Abstract
Mental
health workers often see clients at their worst, when they are in the middle of
a crisis. Keeping both the mental health worker and the client safe is of
utmost importance when providing therapeutic interventions. This paper will
address the need for counselors to assess their own safety measures that are in
place, as well as a few of the options available for counselors to keep their
clients safe during a time of crisis, including suicide evaluation and the laws
governing involuntary commitment in the state of Oregon.
A
therapeutic relationship is often the closest relationship a client has in
their lives, and as such, sometimes a fixation can develop, posing a
challenging which can lead to a dangerous situation. On average, almost one in
every five counselors have reported being physically attacked by at least one
client, with mental health care workers representing one third of the
harassment victims (Mastronardi, Pomilla, & D’Argenio, 2012). Additionally,
over 80% of mental health workers have reported being afraid that a client
would attack them (Vasquez & Pope, 2011). Among mental health students,
client violence has been reported as one of the greatest concerns, with very
little training being involved in the educational curriculum (Gately &
Stabb, 2005). With the majority of mental health workers reporting fear of
their physical safety, there are some valuable resources available for those
who find themselves in such a situation.
Provide
effective counseling interventions, in a safe manner, can at times be a
challenge. Ignoring certain aspects of personal safety can lead to a dangerous
situation. However, preventative action can be taken in order to minimize the
risk to personal safety. The safety of both the client and the counselor is
imperative in such an intimate setting as a counselor’s office. The following
are some steps that have been suggested, which have been brought to light after
a number of unfortunate incidents between clients and counselors, in hopes to
reduce possible future incidents.
Risk Assessment
The setting in which counseling
sessions take place is one aspect which can increase the likelihood of
dangerous interactions. Therapists working alone in home offices or in secluded
rooms of a multi-purpose building have indicated a high level of concern for
their own safety, even when there are other people in the building (Despenser,
2005). Counselors have also voiced their concern when working in large
buildings, as they fear that their calls for help would not be heard.
Additionally, having bars on the windows have been noted as a danger for those
conducting business inside, which could prevent an escape in the event of a
threat or actual physical attack (Despenser, 2005)
Aside
from the environmental safety issues, the first session between counselor and
client has been identified as another instance that can benefit from risk
assessment. One suggestion to increase the safety during the first session is
to have a chaperone on hand when counselors meet with their clients for the
first time (Despenser, 2005). Physical positioning in the counselor’s office
has also been addressed as it is sometimes an overlooked aspect of personal
safety. Sitting with an unobstructed access to the door is one suggestion for
preventative measures that can be taken with respect to the counselor’s office.
There are three categories
identified as being important when assessing a client and the possibility of
future harm, as suggested by counselors within the mental health system. Paying
attention to warning signs within the client’s history, evaluation of the
client’s current emotional state, and the gut reaction of the counselor should
not be ignored (Despenser, 2005). While the aforementioned potential warning
signs do not necessarily indicate a sign of danger for the counselor, they are
important to remember when working with new clients. If a counselor feels
unsafe at any time when working with a client, a possible suggestion raised by
counselors consists of arranging either security personnel or a coworker to
remain near the office during a session with a client with a violent history
(Despenser, 2005). Additionally, under the American Counseling Association Code
of Ethics, if counselors determine that they are unable to offer assistance to their clients
(due to a myriad of reasons, including a threat to their physical safety),
counselors can refer the clients to another mental health professional (Section
A.11.b. of ACA Code of Ethics, 2005).
Mental Illness and
Violence
While individuals with mental
illness are much more likely to be a victim rather than the perpetrator of
violence (Institute of Medicine, 2006), the risk still exists between a
counselor and a client. Counselors who desire to help clients in crisis can
risk overlooking common sense procedures which are in place to reduce the risk
of injury or harm. Even the most seasoned counselors can become blind to the
inherent risks, as seen in the case of Wayne Fenton, who was the associate
director of the National Institute of Mental Health. Fenton met with a client
for an emergency consultation in his office over the Labor Day holiday. Due to
the holiday, Fenton’s office complex was deserted, which ended up being an
unsafe decision, as Fenton was beaten to death by the client in crisis, Vitali
Davydov.
During the initial consultation, a
mental health worker can identify the potential for violence. The population
that has been identified as more likely to exhibit violent outbursts against
mental health workers includes younger males with a history of both substance
abuse and psychosis (Sullivan, 2006). Nonverbal signs can often offer an
insight for counselors to use to evaluate their clients. Signs such as pacing
and darting eye movements can be an indication of a possible violent outburst
(Sullivan, 2006). While it may be in the counselor’s nature to be empathic with
their clients, personal contact may lead to an escalation in an already tense
client.
While verbal de-escalation should be
the first method used when working with a potentially hostile client, some
mental health professionals suggest that counselors should be trained in
self-defense measures. Self-defense can be helpful while waiting for back up to
come to the aide of the counselor (Sullivan, 2006).
Client Safety During a
Crisis
Keeping clients safe during a crisis
can be a challenge, but with specialized training, counselors can be better
equipped in helping clients during what could be the worst and most stressful
time in their lives. Individuals who experience a crisis, often react in one of
three ways (James & Gilliland, 2013, p. 10):
· Effective
coping on their own, and emerge stronger as a result
· Appear
to survive the crisis, but block the pain from awareness, which results in
ongoing impacts of the crisis
· Become
immobilized and incapable of moving on with their lives
While the above
categories are not exhaustive of the coping styles employed during a crisis,
keeping them in mind is a useful tool for mental health workers.
When working with clients who are in
a crisis situation, such as suicidal clients, there are a variety of models to
assist counselors in keeping their clients safe. One such option is a 7-Step
Model developed that has been effective when working with suicidal clients.
The
7-Step Model consists of (Granello, 2010, p. 220):
o Assess
lethality
o Establish
rapport
o Listen
to the story
o Manage
the feelings
o Explore
alternatives
o Use
behavioral strategies
o Follow
up
The above steps
consist of a total of 25 strategies, which help counselors to identify and
evaluate potential indicators of suicidal ideations or future attempts.
Involuntary Commitment
In the event that other crisis
interventions have been exhausted, mental health workers can choose a more
restrictive safety measure for their clients, through involuntary commitment.
An estimated 25% of individuals who have been involuntarily committed for
alcohol dependence have been done so by their counselors (Mindock, Wright,
& Fleming, 2012). However, while involuntary commitment is legal, there are
some considerations to keep in mind when mental health workers are thinking
about an emergency psychiatric hold for their clients.
Studies have indicated several
factors that predicted an involuntary commitment, which if counselors are able
to intervene, may prevent an emergency (5150) psychiatric hold. An
unavailability to alternatives (temporary housing or residential crisis facilities),
evaluation of the client while in police custody (either at the police station
or emergency room), and at risk of self-harm or harm to others (McGarvey,
Leon-Verdin, Wanchek, & Bonnie, 2013).
In the state of Oregon, emergency
commitment admissions are regulated by the Oregon Revised Statutes. Under ORS
426.200, within 48 hours of admission, clients are to be examined by two staff
physicians of the state hospital. If the client is deemed to be in crisis and
in need of treatment, care or custody, or further hospitalization is necessary,
the superintendent can either obtain an agreement from the client for voluntary
admission, or if the client refuses to agree to voluntary admission, the
superintendent can file a complaint with the court, requesting a court
commitment. If the examining physicians certify that the client is not in need
of further treatment, the state hospital shall immediately discharge the
client.
Conclusion
Ensuring the safety of both client
and mental health workers is at times a challenge, but with continued
education, the risk of harm can be reduced. Preventative measures, rather than
reactive actions are essential when working with clients who are in a crisis
situation. There are many options to consider when working with possibly violent
clients, and counselors are reminded to pay attention to their gut instinct, in
addition to what they have learned in their educational endeavors.
*References Available Upon Request*
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