Managing Client Violence

Acknowledgments
Introduction

Chapter 1: How and Why Client Violence Is an Issue for Social Workers

Chapter 2: Risk Factors Associated with Violent Behavior

Chapter 3: Best Practices for the Risk Assessment of Violent Clients

Chapter 4: Approaching and Engaging Violent and Aggressive Clients

Chapter 5: Intervention Modalities for Treating the Violent Client

Chapter 6: Managing Client Threats toward Social Workers

Chapter 7: Strategies to Prevent Client Violence in Office and Community Settings
with Janet Nelson

Chapter 8: Ethical and Legal Issues in the Management of Violent Clients for Social Worker Safety

Chapter 9: The Impact of Client Violence and the Importance of Self-Care

Chapter 10: Future Directions for the Prevention of Client Violence and the Promotion of Social Worker Safety

Appendix A: Summary of Risk Factors Associated with Interpersonal Violence

References
Index
About the Author

Christina E. Newhill, PhD, LCSW, is Professor Emerita of Social Work at the University of Pittsburgh (Pitt), where she taught in the MSW and PhD programs from 1990 to 2024. In 2008, she received the Chancellor’s Distinguished Teaching Award, Pitt’s highest teaching honor. Dr. Newhill earned a PhD in social welfare from the University of California, Berkeley; an MSW from Syracuse University; and a BA in sociology from the State University of New York, Binghamton.

Dr. Newhill’s primary research interests are violence risk factors and psychopathology, improving the risk assessment of violent clients and social worker safety, intervention development for individuals with serious mental illness and their families, psychiatric emergency services, and racial disparities in mental health services. Her Families as Partners in Reducing Violence project, funded by the National Institute of Mental Health, laid the groundwork for the development of an innovative refinement of existing family psychoeducation interventions that will assist family members/caretakers in coping successfully with potentially violent situations involving their ill relative.

Dr. Newhill has more than 10 years of community mental health practice experience, primarily in psychiatric emergency and inpatient settings. She has conducted training workshops on client violence and social worker safety at the local, state, and national levels for more than three decades and authored Client Violence in Social Work Practice: Prevention, Intervention, and Research, published by Guilford Press in 2003. Her other books include Interventions for Serious Mental Disorders: Working With Individuals and Their Families published by Pearson/Allyn & Bacon in 2015; Skill Development for Generalist Practice: Exercises for Real-World Application (with coauthors Elizabeth Mulvaney and Bobby Simmons) published by SAGE in 2019; and Dynamics of Family and Intimate Partner Violence (with coauthors Irene Frieze and Rachel Fusco) published by Springer in 2020. Dr. Newhill has 75 peer-reviewed publications based on her work. Dr. Newhill is a member of the Academy of Certified Social Workers and the NASW Register of Clinical Social Workers, holds a Diplomate in Clinical Social Work, and is a licensed clinical social worker in California and a licensed social worker in Pennsylvania.

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On February 22, 1989, Robbyn Panitch, a 36-year-old Los Angeles County, California, social worker, was stabbed to death by a client in her office at Santa Monica Mental Health Center (Simon, 1989). The client burst into her office unannounced and attacked her with a knife. Panitch was talking to her fiance on the phone at the time. Her fiance, hearing her screams over the phone, immediately called the front desk and police were notified. By the time two male employees were able to disarm the client, Panitch had been stabbed 31 times in the face and neck. She died two hours later. Her assailant, 26-year-old David Smith, told police that he murdered Panitch because he thought she looked like a childhood friend whom he believed was the Antichrist. Smith also complained that he was tired of living on the street and was angry at Panitch for not finding him shelter. In fact, she had made a reservation for him at a shelter and referred him to it, but he never showed up. Smith had threatened Panitch previously, and she had tried to get him hospitalized, but the evaluating psychiatrist had refused to admit him. There were no security guards or alarm systems at the Santa Monica Mental Health Center, and the center was operating with only half of its staff despite increasing caseloads. Staff had expressed concerns about safety, but mental health administrative personnel claimed that because of budget cuts, they had no money to hire security guards. Following Panitch’s death and a strong professional and public outcry, money was allocated to improve security. As one of Panitch’s colleagues, Reevah Simon, LCSW, commented:

I knew Robbyn mainly through her work with the Association of Psychiatric Social Workers. . . . She was intensely dedicated to the welfare of patients and improving the lot of her coworkers. It is a terrible irony that it is only the ultimate sacrifice of her life that may lead to the achievement of her goals. I am sure that it is only Robbyn’s death that has spurred all the publicity and media attention; that led to the Board of Supervisors finally making security a priority after years of futile pleading by employee unions. (Simon, 1989, p. 5)

In December 1991, David Smith was convicted of first-degree murder and sentenced to life in prison. Although Smith attempted to be declared legally insane, the Santa Monica Superior Court jury determined that Smith was sane at the time of the killing and was able to tell the difference between right and wrong. Although the jury recognized Smith’s diagnosis of paranoid schizophrenia, they also concluded that Smith knew society’s rules and made a choice not to follow them. NASW’s board of directors established a fund in Robbyn Panitch’s name, in memory of social workers killed in the line of duty (NASW, 1991).

In April 1989, when I retrieved the latest issue of the NASW California News from my mailbox, the leading front-page article, “Social Worker Stabbed to Death by Patient in Santa Monica Clinic” (Simon, 1989), affected me deeply as a social worker. I read the article, which described the murder of Robbyn Panitch, and said to myself, “Something has to be done!” After a total of eight years of 24-hour mobile crisis work in which I personally experienced three client assaults, I knew that I wanted to pursue research with the goal of assessing the scope of client violence toward social workers, an area woefully understudied at that time in the United States. Robbyn Panitch’s death was the event that spurred me into action.

Overall Purpose of This Book

The purpose of this guide is to help social work practitioners and agencies prevent and effectively manage commonly occurring incidents of client violence. The book is designed for the busy social work professional who needs a set of how-to guidelines that can be kept in the office or stored in their car to refer to when working in their office and in the community. The guidance provided can be used to help social workers manage the challenges presented by violent and aggressive clients, promote their own safety, and improve their practice skills in this area. The book can also be used as a basis for agency in-service training, for developing agency safety protocols, and as part of new employee orientations across staff levels. At the end of each chapter is a section called “Key Takeaways,” which comprises bulleted lists of the main points in the chapter that can be used for a quick review of the chapter content.

Throughout the various chapters, the main emphasis will be on managing the problem of client violence toward social workers from a proactive prevention approach. What this means is, rather than waiting for a violent incident to occur and then reacting to it, social workers and agencies can prepare ahead of time and do what they can to prevent such incidents from occurring in the first place. Composite case vignettes and dialogues based on the author’s practice and the client violence study are used throughout to provide a clinical context for the information discussed.

Organization of the Book

Chapter 1 introduces the topic of client violence and safety as issues for social work practice across settings and describes some of the factors that contribute to its occurrence. The chapter addresses the challenges and dilemmas unique to social work that contribute to the risk of experiencing an incident of violence and identifies some of the societal factors that form the larger context in which incidents of client violence occur. Finally, the chapter presents an overview of the author’s Client Violence Against Social Workers study (Newhill, 2003), which paints a picture of the frequency and nature of client violence toward social workers across practice settings.

Chapter 2 provides an overview of the risk factors associated with violent and aggressive behavior. Such risk factors can be divided into three domains: individual/clinical risk factors, historical risk factors, and environmental/contextual risk factors. A summary table is provided at the end of the chapter that clinicians can use as a tool to quickly identify such risk factors when conducting a risk assessment with a client, when obtaining a psychosocial history, or when reviewing a client’s chart before interviewing them or making a home visit.

Chapter 3 addresses best practices for the risk assessment of violent and potentially violent clients, providing guidelines to assist you in planning, organizing, and conducting the assessment. These guidelines include aspects to be considered related to background information, the clinical status of the client, how to approach conducting a brief but useful diagnostic assessment, guidance for conducting the assessment interview with both agitated and quiet/guarded clients, and, finally, considerations for assessing the client’s environmental context. The next two chapters address how to effectively approach, engage, and intervene with angry, agitated, and aggressive clients, including those who are legally or socially involuntary clients, while maintaining your safety.

Chapter 4 provides guidelines for how to approach, engage, and establish rapport with such a client and how to prepare for the interview. The chapter provides guidelines for choosing a safe interviewing environment, engaging and talking with someone who is angry and aggressive, using empathy and communication skills when working with potentially violent clients, and, finally, employing a strengths perspective in de-escalating anger and aggressive behavior.

Chapter 5 addresses the various intervention strategies that can be effective in treating violent clients and reducing their risk for future violence. Topics include medication and the role of the social worker in medication treatment, the therapeutic use of food or drinks, evaluating and managing agitation, guidelines for verbal de-escalation, when to hospitalize and how to facilitate hospitalization to avoid sanctuary harm, principles for psychotherapy with violent clients, and behavioral therapy strategies appropriate for working with violent clients. Many social workers and other mental health professionals assume that there is nothing anyone can do when a client makes a threat except hope that they will not carry it out. In fact, there are many strategies that can be effective in containing a threat and reducing the probability that the threat will escalate into violence.

Chapter 6 will review the various strategies that are effective in managing client threats, discuss the individual and group factors that may undermine effective threat management, and provide advice on how to mitigate undermining factors. The chapter will address the various modalities of threats including cyber threats, hostage situations, and stalking behavior. Recommendations from the Federal Bureau of Investigation on how to handle threats are reviewed.

Chapter 7 discusses strategies for preventing and dealing with client violence in the two settings where social workers most commonly practice: the agency office setting and out in the community. Topics related to the office setting include identifying practice areas that are the riskiest, prevention strategies for agency offices, enhancing safety by altering the physical environment of the office, preventing injury from weapons, and developing an agency safety policy. The chapter then provides concrete strategies for anticipating and managing client violence when practicing in the community, including home visits and assessments delivered in community service settings such as emergency rooms. The chapter discusses the assessment of environmental factors, the condition of emergency equipment, the client’s living space, the proposed work activities, any increased risk due to the client’s condition, and any worker vulnerabilities. Contributor Janet Nelson, MSW, addresses physical techniques that can help improve your personal safety, including exercises for breathing, centering, and self-defense.

Chapter 8 focuses on ethical and legal issues in the management of violent clients for social worker safety, especially the general challenge of balancing client rights with the protection of others. The chapter begins with a review of professional values and ethics including discussion of the NASW Code of Ethics and the core values of social work as conceptualized by NASW and the Council on Social Work Education. Ethical dilemmas are discussed with involuntary outpatient commitment as an example. Client rights and the difference between confidentiality and privileged communication are addressed. The chapter then discusses the Tarasoff “duty to warn,” including its origin, interpretation, where clinicians face dilemmas, and a three-stage model clinicians can use to fulfill the mandate of taking “reasonable care” when a threat is made toward a third party. Clinician–client dialogue illustrating how to approach issuing a Tarasoff warning is provided. Finally, HIPAA and its parameters and the controversial issue of pressing charges or prosecuting clients for violent behavior are discussed. An important consideration regarding client violence and social work practice is the psychological effect of client violence on the practitioner.

Chapter 9 addresses the emotional and psychological impacts of experiencing an incident of client violence on the social worker and the factors that contribute to enhancing or buffering trauma responses. The problem of underreporting incidents of violence and social workers blaming themselves when an incident occurs and how to change that is discussed. Because client violence can elicit trauma symptomatology in clinicians, the chapter discusses the immediate emotional impact plus the stages of trauma resolution. Finally, the chapter addresses the topic of self-care in the context of risk for burnout and secondary traumatic stress in social work practice.

Chapter 10 wraps up the book with a discussion of continuing challenges, progress made, and future directions in the area of social worker safety in the workplace. Welcome to Managing Client Violence: A Practical Guide for Social Workers! I hope this book will be both interesting reading for you and helpful in your practice.