsl.741
Sandvide, Å., Åström, S., Norberg, A., Saveman, B., & RNT. (2004). Violence in institutional care for elderly people from the perspective of involved care providers. Scandinavian Journal Of Caring Sciences, 18(4), 351-357. doi:10.1111/j.1471-6712.2004.00296.x
Stuart, H. (2003). Violence and mental illness: an overview. World Psychiatry, 2(2), 121–124.
Tomlinson, M. F., Brown, M., & Hoaken, P. N. (2016). Recreational drug use and human aggressive behavior: A comprehensive review since 2003. Aggression And Violent Behavior, 279-29. doi:10.1016/j.avb.2016.02.004
Torrey, F.E. (2015). Deinstitutionalization and the rise of violence. CNS Spectrums, 20(3), 207-214. doi:10.1017/S1092852914000753
The Sequential Intercept Model was developed by Mark Munetz and Patricia Griffin (2006) to help communities understand the way people with mental health issues interact with the criminal justice system and to target interventions to prevent people from getting deeper involved in the system.
The Sequential Intercept Model is usually focused around 5 broad target points, or areas where people with mental health issues may find themselves in contact with police or legal officials.
The five Intercepts are:
- Law Enforcement
- Initial Detention / Court Hearings
- Jail / Court
- Community Corrections
The model was based on ensuring that people with mental health issues are not forced into the criminal justice system at greater rates than people without mental health issues.
Law Enforcement and Emergency Services
Noting that up to 10% of police calls by patrol officers involve mental health issues (Cordner, 2006), the first interception point is front-line police and emergency services workers. Munetz & Griffin (2006) describe several strategies to help intervene at this point:
- Mobile Crisis Teams of mental health workers
- Employing mental health workers as civilians in the Police Service
- Pairing police officers with mental health workers to go on patrol calls
- Specially trained mental health police officers
All of these approaches involve combining front-line policing with mental health support to ensure that sensitivity is respected. Emergency services may also respond to mental health issues where individuals are psychotic or otherwise struggling with a connection to reality, which can put these staff in danger.
Initial Detention / Court Hearings
After an individual has been arrested, the next interception point of the sequential intercept model is initial detention and hearings post-arrest. Individuals may be diverted at this point to programs for non-violent, low level crime (such as petty theft or trespassing) based on the symptoms of their mental illness.
Diverting this individual to mental health treatment can avoid exacerbating their mental health issues. Additionally the court may “employ mental health workers to assess individuals after arrest in the jail or the courthouse and advise the court about the possible presence of mental illness and options for assessment and treatment, which could include diversion alternatives or treatment as a condition of probation.”
Jail / Court
Individuals who have mental illnesses and get involved in the criminal justice system are likely to spend a significantly longer jail term than individuals with the same charges who do not have mental illnesses. (Hoke, 2015) For this reason, the third intercept point is the jail or court system, where many individuals with mental illness are managed.
One important opportunity is the establishment of Mental Health Courts set up specifically for people with diagnosed mental illnesses relevant to their crimes.
After an individual has exited the court system (if on probation) or jail (if sentenced to serve time), it is time for them to re-enter society. Transition points like this are times where an individual may be feeling the least supported and at greatest risk of suicide (Pease, Billera & Gerard, 2016) or of reoffending. (Caudill & Trulson, 2016) Discharge planning is common in hospitals but not in jail, which can make continuing care difficult for clients who are released from jail.
One potential model for solving this noted by Munetz & Griffin is the APIC (Assess, Plan, Identify, and Coordinate) Model by Osher, Steadman & Barr (2003). This plan “highlights the importance of collaboration among multi-sectoral community partners to ensure that the community is committed to the transition process.” (Evidence Exchange Network, 2014)
The final intercept in the Sequential Intercept Model is community corrections, which is probation or parole. Since mental health treatment is often a condition of staying out of jail, these individuals represent an excellent opportunity to help those in the criminal justice system continue to access care, despite the adversarial nature of the parole/probation relationship.
Evidence Exchange Network for Mental Health and Addictions. (2014). “The Assess, Plan, Identify, and Coordinate (APIC) Model.” Retrieved on March 15, 2017 from http://eenet.ca/wp-content/uploads/2014/04/APIC-summary-addendum_March2014.pdf
Caudill, J. W., & Trulson, C. R. (2016). The hazards of premature release: Recidivism outcomes of blended-sentenced juvenile homicide offenders. Journal Of Criminal Justice, 46219-227. doi:10.1016/j.jcrimjus.2016.05.009
Cordner, G. (2006) “People with Mental Illness”. Center for Problem-Oriented Policing. No 4. Retrieved on March 17, 2017 from http://www.popcenter.org/problems/mental_illness/print/
Pease, J. L., Billera, M., & Gerard, G. (2016). Military Culture and the Transition to Civilian Life: Suicide Risk and Other Considerations. Social Work, 61(1), 83-86. doi:10.1093/sw/swv050
Hoke, S. (2015). Mental Illness and Prisoners: Concerns for Communities and Healthcare Providers. Online Journal Of Issues In Nursing, 20(1), 1. doi:10.3912/OJIN.Vol20No01Man03
Osher, F., Steadman, H. J., & Barr, H. (2003). A Best Practice Approach to Community Reentry From Jails for Inmates With Co-Occuring Disorders: The APIC Model. Crime & Delinquency, 49(1), 79.
Munetz, M.R. & Griffin, P.A. (2006) Use of the Sequential Intercept Model as an Approach to Decriminalization of People With Serious Mental Illness. Psychiatric Services. 57(4) Accessed electronically on March 25, 2016 from http://ps.psychiatryonline.org/doi/pdf/10.1176/ps.2006.57.4.544
Financial social work is an under-valued component of a counsellor or social worker’s activities, however with the average debt level in the US (including mortgages) above $130,000 and credit card debt above $16,000 (El Issa, 2016), financial issues are a significant component of many individual’s negative emotional health.
Money problems are a leading cause of divorce (Dew, Britt, & Huston, 2012), anxiety (Archuleta, Dale & Spann, 2013) and suicide (Coope, et. al., 2015; Hempstead, et. al., 2015). Poor financial skills can cause even an individual with a high income to experience stress, much less low-income individuals who may find themselves accessing counselling or community social work services.
What is Financial Social Work?
Financial social work or financial counselling is the process of working with clients to “provide practical, sustainable skills for controlling and managing finances…and create real behavioral change in your clients.” (Center for Financial Social Work, n.d.) This is a comprehensive process of assessing an individual’s financial situation and building lifeskills of budgeting, responsible use of credit and debt management.
Financial social work is often performed by non-profit credit counsellors, Marriage and Family Therapists (MFT) and may be performed by social workers in other capacities, such as those who work as case managers with individuals on a low-income or struggling with substance abuse issues.
Assessing Financial Anxiety
Archuleta, Dale & Spann (2013) discuss the Financial Anxiety Scale (FAS), a tool that can be used to assess the impact of financial counselling or financial social work’s on an individual well-being. As they proceed through their treatment, their anxiety reduces.
Financial Anxiety Scale (FAS)
Each item on the FAS can be rated either yes/no (with a cut-off score of 4 or higher) or on a Likert scale for clinical purposes.
- I feel anxious about my financial situation.
- I have difficulty sleeping because of my financial situation.
- I have difficulty concentrating on my school/or work because of my financial situation.
- I am irritable because of my financial situation.
- I have difficulty controlling worrying about my financial situation.
- My muscles feel tense because of worries about my financial situation.
- I feel fatigued because I worry about my financial situation.
Money personalities (Mellan, 1995) describe an individual’s approach to working with money, and what makes an individual happiest or unhappiest as they work with money. Brief descriptions of the money personalities are below:
- Amasser – an individual who prefers to have large amounts of money but may also struggle with significant anxiety as they try to do this
- Avoider – an individual who avoids working with money because of the negative emotions involved, because of feelings of inadequacy or overwhelm
- Hoarder – an individual who likes to save money. In extreme cases a hoarder may literally hoard money in their house or other areas instead of investing them
- Money Monk – an individual who is afraid of money, considers it unclean or dirty, and tries to avoid having a relationship with it at all
- Spender – an individual who likes to spend money and gets immediate satisfaction from spending
Financial Social Work Qualifications
In order to practice financial social work or credit counseling it is important to receive training in this area. Rappleyea, et. al. (2014) discuss a curriculum for financial social work training that was designed for Marriage and Family Therapist (MFT) students. Some of the many topics suggested in this paper that are valuable to learn include:
- Money personalities (described above)
- How to track expenses
- How to live within your means
- How to spend money in a way that leads to happiness rather than guilt or unhappiness
- How to understand emotions created by money
Financial Social Work Certification
The Center for Financial Social Work provides the Certification in Financial Social Work. It provides 20 CE credits, workbooks and curriculum on financial planning, credit, debt, savings and spending plans and investing. The whole package costs $595. There is also information available from the Center on how to develop financial support groups to help individuals make better choices.
Financial Social Work Jobs
Financial social work job titles include Case Manager, Credit Counsellor, Financial Counselor, and Marriage and Family Therapist (MFT). All of these job roles may involve elements of financial counselling or financial social work either as a primary or secondary function of the role.
It’s important that social workers recognize that financial health is a part of their own development and self-care. If you are worried about money, it’s difficult to be fully present for your clients. Developing a budget, reducing and eliminating debt, and investing are valuable skills for both your clients and yourself.
Taking care of these things will help reduce your burnout and make you a more effective social worker.
Archuleta, K. L., Dale, A., & Spann, S. M. (2013). College Students and Financial Distress: Exploring Debt, Financial Satisfaction, and Financial Anxiety. Journal Of Financial Counseling And Planning, 24(2), 50-62.
Center for Financial Social Work. (n.d.) “Become Certified in Financial Social Work”. Retrieved on March 8, 2017 from https://www.financialsocialwork.com/financial-social-work-certification
Coope, C., Donovan, J., Wilson, C., Barnes, M., Metcalfe, C., Hollingworth, W., & Gunnell, D. (2015). Research report: Characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010–2011): A review of coroners׳ records. Journal Of Affective Disorders, 18398-105. doi:10.1016/j.jad.2015.04.045
Dew, J., Britt, S., & Huston, S. (2012). Examining the Relationship Between Financial Issues and Divorce. Family Relations, 61(4), 615-628. doi:10.1111/j.1741-3729.2012.00715.x
El Issa, E. (2016) 2016 American Household Credit Card Debt Study. NerdWallet. Retrieved on March 8, 2017 from https://www.nerdwallet.com/blog/average-credit-card-debt-household/
Mellan, O. (1995). Money Harmony: Resolving money conflicts in your life and relationships. New York, NY: Walker & Company.
Rappleyea, D. L., Jorgensen, B. L., Taylor, A. C., & Butler, J. L. (2014). Training Considerations for MFTs in Couple and Financial Counseling. American Journal Of Family Therapy, 42(4), 282-292. doi:10.1080/01926187.2013.847701
Hempstead, K. A., & Phillips, J. A. (2015). Research Article: Rising Suicide Among Adults Aged 40–64 Years. The Role of Job and Financial Circumstances. American Journal Of Preventive Medicine, 48491-500. doi:10.1016/j.amepre.2014.11.006
Studies on the connection between religion and suicide have led to mixed results. Some studies indicated higher levels of suicidality, no relation or reduced risk. Many of the studies that indicated a relationship (either positive or negative), had mediators attached – such as that individuals who were more religious were less likely to attempt suicide as long as they lacked other social supports.
Religiosity and Suicide
Meta-reviews, large scale analyses of suicide risk have helped shed some evidence on the connection between religion and suicide.
Lawrence, Oquendo & Stanley (2016) noted that suicide and religion are both complex dimensions (e.g. suicide ideation versus attempts versus death, religious affiliation versus attendance.) Being part of a majority religious community was found to be a greater protective factor against suicide than a minority community, but that attending religious services was not as important as having social supports (whether religious or not.)
Norko et. al. (2017) noted that all major faith communities (including Islam, Hinduism, Judaism, Buddhism, and Christianity) have strong objections to suicide.
In Lawrence et. al. (2016) a sample of clinically depressed patients in a hospital setting were found to have a higher rate of suicidality if they identified a religious affiliation, the more they attended religious services, and the more they indicated religion was important.
Finally, Wu, Wang & Jia (2015), analyzing over 5000 participants across several large studies identified the three elements that are responsible for the protective factor of suicide: being of a western culture, being older, and living in a area with religious homogeneity.
Spirituality and Suicide
Spirituality can be examined through a lens different from organized religion. While religion may entail specific doctrine, spirituality instead examines one’s relationship with “self, others and ‘God’” (Mandhoui, et. al., 2016), in whatever form that takes.
Mandhoui et. al. (2016) surveyed individuals who were in hospital for suicide attempts. Those individuals lower in spirituality were more likely to attempt suicide at 18 months, with “value of life” tending to reduce the chance that someone re-attempts.
Amato, et. al. (2016) noted that spirituality can be integrated into suicide prevention programs such as case management, therapy and suicide assessment to determine the impact for that individual. They summarize the impact of spirituality by noting that “some individuals at high risk of suicide may find fellowship in an affirming community of faith; others may be helped by rituals that confer atonement or a state of exaltation; still others may learn, through mindfulness meditation, to suspend their inclination to judge themselves harshly.”
Specific Religions / Denominations and Suicide
Buddhism and Suicide
Buddhism has received some exploration in the scientific literature, especially in light of Buddhist monks who have self-immolated for political reasons, the most famous of whom was Thích Quảng Đức in 1963, but research on the exact suicide rate, especially when considered with other religions is lacking.
Lizardi & Gearing (2010) noted several elements that may decrease suicide in Buddhist individuals, including that the largest communities of Buddhists (Asian Americans and Pacific Islanders) have lower suicide rates than whites (who tend to belong to different religious communities) and a strong aversion to killing. In contrast, a belief in reincarnation and life-after-death may contribute to an increase in the suicide rate among specific individuals who adhere strongly to Buddhist traditions.
Catholicism / Protestantism and Suicide
Emile Durkheim in his 1897 work Suicide examined the suicide rates among Catholics and Protestants. He found that Catholics had much lower rates of suicide than Protestants and theorized that it was the result of social support provided in the Catholic community. Additional support was confirmed by Torgler & Schaltegger (2014) and Siegrist (1996) in a modern sample, who also found that church attendance reduced suicide.
Hinduism / Islam and Suicide
Ineichen (1998) examined a number of studies on Hinduism and Islam and consistently found that Muslims had much lower suicide rates than Hindus, focused on a variety of South Asian diaspora (such as individuals in the United Kingdom from other countries.)
Following up on this research, Thimmaiah et. al. (2016) explored a population of Muslims and Hindus in India and found that , while Muslims indicated more negative attitudes towards suicide which may help explain why they are less likely to attempt suicide.
Judaism and Suicide
Examining Jewish Israelis, Eliezer & Daniel (2012) found a rate of suicide lower in Jewish individuals than those who are Catholic or Protestant. Significantly, those with other risk factors for suicide (like veterans, immigrants or those who have experienced trauma) are at elevated at risk of suicide despite their religiosity.
After a review of the literature, it emerges that religious denominations and other factors can have an influence on suicide. Some religions have higher rates of suicide, and some have lower rates, which may be explained by the value system of those religions or the social support of those religions.
The suicide risk by religion, from highest to lowest is below:
- Protestant Christian
- Catholic Christian
Other religions with less well established data sets can be compared to each other, but not necessarily to other religions: Islam has a lower level of suicide than Hinduism, while Buddhism has a lower level of suicide than Native American spirituality.
Amato, J. J., Kayman, D. J., Lombardo, M., & Goldstein, M. F. (2016). Spirituality and religion: Neglected factors in preventing veteran suicide?. Pastoral Psychology, doi:10.1007/s11089-016-0747-8
Dyson, J., Cobb, M., Forman, D. (1997) The meaning of spirituality: a literature review. Journal of Advanced Nursing. 26(6). Retrieved on March 3, 2017 from http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2648.1997.00446.x/abstract doi: 10.1046/j.1365-2648.1997.00446.x
Durkheim, E. (1897). Le suicide: étude de sociologie. F. Alcan: Chicago, IL.
Eliezer, W., & Daniel, S. (2012). Suicide in Judaism with a Special Emphasis on Modern Israel. Religions, Vol 3, Iss 3, Pp 725-738 (2012), (3), 725. doi:10.3390/rel3030725
Ineichen, B. (1998). The influence of religion on the suicide rate: Islam and Hinduism compared. Mental Health, Religion & Culture, 1(1), 31.
Lawrence, R. E., Brent, D., Mann, J. J., Burke, A. K., Grunebaum, M. F., Galfalvy, H. C., & Oquendo, M. A. (2016). Religion as a risk factor for suicide attempt and suicide ideation among depressed patients. Journal Of Nervous And Mental Disease, 204(11), 845-850. doi:10.1097/NMD.0000000000000484
Lawrence, R. E., Oquendo, M. A., & Stanley, B. (2016). Religion and suicide risk: A systematic review. Archives Of Suicide Research, 20(1), 1-21. doi:10.1080/13811118.2015.1004494
Mandhouj, O., Perroud, N., Hasler, R., Younes, N., & Huguelet, P. (2016). Characteristics of spirituality and religion among suicide attempters. Journal Of Nervous And Mental Disease, 204(11), 861-867. doi:10.1097/NMD.0000000000000497
Norko, M. A., Freeman, D., Phillips, J., Hunter, W., Lewis, R., & Viswanathan, R. (2017). Can Religion Protect Against Suicide?. Journal Of Nervous & Mental Disease, 205(1), 9-14. doi:10.1097/NMD.0000000000000615
Siegrist, M. (1996). Church Attendance, Denomination, and Suicide Ideology. Journal Of Social Psychology, 136(5), 559-566.
Thimmaiah, R., Poreddi, V., Ramu, R., Selvi, S., & Math, S. (2016). Influence of Religion on Attitude Towards Suicide: An Indian Perspective. Journal Of Religion & Health, 55(6), 2039-2052. doi:10.1007/s10943-016-0213-z
Torgler, B., & Schaltegger, C. (2014). Suicide and Religion: New Evidence on the Differences Between Protestantism and Catholicism. Journal For The Scientific Study Of Religion, 53(2), 316-340. doi:10.1111/jssr.12117
Wu, A., Wang, J., & Jia, C. (2015). Religion and Completed Suicide: a Meta-Analysis. Plos ONE, 10(6), 1-14. doi:10.1371/journal.pone.0131715