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.
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