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When Clients Threaten Therapists: Ethics and Practical
AspectsKarianne Bilsky, Ph.D.
Aviva Gaskill, Ph.D.
Robin Hornstein, Ph.D.
Donald McAleer, Psy.D., ABPP
Richard Small, Ph.D., ABPP
Dr. Small
•Overview•Learning Objectives•Ethical Components
Learing objectives
•Participants will be able to:•1. Identify potentially threatening situations•2. Have a wide range of options to deal with these situations
•3. Examine the ethical implications of these actions
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DISCLAIMER
•Drs. Small and McAleer are on the Pennsylvania Board of Psychology.
•All opinions expressed in this workshop are their own and do not represent the views of the Board.
OUTLINE
• 5:00‐5:20 Introduction and general ethics overview
• 5:20‐5:40 Research on threats to therapists
• 5:40‐6:15 Practical guide to therapist safety
• 6:15‐6:30 Break
• 6:30‐7:10 Training clinicians, supervisors and students to address client aggression
• 7:10‐7:35 Personal perspectives
• 7:35‐8:00 Discussion and evaluation
General ethical principles
•A. Beneficence and Nonmaleficence
•B. Fidelity and Responsibility
•C. Integrity
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General ethical principles (2)
•D. Justice
•E. Respect for People’s Rights and Dignity (Autonomy)
APA CODE: Competence
•2.06 Personal Problems and Conflicts ?
(a) Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work‐related activities in a competent manner.
APA CODE: COMPETENCE
•b) When psychologists become aware of personal problems that may interfere with their performing work‐related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work‐related duties.
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Apa code: Human relations
• 3.04 Avoiding Harm•(a) Psychologists take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients, and others with whom they work, and to minimize harm where it is foreseeable and unavoidable.
Apa code: human relations
• 3.06 Conflict of InterestPsychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation.
APA code: therapy
•0.10 Terminating Therapy(b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.
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Dr. Gaskill
•Speaker Introductions,
• Statistics, and Tips on Violence in Healthcare.
Dr. McAleer
•Safety Mindset
•Practical Matters
•Stages of Self protection related to•Stages of Violence
Self Defense???
• Most training focuses on technical development of motor skills whether that’s shooting, blade work, or empty hand skills.
• So what we’re going to focus on in this tutorial are tactics, particularly pre‐engagement tactics.
• Safety is something that happens between your ears, not something you hold in your hands.
• Awareness makes up 90 % of safety, the remaining 10% is physical technique
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Vulnerable Population
• Targeted because of your position
• Usually in a sterile environment
• Nature of our work• Our patients
• Families of our patients
• Things can happen fast
Nobody is coming to save you• You are responsible in that moment for your own self protection
• The mindset and mental preparation for safety• Think / plan ahead of time
•YOU HAVE PERMISSION TO TAKE CARE OF YOURSELF AND TO BE SAFE
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Decide
• Acknowledge the existence of risk but decide not to be a victim.
• planning, education, acceptance, training,conditioning, avoidance, and strategy.
• Use preparation and planning prior to an act of aggression. Learn about crime and criminal behavior.
• Train to respond to all forms of aggression. Practice avoidance and risk reduction. Condition your body and mind for the realities of violence
Intent
• There is an intent to violence
• Preparations have been made:• MENTALLY ready
• Searching
• Tools as necessary
• Fore planning
• Visible and discernable physiologic manifestations that a person is ready to commit violence
DENIAL!!!• Victims routinely express they were in denial at the time they were attacked.
• Common statements in victim interviews
• “Is he serious?
• “I couldn’t believe it was happening to me”
• “I was stunned”
• The time to work through that surprise is NOW.
• Accept that you could be the target of violence and work out the implications of that, realizing that you don’t have to do anything wrong or have “bad karma” to be selected as a victim.
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Deter
• Building Skills
• awareness, intuition, attitude and appearance, assertiveness, body language, boundary setting, and deception.
• Deter and prevent an act of aggression. Learn how to de‐escalate a confrontation. Project confidence with body language. Be assertive.
Victim Selection / Interview
• Your suitability as a victim• Awareness/ inattention
• Signs of submission
• Stride – shuffling uncertain gait
• Grayson and Stein• Consensus as to who the criminals picked as victims
• NOT based on gender , race or age
• posture, body language, pace of walking, length of stride, and awareness of environment. Neither criminals nor victims were consciously aware of these cues.
• Perpetrators notice a person whose walk lacks organized movement and flowing motion. Criminals view such people as less self‐confident—perhaps because their walk suggests they are less athletic and fit—and are much more likely to exploit them.
• People who drag their feet, shuffle along, or exhibit other unusual gaits are targeted more often than people who walk fast and fluidly.
• somebody who's not paying attention, who looks like they're not going to put up a fight, who's in a location that's going to make this more convenient,
• Someone who’s distracted
Awareness/Focus
• That ‘little voice inside’
• Your internal environment, what is in your head, what distracts you
• If it doesn’t look right• OR doesn’t sound right• OR doesn’t feel right
•IT ISN’T RIGHT
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Awareness/Distance and Time
• Maintaining Distance• So we should understand that awareness is a key factor in identifying a potential problem early.
• The earlier I identify a potential problem the more time I have to choose a solution.
Awareness and Positioning
Intimate Space – where we only allow loved ones to be.
Personal Space – the area in which we are comfortable having people we know and trust.
Social Space – the zone where we communicate and/or interact with others generally.
Public Space – an area where we accept that people in general can be, regardless of whether we know them or are interacting with them.
Claude Werner
Pre Assault Cues
• Grooming• any kind of movement of the hand around the face.
• Perhaps an unconscious effort to mask deception .
• A grooming cue might be rubbing the back of the head.
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Pre Assault Cues
• Target Glancing
• usually to the subject’s own 3, 9 or 6 o’clock.
Pre Assault Cues
• Discernible Weight shift.• when someone shifts their weight noticeably from one foot to the other, or from one side to another, the reason for this, is that it’s an effort to increase traction. They might not be aware of why they’re doing it but that’s the reason. Often combines with ‘quartering’
Disrupt
• Expecting a victim‐ foil the plan
• Apply verbal and/or physical techniques.
• Disrupt the aggressor. “Stop. That’s close enough.”
• Change your direction.
• Execute a decisive strategy to cause the aggressor to to falter/ hesitate
Positioning / Dominate
• Putting you in a position where you can be attacked:
• Closing Distance
• Target Glancing
• Grooming
• Hidden Hands causing odd movement
• Impeding movement/ cut off
• Unsolicited conversation
• Inexplicable presence
• They set the pace
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Unsolicited Conversation
• The person may try to engage you in conversation. He may ask for the time, directions, bus fare, or try to tell you about a nice club or restaurant just around the corner.
• Once you stop and let this guy engage you in conversation, you're opening yourself up
• Some people you don't talk to. You just keep going.
• To maintain range I have to use some kind of verbage. I have to tell him something that makes him stop coming closer.• “Hey buddy would you hold there for a minute?” allows someone to comply with your request, which isn’t rendered rudely. If they stop advancing, then you can ask them what they want.
• So if we have range and time we can escalate within our verbal options
• from:• A polite request to stop advancing.
• A louder command to stop advancing, using different specific language.
• Shout the same command at the top of your lungs and accentuate that with carefully selected common criminal vernacular, i.e. profanity.
Disengage
• Evade and Escape
• DISENGAGE is the immediate goal of self‐defense. It involves your complete commitment to get away from your attacker.
• Alternatively, it is the result of your actions that has caused your aggressor to discontinue the attack. It is characterized by your flight to safety, or either the aggressor is unwilling, or unable to continue his attack.
• ATTACK your attacker with everything you’ve got
• Use tactics such as the employment of weapons of opportunity.
• Create an ending. Carryout an exit strategy.
Attack – Effect the Crime
• Once the fist three stages are achieved, there is no reason for the criminal not to use force or the threat of force to achieve their ends
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Debrief
• Involve law enforcement
• Preserve evidence if any
• Do whatever you can to reduce after effects:• Debrief and discuss the consequences of aggression.
• Promote physical and emotional healing.
• Get legal advice. Seek support and assistance.
• Learn resilience
Reaction
• Until she/ he is out of sight, you are at risk of the reaction whether you cooperated or not.
• Your reaction interacts with their reaction
• May be volatile. Crime one leads to crime two eg: robbery –assault/ rape
• Repeat
• As a solo practitioner in a rural area for 30+ years, I’ve had my share of difficult and dangerous clients. I have tried to schedule such clients during steadily full office hours and while others are still in the building. I am usually the only one working at night. This is not foolproof. I am 8 to 10 miles from the two nearest PSP stations and about 2 miles from a small part time municipal PD, so I am on my own. My usual tactic, if I have no scheduling option, is to ask one of my adult sons to come and sit in the waiting room. A friend or spouse could fill the same role. A panic button would likely be of no use.
• Fortunately, I have only needed help on 4 or 5 occasions during all those years. All were during the day. My calls are all taken by a live answering service located in the community I serve. A quick call to them would trigger them to make further calls.
• Kay Vennie PPA List serve 2019
• “If you look like food, you will be eaten. If you think about it, one definition of “predator” would be “an expert in prey selection.”
• If, by not looking like prey, you keep from being attacked at all, it’s hard to imagine a better resolution.
Clint Smith – Thunder Ranch
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Training Clinicians and Supervisors to address Client Aggression:
What tools do we need?
Assessment Skills
Coping Skills
Knowledge of the Policies
Practice
Debriefing
Dr. Hornstein
Story
Story – happens to newest providers
Feelings – some common features
Supervisory Response –Training Important
Agency Response – Should be in P & P
Recovery – Processing of self blame ‐ Processing of “normalization”
APA Suggestions
• Evaluation of Clients Have a way out • Locked Doors How to get help
• Screening Colleague Pop‐In
• Evacuation Policy Remove Potential
• Panic Room Remove Potential Weapons
• Lockers for Patients Night time
• Self Defense TRAIN AND PRACTICE
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Symptoms
•What to Expect Post Event
(Abbot and Brinkman)
PTSD, Fear, Avoidance, Anger, Need for Time Off, Sleep Issues, Confidence Issues, Intrusive Thoughts, Leaving Job/Field, Decline Certain Types of Clients, Reduced Empathy, Concentration Issues
COPING
• SHARE• GET HELP
• ASK FOR WHAT YOU NEED
• THERAPY•WHAT IS THE ROLE OF THE SUPERVISOR
Small Group
What is the best way to augment our training of Supervisors and Students/Interns to decrease the number of incidents and to provide a quick response when these traumatic incidents occur? Share your own ideas/how your current worksite addresses this now and what you would like to see happen.
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Dr. Bilsky
•The Personal Perspective
•Discussion Period
Questions/ Comments
Source material
• Craig Douglas – http://shivworks.com/
• Massad Ayoob – http://massadayoobgroup.com/
• Claude Werner‐ https://tacticalprofessor.wordpress.com/
• John Farnam – http://defense‐training.com/
• Marc MacYoung ‐ https://www.nononsenseselfdefense.com/
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Source Material
• John R. Murphy‐ www.fpftraining.com
• Active Self Protection https://activeselfprotection.com
• Mary Hayes https://armedcitizensnetwork.org/
• Mike Wood https://www.policeone.com/active‐shooter/articles/196375006‐Why‐Move‐Escape‐or‐Attack‐is‐superior‐to‐Run‐Hide‐Fight/
• LiveLeak.com
Source Material
• Pope, K. and Vasquez M.J.T Ethics in Psychotherapy and Counseling: A Practical Guide, 5th Edition (Wiley, 2016)
• Kivisto, A. J., Berman, A., Watson, M., Gruber, D., & Paul, H. (2016). North American Psychologists' Experiences of Stalking, Threatening, and Harassing Behavior: A Survey of ABPP Diplomates. Professional Psychology: Research and Practice. 46(4): 277‐286.
• Kasai, et al. (2018). A survey of workplace violence against physicians in the hospitals, Myanmar. BMC Research Notes. 11:133.
• Coutre, L. (March 11, 2019). Healthcare workers face violence ‘epidemic.’ Retrieved from: https://www.modernhealthcare.com/providers/healthcare‐workers‐face‐violence‐epidemic
Source Material
• Abbott, A & Brinkman, J.T. (2017). Workplace Violence Against Healthcare Providers. Retrieved from: The O&P Edge.
• Anderson, A & West, S.G. (2011). Violence Against Mental Health Professionals: When the Treater Becomes the Victim. Retrieved from: Innovations in Clinical Neuroscience. 8(3): 34‐39.
• Galeazzi, Gian Maria; & De Fazio, Laura. (2006). “A review on the stalking of mental health professionals by patients, prevention and management issues.” Primary Care & Community Psychiatry, vol. 11, #2, pp. 57‐66.
• Schwartz, T.L. & Parks T.L. ((1999). Assaults by Patients on Psychiatric Residents: A Survey and Training Recommendations. Published online: https://doi.org/10.11176/p.s.50.3.381.
• Tripp, A. (2009). After an attack: How to deal? Academic Psychiatry, 33, 345‐346
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