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Client Violence

Abstract and Keywords

Client violence and workplace safety are relevant issues for all social workers across practice settings. This entry addresses why and how social workers may be targets for a client's violent behavior, and what we know about who is at risk of encountering violence. Understanding violence from a biopsychosocial perspective, identifying risk markers associated with violent behavior, and an introduction to guidelines for conducting a risk assessment will be discussed. The entry concludes by identifying and describing some general strategies for the prevention of client violence.

Keywords: safety, client violence, risk management, risk assessment, violence, risk markers

Introduction

Violence in the workplace is a critical issue in the United States today for a wide range of workers including retail clerks, taxi drivers, police officers, teachers, nurses, and social workers (LeBlanc, Dupre, & Barling, 2006). Some social work practitioners may assume that if they have not encountered violence in the past, there is no need to be concerned about safety (Griffin, Montsinger, & Carter, 1995). However, much has changed in the practice of social work since the 1990s, and the reality is that client violence toward social workers and workplace safety are issues relevant for all social workers today, regardless of practice setting or years of experience (Griffin, 1995).

Most people choose to become social workers because they want to foster social justice and help disadvantaged people in need. They may not, however, anticipate that some individuals may not want a social worker's help and, under certain circumstances, may even strike out at the very person who is attempting to help them.

What causes social workers to be targets of a client's violent behavior? The answer to this is complex and not entirely clear. Some argue that such violence simply represents a barometer for America's violent society (Dillon, 1992). Long-standing social problems such as unemployment, poverty, and racism create an environment in which violence can thrive. Budget cuts, the ensuing understaffing of many social service agencies, and rising caseloads further compound social workers' vulnerability.

Others argue that the answer also lies in the unique nature of the social work profession. Social work is caring, but can also be controlling, since it often involves the task of interpreting government regulations and mandates, and determining eligibility for resources that clients desperately need (Newhill, 2003). Through this process, a client's rage, frustration, and feelings of helplessness may emerge (Euster, 1992). For example, in June 1991, 34-year-old Arnold Bates walked into a Baltimore, Maryland, welfare office to apply for food stamps. When told he was not eligible, he became enraged, pulled out a knife, and stabbed to death one of the caseworkers. The aggressive public reaction to this tragic incident included phone calls to the agency, threatening to “take out more of you social workers” (Dillon, 1992, p. 1). This example illustrates how many social workers are caught between desperate clients and a government that is perceived by them as a cause of their problems or an entity that cannot or will not help them. Society asks social workers to be both agents of social care and agents of social control (Townsend, 1985). Deciding whether to remove a child from a home because of allegations of abuse, or whether to involuntarily commit a client to a psychiatric hospital are prime examples of the social care/social control dichotomy and carry risk for violence to occur. Furthermore, because of confidentiality restrictions, social workers are often unable to explain or defend their actions publicly.

The Prevalence and Nature of Client Violence Toward Social Workers

Over the past three decades, there have been more than two dozen studies addressing the issue of client violence toward social workers, with the bulk of the studies published since 1988 (Newhill, 2003). Researchers in the United Kingdom led the way toward investigating this topic (Rowett, 1986) and, since then, there have been several studies conducted in the United States which collectively demonstrate that the issue of client violence is a serious practice concern. For example, Newhill (1996) conducted a study examining the nature and prevalence of four types of client violence toward social workers—property damage, threats, attempted physical attacks, and actual physical attacks—employing a random sample of 1,600 members of the National Association of Social Workers. The study had a survey return rate of 71% (N = 1,129) and reported the following conclusions:

  1. 1. Client violence is not a rare event, that is, a majority (58%) of the respondents reported experiencing one or more incidents of client violence at some point in their career.

  2. 2. Practice setting affects level of risk, with the highest risk settings including criminal justice services, drug and alcohol services, and child welfare.

  3. 3. Male social workers are significantly more likely to report experiencing client violence than female social workers and greater numbers of incidents, although females are more likely to report concerns about safety.

  4. 4. Experiencing an incident of client violence exacts a significant emotional toll on the social worker involved and may result in changes in practice habits and feelings about social work.

Other studies (see, for example, Beaver, 1999; Mace, 1989; Rey, 1996) have reported comparable findings, suggesting that the issue of safety and violence is not just a perceived issue, but a real issue for many social workers in their day-to-day practice. It is critical that strategies for assessing and preventing client violence be developed that will serve to enhance safety while not compromising client services.

A Biopsychosocial Framework for Understanding Violence

The most appropriate framework for understanding violent behavior is a biopsychosocial systems approach. Violence is a multifaceted multidimensional phenomenon that results from interactions between individuals and certain situational and environmental factors, and affected by certain aspects of the histories of the individuals involved (Newhill, 2003).

The question of whether clinicians can reliably predict violence has received considerable research effort since the late 1970s, with the conclusion that clinicians are generally inaccurate when predicting future violence over the long term (Monahan & Steadman, 1994). They most often err toward false positive predictions, that is, predicting that a client will be violent when, in fact, the client does not behave violently.

The cornerstone to improving the assessment of violence risk over the short term, that is, 24–48 hr, is knowing how to properly assess the client within the context of his or her individual attributes, history, and environment. By relying on a thorough knowledge of what we know about the risk markers associated with violent behavior, a social worker can more likely determine which aspects of the client's situation suggest there may be an elevated risk for future violence. This knowledge, then, can help shape the choice of an appropriate and effective intervention.

In the area of violence risk assessment, the term “risk marker” is preferred over the term “risk factor” because many of these markers are associated with an elevated risk for violence, but are not established causal predictors of violence (Kraemer et al., 1997). That is, a client may evidence a particular risk marker, or even several risk markers, but that does not mean that particular client will definitely engage in violence. Violence has a low base rate, meaning that in the range of all possible human behaviors, violence is a comparatively rare event. However, certain risk markers do represent “warning flags,” and the more “warning flags” a client has, the greater is the probability that future violence may occur. Thus, some kind of intervention to address and mitigate these warning flags is warranted. Some risk markers are unchangeable, for example, biological sex, but others can be mediated via various clinical and environmental interventions, many of which social workers can provide.

Risk Markers Associated With Violent Behavior

Risk markers associated with violence fall within three spheres: individual/clinical risk markers, historical risk markers, and environmental/contextual risk markers (Monahan et al., 2001; Newhill, 2003).

There are three categories within the sphere of individual/clinical risk markers: demographic risk markers, clinical risk markers, and biological risk markers. Demographic risk markers include age, gender, and socioeconomic status. Although results are somewhat mixed, the bulk of existing research suggests an association between younger age and violent behavior, with the highest risk occurring between the ages of 15 and 24. In general, as individuals age, rates of violence fall (Swanson, Holzer, Ganju, & Jono, 1990). Being male also elevates risk for violence; however, since the late 1980s, reports of violence among women have increased dramatically (Newhill, Mulvey, & Lidz, 1995; Vaughn, Newhill, Litschge, & Howard, in press). Low socioeconomic status operates as a risk marker because individuals who live in lower socioeconomic strata have a greater probability of being a victim of violent crime, being forced to live in a dangerous neighborhood, and being exposed to violent group norms, all of which enhance risk of violence (Silver, Mulvey, & Monahan, 1999).

With respect to clinical risk markers, although the vast majority of individuals with mental illness are not violent, certain psychiatric symptoms are associated with aggressive behavior (Link & Stueve, 1998). These symptoms include (a) paranoid delusions and auditory command hallucinations, particularly if the individual is under stress and not taking prescribed medication to control symptoms; (b) repetitive fantasies of harming others; (c) certain personality features, such as impulsivity, and overwhelming negative emotions, for example, intense anger; and (d) substance abuse, particularly alcohol (Monahan et al., 2001). Finally, there are biological risk markers, most significantly neurological impairment, for example, dementia and traumatic brain injury (Crowner, 2000).

The second sphere of risk markers is historical risk markers. The best single predictor of future violence is a history of recent, repetitive past criminal violence (Monahan et al., 2001). The second risk marker is a history of repeated exposure to violence in one's family or social environment. Such early exposure to violence includes experiencing severe abuse by a parent or other caretaker or being a witness to domestic violence; being severely neglected or rejected by a parent or other primary caretaker; having a parent with serious mental health or substance abuse problems; and being raised with tacit family approval of cruelty toward other people and/or animals. Two other historical risk markers include having a history of repetitive economic instability or unemployment, and having a history of involuntary psychiatric treatment and hospitalization.

The final sphere of risk markers is environmental/contextual risk markers, including the level and quality of the individual's social support network; peer pressure from peers who endorse violence to achieve power and status; the influence of popular culture that endorses use of violence, whether the individual has means for violence, that is, access to lethal weapons and knowledge of how to use them; and finally, whether the individual has access to potential victims. It is important to note that the best single protective factor against violence is stable positive social support.

All three domains—individual/clinical, historical, and environmental/contextual risk markers—must be considered when conducting a violence risk assessment or providing treatment targeting violence and aggression. The strength or weight of each risk marker varies across individual clients and, thus, one must examine the client's situation ecologically on a case-by-case basis when determining risk status. Furthermore, identification of risk markers must be paired with identification of protective factors that can mitigate against violence. For example, a young chronically unemployed man who abuses alcohol and has problems with anger and impulsivity evidences several risk markers for violence, but if he also has a strong social support network, he may be able to manage the problems in his life including any violent thoughts or impulses without harming others or himself.

Practice Interventions

As the first step, the social work profession must openly acknowledge that client violence is a real and legitimate practice concern. Second, agency administrators and supervisors must take the lead in developing a risk management approach to facilitate the development of a safe workplace, including providing high-quality safety training that meets workers' self-identified needs. To develop a safety policy specific to an agency's needs, staff can convene a safety committee to guide the development and implementation of safe workplace strategies including policies on how to respond to and support workers who have experienced client violence (see, for example, Griffin et al., 1995). Underreporting of client violence is common (Rowett, 1986); thus, agencies should develop a user-friendly means for reporting and tracking all incidents of violence toward staff and strongly encourage and support staff in documenting such incidents (for an example of a violence report form, see Newhill, 2003).

Social work educators and the Council on Social Work Education must continue to acknowledge the risks faced by social work students and field instructors, and respond by requiring content on safety and risk assessment and skills for practice with involuntary and violent clients in both undergraduate and graduate curriculums. Field faculty should ensure that field placement agencies have a safety policy in place and a plan for student orientation to the policy.

Table 1 provides an overview of guidelines for conducting a violence risk assessment.

Following the evaluation, consultation from colleagues must be obtained and written documentation provided that sufficient risk assessment information has been obtained and evaluated, and that the decision as to whether the client poses a potential for violence has been based on that information and a follow-up plan for reevaluation of violence potential has been implemented. Social workers must strive to give a clear, consistent message to clients that using violence to solve problems is not acceptable and assist clients in developing skills in nonviolent approaches to resolving problems.

There have been a number of positive recent developments suggesting a trend by government and social service agencies toward taking the issue of social work safety seriously by providing resources to support prevention strategies. For example, in April 2007, a bill to improve protections for social workers was signed into law by Kentucky Governor Ernie Fletcher six months after social service worker Boni Frederick, from the Kentucky Cabinet for Health and Family Services, was killed by a client during a home visit. This new law provides 6 million dollars to improve safety for state social services workers, including funding the hiring of more staff and security improvements at state child welfare offices (Associated Press, 2007).

Table 1 Guidelines for Conducting a Risk Assessment

Background/collateral information

review available official documents including clinical and criminal justice records

determine whether there is any past history of violence toward self or others or any history of abuse either as perpetrator or victim

Clinical assessment of the client

note anything significant about the client's physical appearance suggestive of risk for violence including scars, tattoos, or certain dress patterns

note if the client is angry, hostile, agitated, threatening, or verbally abusive

note the extent to which the client is compliant with routine requests and procedures as an indicator of the client's ability to control his or her behavior

conduct a diagnostic assessment to determine the presence of any psychiatric or medical risk factors including whether there is evidence of substance abuse

inquire about the client's potential for violence toward others including who, why, how, and when he or she may harm another individual

inquire about the client's potential for violence toward self

Following evaluation, obtain consultation from colleagues and provide written documentation that sufficient risk assessment information has been obtained and evaluated, and that the decision as to whether the client poses a potential for violence has been based on that information and a follow-up plan for reevaluation of violence potential has been implemented.

Most recently, in July 2007, the National Association of Social Workers sponsored a news conference and Capitol Hill briefing to promote a federal bill that supports protecting social workers from violence by asking Congress to authorize 5 million dollars each year for the next five years to fund the development of safety measures with state matching funds. The proposal is named after Teri Zenner, a social worker who was stabbed to death by a client in 2004 during a routine home visit (Pace, 2007). These are just two examples of the efforts currently being made to protect social workers and clients from violence.

In the world of social work today, client violence is increasingly recognized as a common occupational hazard. Every day across the country, family and community stresses and problems, magnified by worsening economic conditions and scarcer benefits and services, boil over into acts of violence directed at individuals both within and outside of the family, including toward social workers. Agencies must acknowledge the reality within which their staff practice and take definitive preventive action to foster worker safety. Social workers who are prepared with the resources and skills to meet the unexpected are in the best position to protect themselves and continue to provide the best services for their clients.

References

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                      Mace, P. (1989). The effect of attitude and belief on social workers' judgments concerning potentially dangerous clients (unpublished doctoral dissertation). Los Angeles: University of California.Find this resource:

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                            Newhill, C. E. (1996). Prevalence and risk factors for client violence toward social workers. Families in Society, 77, 488–495.Find this resource:

                              Newhill, C. E. (2003). Client violence in social work practice: Prevention, intervention and research. New York: Guilford.Find this resource:

                                Newhill, C. E., Mulvey, E. P., & Lidz, C. W. (1995). Characteristics of violence in the community by female patients seen in a psychiatric emergency service. Psychiatric Services, 46, 785–789.Find this resource:

                                  Pace, P. (2007, September). Worker safety bill promoted. NASW News, p. 52.Find this resource:

                                    Rey, L. (1996). What social workers need to know about client violence. Families in Society, 77(1), 33–39.Find this resource:

                                      Rowett, C. (1986). Violence in social work. Cambridge, MA: Institute of Criminology.Find this resource:

                                        Silver, E., Mulvey, E. P., & Monahan, J. (1999). Assessing violence risk among discharged psychiatric patients: Toward an ecological approach. Law and Human Behavior, 23(2), 237–255.Find this resource:

                                          Swanson, J. W., Holzer, C. E., Ganju, V. K., & Jono, R. T. (1990). Violence and psychiatric disorder in the community: Evidence from the epidemiological catchment area surveys. Hospital and Community Psychiatry, 41, 761–770.Find this resource:

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                                              Vaughn, M. G., Newhill, C. E., Litschge, C. M., & Howard, M. O. (in press). Cluster profiles of residentially incarcerated adolescent females: Violence and clinical mental health characteristics. Residential Treatment for Children and Youth.Find this resource:

                                                Further Reading

                                                Slaby, A. E. (1986). Handbook of psychiatric emergencies (3rd edition). New York: Medical Examination Publishing Company.Find this resource:

                                                  Tardiff, K. (1996). Assessment and management of violent patients (2nd ed.). Washington, DC: American Psychiatric Press.Find this resource:

                                                    Weinger, S. (2001). Security risk: Preventing client violence against social workers. Washington, DC: NASW Press.Find this resource:

                                                      Zanarini, M., & Gunderson, J. (1997). Differential diagnosis of antisocial and borderline personality disorders. In D. M. Stoff, J. Breiling, & J. D. Maser (Eds.), Handbook of antisocial behavior (pp. 83–91). New York: Wiley.Find this resource:

                                                        A Look at Safety in Social Work. http://www.ssw.unc.edu/fcrp/cspn/Vol3_no2.htm

                                                        OSHA Guidelines for Preventing Workplace Violence for Healthcare Workers and Social Services Workers. http://www.osha.gov/Publications/osha3148.pdf

                                                        Project Safe. http://www.albany.edu/ssw/projectsafe/about.html

                                                        Personal safety when visiting patients in the community. http://apt.rcpsych.org/cgi/content/full/8/3/214

                                                        Canadian Centre for Occupational Health and Safety—Violence in the Workplace. http://www.ccohs.ca/oshanswers/psychosocial/violence.html