Your hospital beeper summons you to the emergency room to assess the condition of an assaultive patient. Are you safe as you enter the room? In your private practice office, you are assessing a patient with a known history of organic impairment and impulsiveness. Have you thought to ensure your own safety? You are about to apprehend the suspect. Are you at risk for a sudden eruption of violence? You are making a home visit to a family known for domestic violence. Are you safe or at risk when you ring the doorbell? You are a community reach outworker. Are you surveying the scene as you walk the streets?
Recent years have seen an unacceptable increase in violence and police, health care, and human services providers have not been immune from this violence. In fact, these helpers are often asked to provide services to these violent or potentially violent patients, clients, or suspects. How to provide these services safely in a way that reduces the risk of violence is the subject of this essay. It provides six general guidelines or risk management strategies for safety: four for specific and commonly encountered risk situations, and two for self-care. Responding to violent or potentially violent behavioral emergencies is very stressful and this essay can provide only a rudimentary overview of safety practices that are covered in depth elsewhere (1). This essay assumes that you have been well-trained in the basic standards of practice for the services that you provide to patients, clients, or suspects and that you will obtain any further needed training raised by the risk management strategies outlined here. If you work with a partner(s), be sure that you are all in agreement about how you will implement any of the risk management strategies noted herein.
I. General Safety Guidelines
(1) Think Medical or Psychiatric Illness. When the call for assistance is received, the first safety guideline is to consider any possible medical or psychiatric illness that is associated with the potential for violence. Common medical illnesses possibly associated with violence may include glycemic conditions, head trauma, lupus, multi-infarct dementia, Parkinson’s disease, and stroke. Typical psychiatric examples may include conduct disorder, domestic violence, intermittent explosive disorder, psychological trauma, serious mental illness, and substance abuse. [See (1) for a more complete listing.] If the call for assistance provides any information about a possible medical or psychiatric issue, ask yourself if the medical condition is known to be associated with violence.
(2) Think Call Log. Most of us would not think of the patient’s admitting chart or the emergency services and police logs as safety tools but they may well be helpful. These resources may provide important information about past episodes of violence, reveal timing patterns in violent situations that may at first appear random, and may assist in developing staffing levels for high-risk periods. Medical and behavioral science is demonstrating that random acts of violence, if studied in longer time frames, are very often not random and follow a specific time pattern. To document these possible temporal patterns, logs or admitting charts need to record relevant information of the identified client and responding agency staff as well as the environmental context, the time of the event (hour/day/week/month), and any other salient variables for a specific agency’s mission. These reports can use check off boxes to heighten compliance and save staff time.
(3) Think Scene-Surveillance. Scene-surveillance refers to assessing the scene for any potential risks for violence as you arrive onsite. Police are well-trained in scene surveillance but other provider groups are not. For example, if one is called to a family known for domestic violence, begin by driving by the back of the house on the next street over. Check if there is anyone who could become violent in the backyard of the house that you have been called to. Next, approach the street where the house call is to be made. Assess any people on the street for violence potential. Look behind mailboxes, lamp posts, trees and shrubs, second-story windows, or porches. Can you explain why everyone is where they are? Look at the remaining three sides of the building you have been called to. Approach the house and its doors from the sides of the building. Do not walk up the front entrance. As you approach, listen for voices. How many? How angry? Open the door from the side and step in quickly to the side. Next, assess the family unit for potential weapons and possible assailants. When you are sure that you are safe, begin to provide your care or service. As you can see, scene-surveillance is a complex but necessary safety tool. Scene-surveillance training may be obtained in consultative exchanges with local police or from private companies who provide such training.
(4) Think Old Brain Stem. The cortex of the brain is our highest power of thinking and problem solving. It receives messages from our senses, reviews past memories, and then makes judgments about what to do. The old brain stem is the seat of our vital functions, such as breathing, sleeping, feeling hungry, and responding instantly and instinctively to situations of fear and we are not conscious of its automatic functioning. In some severe stress situations, the person may move from cortex functioning to old brain functioning, where the person acts on instinct rather than with higher cortical reasoning. Violence potential may increase in these circumstances. Give the person some breathing space, proceed slowly, and use simple statements relevant to the situation, so that the client or suspect has time to revert back to higher cortex functioning.
(5) Think Early Warning Signs. Sometimes potentially violent persons demonstrate early warning signs of impending loss of control and helpers should be alert for such signals. Warning signs are three-fold in nature: medical, appearance, and behaviors. If the person has a medical or psychiatric condition associated with violence, that is a warning sign. The appearance of the client/suspect may also provide signals, such as disorganized appearance, tense facial expressions, and glazed eyes. Behavioral signals to look for are pacing with severe agitation, verbally hostility, suggestions of substance abuse, and threat of weapons. The more warning signs that are present, the greater the likelihood of violence.
(6) Think Theories of Violence. Another useful source of assistance for helpers is to have a basic understanding of why individuals become violent. Medical-and-biological science have grouped these findings into four theories: cultural, biological, sociological, and psychological. Each theory is true in some cases and, often, more than one theory is applicable in any given situation. These theories have been reviewed elsewhere (2,3) and are summarized here:
The first theory is the cultural theory which focuses on what is occurring in society in general. The Theory of Anomie is relevant for today’s age. Societies have five institutions that govern how their citizens behave. Business, government, family, schools, and religious faith traditions instill values and behavioral expectations for communities. When these institutions agree on the values and behaviors, citizens know how to behave and a sense of community cohesion results. If a society undergoes a significant transformation, these institutions are impacted, the common set of values and expectations are uprooted, and the sense of community cohesion is disrupted. Anomie follows with resultant increases in suicide, mental illness, substance abuse, and violence. Today’s society is undergoing one such major transformation, as we move to a global economy and ubiquitous-computerized age. Many people in these circumstances feel adrift, unaccepted, and some become violent.
The second theory of violence is biological in nature. Whereas there is no known genetic basis for violence at present, medicine does know that injuries to the cortex, our thinking brain, and the limbic system where emotions register, may result in violent behaviors. In Guideline 1, we noted several common medical and psychiatric illnesses that are associated with potential violence.
The third set of theories are the sociological theories, commonly reported in the media and widely known. The most common ones include poverty, discrimination, domestic violence, inadequate schooling, substance abuse, and easily available weapons. Each factor has been associated with violent individuals. Lastly, the psychological theories address mastery skills and a meaningful purpose in life. Mastery skills include personal self-care, interpersonal social skills, and academic/work skills. Adequate parenting and schooling result in citizens with pro-social values. However, poor parenting and inadequate schooling may result in poor coping and antisocial values that include selfishness, revenge, and the imposition of personal justice on others.
An awareness of these potential source(s) of violence in the client or suspect with whom you are about to interact may help you defuse or deflect possible violence.
II. Specific Safety Guidelines
Although a helper would want to consider the six general safety guidelines noted above,
there are four additional guidelines for commonly encountered situations where help has been requested but the potential for violence is also present.
(7) Think Psychological Trauma. Psychological trauma is the physical and mental response that an individual may have to any sudden, unexpected, potentially life-threatening event over which the person has no control. Individuals may also be traumatized by witnessing such life-threatening situations. Traumatic situations may arise from natural and man-made disasters as well as the various types of human-perpetrated violent acts. Victims withdraw from others, do not want to be a part of an unsafe world, and may experience symptoms of hyper-vigilance, startle response, and continuous and disruptive memories of the event. The presence of adrenalin in the body overtime in conjunction with other brain neurotransmitter changes may result in fear for one’s safety. In some cases, this fear may lead to violent eruptions. A common potentially violent situation may occur when helpers try to provide assistance without being clear about who they are and what they are going to do. In these circumstances, the traumatized victim may assume you are another assailant and strike out. Be clear about who you are and why you are there.
(8) Think domestic Violence. The home is the most dangerous institution in today’s society (4). Murder, physical and sexual abuse of adults and children, torture, nonverbal intimidation (threatening harm with an inanimate object), and verbal abuse are frequent visitors to the home. Since violent parents, grandparents, aunts, and uncles are the adult role models for coping, and since children in these homes are often the direct victims of such violence or have witnessed the violence, it is not surprising that over two-thirds of them subsequently go on to be violent in their own lives. Approach domestic violence situations with great care.
(9) Think Psychiatric Emergencies/Substance Use. Schizophrenia, bipolar disorder, major depressive episode, and schizo-affective disorder comprise the serious mental illnesses. These illnesses are genetic, run in families, and may result in disruptions in thinking, emotions, and behaviors that the individual cannot control without medications. Feeling persecuted, being in intense rage, hearing voices that tell you to harm someone else are examples of symptoms that may lead some of these individuals to engage in violent behaviors.
A second category of at-risk individuals is those who have ingested alcohol or drugs and whose brain chemistry is now altered. Excessive use of alcohol dis-inhibits the cortical control centers of the brain, impairs reasoning, and judgment, and may result in violent outbursts. Crack/cocaine, methamphetamine, and opioids each alter brain chemistry and reasoning and may again result in violent outbursts. Individuals in withdrawal may also experience intense agitation that may lead to violence. Approach chemically altered brains cautiously.
(10) Think Continuum of Youth Warning Signs. Rare is the episode of youth violence that is sudden in onset. More common is the presence of warning signs, often several signs, and frequently signs that have been there for several years. These warning signs have been consistent for one-hundred years and I have arranged them on a continuum of severity (3). The first are the early warning signs. These include disrupted caring attachments to others at home, at school, and in the community; inadequate mastery skills in personal self-care, interpersonal cooperation, and academic/work skill deficiency; and the absence of a meaningful pro-social meaning in life, an absence that may result in states of anger, revenge, and hatred. If these early warning signs are ignored, the child may progress to the serious warning signs: depression, substance use, and/or untreated Post Traumatic Stress Disorder (PTSD). If these serious warning signs are also ignored, the child may proceed to the urgent warning signs of conduct disorder with criminal behavior and moral depravity. As with the other three specific guidelines, approach these troubled youth with caution and concern for everyone’s safety.
III. Self-Care Guidelines
Assisting violent and potentially violent persons as part of one’s work is potentially dangerous. It requires constant, vigilant attention and some times physical strength, when verbal strategies fail to defuse the situation. These situations are both physically and psychologically exhausting and may result in one’s being injured during the incident or being psychologically demeaned with an end result of burnout and possibly leaving the field. It does not have to be this way. There are strategies helpers may employ to reduce the stress at work.
(11) Think Self-Defense. We are always communicating. Even when we are asleep, we are telling others something about ourselves. Communication can be verbal/oral as well as nonverbal. Nonverbal communication is all of the messages that we send to others by dress, posture, nonverbal behaviors, and the like. Nonverbal communication can be an important self-defense strategy for enhancing safety. Wear an appropriate wardrobe for your role as helper, assume appropriate posture, utilize a reasoned tone of voice, and learn verbal-deescalation skills. Also be sure that, as you provide your assistance, there is nothing in the immediate environment that can be used as a weapon against you. Depending upon your role as helper, you may need to learn some system of nonviolent self-defense, alternatives to restraint usage, and how to implement restraints correctly, when safety is at stake. Employing these strategies can further enhance your safety and make you work more manageable and less emotionally taxing.
(12) Think Health and Wellness. Our work and our lives should be reasonably satisfying and meaningful. A steady workload of violent or potentially violent incidents can wear anyone down, so it is important for helpers to look after their own stress management needs as they go along. There are strategies that all of us can utilize to reduce stress. The first is the use of right-brain activities. The left-brain cortex is largely for language, thinking, and problem-solving. The right brain is more for visual spatial locomotion in the environment. Right-brain activities also dampen down left-brain activity, unless one is facing a true life-threatening situation. (In a true life-threatening situation, your brain will not let you switch.) An active right-brain lowers the level of stress in our bodies and increases a sense of well-being. Common right-brain activities that helpers can utilize include aerobic exercise, brisk walking, relaxation exercises, biofeedback, prayer and mediation, humor and crying, and the arts. Helpers might also want to acquire the skills of stress-resistant persons (5). Stress-resistant persons employ reasonable mastery, have a person commitment to something that is important to them, have a social support network, utilize a sense of humor, and are concerned for the welfare of others. They also follow a sensible diet, that includes reduced sugars and fats, no smoking, and moderate drinking, along with regular exercise. Helpers may also need to discuss the violence-related incidents encountered in their work so as to reduce stress and to avoid developing psychological trauma and untreated PTSD (5).
Helping troubled individuals who are potentially violent or violent is noble work for the individual in need, the immediate family, neighbors, and the community at large. Police, fire, emergency services, health-care providers, social workers, pastoral counselors, community outreach workers, and others quietly and effectively address these episodes of violence or potential violence regularly in their careers. However skilled they may be, violence always lurks in the background. The ten guidelines for safety and the two guidelines for self-care noted here can be easily implemented to reduce the risk of violence at work and to enhance the welfare and well-being of those who work on behalf of others in need.
1. Flannery R. B. Jr. The Violent Person: Professional Risk Management Strategies for Safety and Care. New York: American Mental Health Foundation, 2009.
2. Flannery, R. B., Jr. Violence in America: Coping with Drugs, Distressed Families, Inadequate Schooling, and Acts of Hate. New York: American Mental Health Foundation, 2012.
3. Flannery, R. B., Jr. Preventing Youth Violence: A Guide for Parents, Teachers, and Counselors. New York: American Mental Health Foundation, 2012.
4. Strauss, M. A. and Gelles R. I. Physical Violence in American Families: Risk Factors and Adaptation to Violence in 8,145 Families. Edited with Smith, C. New Brunswick, NJ: Transaction, 1992.
5. Flannery R. B. Jr. The Assaulted Staff Action Program: Coping with the Psychological Aftermath of Violence. Ellicott City, MD: Chevron, 1998.
Raymond B. Flannery, Jr., Ph.D. FAPM, is an internationally recognized scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops for all types of groups and may be reached at the American Mental Health Foundation. elomke [at] americanmentalhealthfoundation [dot] org.