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Safety in the Community


Terry Barkley

on 20 February 2014

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Transcript of Safety in the Community

Safety in the

Ten Good
What is Violence?
Risk Factor

in a Crisis


Factors that Influence Behavior
Planning For Safety
Something to think about
Ten Good Ideas
1. RESPECT - offer it and expect it

2. OFFER SPACE - keep safe by not getting too close

3. BE AWARE - assess each person, each day, each situation
(I don’t know what their weekend was like.)

4. TRUST YOUR INSTINCTS - Fear is the ability to recognize
danger leading to an urge to confront it or flee from it
(also known as the fight or flight response).
A basic survival mechanism.

Ten Good Ideas




Behaviors by individuals that
intentionally threaten, attempt or
inflict physical harm on others

Aggressive behavior aimed at inflicting
harm/discomfort on its victims, whether they
be intentional targets or innocent bystanders

To inflict physical, psychological,
emotional harm on others
1. What is the most significant factor in determining risk of violence in persons with mental illness?
2. Substance abuse is a high
risk factor for violence due
to the following:
A. History of violence

B. A previous or current diagnoses of serious
mental illness and prescribed medication

C. Current use of alcohol or other drugs

D. Both A and C
A. The psychoactive effects of drugs
B. Individual sensitivity to the
effects of some drugs
C. Drug use may exacerbate symptoms
of mental illness
D. Effects of withdrawal
E. All of the above
3. Circle the letter(s) of
the correct statements.
A. Concentrated poverty has not been determined to be a risk over other
significant factors
B. Positive social supports have been correlated with less violence
C. Employment has been negatively correlated to violence
D. Adverse family circumstances
can increase risk
4. Circle the letter(s) of
the correct statements.
A. Neurological problems combined with other factors may increase risk
B. Current research has clearly demonstrated a causal link between brain abnormalities and aggression
C. Violent behavior has been related to certain neurological disease and seizure disorder
D. Endocrine disorders including diabetes have been associated with aggressive behavior
5. In a mental health inpatient setting, males are most likely to cause significant injury to staff.
A. True

B. False
6. Which diagnosis is most frequently associated with violence?
A. Schizophrenia
B. Bipolar disorder
C. Major depression
D. Psychopathy
E. Anxiety disorder
7. Which symptom is most
associated with violence?
A. Psychosis
B. Delusions
C. Violent fantasies
D. Anger
E. Both C and D
8. Circle the letter(s)
of the correct statements.
A. The vast majority of individuals with serious mental illness are not violent

B. A small subgroup of individuals with serious mental illnesses are at risk for becoming violent

C. People with mental illness are much more likely to be victims of violence than perpetrators

D. When there is increased risk of violence, risks can be reduced by working with persons with serious mental illness and co-occurring
substance abuse disorders to develop
therapeutic routines
Prior Violence
Substance Abuse
Strongly related to future violence

Histories – are often incomplete

Records are frequently inaccurate or skewed, including criminal justice records

Important to use all available
resources for information
Along with prior history, the strongest
risk factor

Substantial increase in risk of violent behavior in persons with mental illness who USE alcohol and other drugs

Primary Association:
exacerbation of symptoms
All of the Above
Psychoactive Drugs
Exacerbation of
Certain drugs associated with aggression
Dose related response
Drug sensitivity
Some drugs impact on same neural mechanisms as aggressive behavior
Drug effects may activate other factors
Drug withdrawal
Most mental illness is associated with biochemical imbalances
Drug use further disrupts this chemistry
Results in exacerbation of symptoms
Familial Factors
Adverse family circumstances in childhood can increase risk, including:
Serious and frequent childhood physical abuse
Parental substance abuse
Parental violence/crime
Other Social Factors:
Concentrated poverty Lack of social supports Lack of employment Domestic violence may play a role Significant losses in relationships, health, housing stability, children . Adjustments such as re-entry from jail, prison or long hospital stays
Neurological Factors
Neurological factors combined with other factors may increase risk
Violent behavior has been noted with certain neurological disease
and seizure disorder
Head injury stands out as
an associated factor
Brain abnormalities and
neurochemical imbalances
Gender - M>F in general population

BUT - M = F among persons with
mental illness

Young more likely than older

Violence is more in relation to home & family with women
Age & Gender
Psychopathy – highest risk

Co-occurring substance abuse
highly significant

Other research regarding patient diagnosis
is conflicting

Schizophrenia has been cited as a high risk factor or low risk factor depending upon sources
Diagnosis & Risk
& Risk
Delusions can precipitate violence in individual cases
More significant in the presence of other factors
Fear of imminent harm; external forces override self controls; more significant in the presence of
other factors
Hallucinations in general do not increase risk
Command hallucinations should be given special consideration
Fantasies of violent acts increase risk
Impulsivity is significantly related
Anger – an activator of violence
Factors That
Mitigate Risk
Involvement with treatment
Taking medication as prescribed
Involvement with self-help groups
Strong social supports, including family, friends and peers
Outreach services
Monitoring (e.g. clinical, criminal justice)
Safe Space
Keep safe by not getting
too close!
Proxemics is the study
of how people use space
Safe Conduct
in the Field
-Collect information
-Individual functioning
-Significant others/neighbors
-Assess location
General safety precautions
-Hands free
Partnerships – police, informal, other
Safety Routines
Location of All Staff
-Log information
Regular Contact
-Agency contact person
-Telephones/beepers/GPS System
-Safe and reliable transportation
Team Work
Safe Arrival
Parking rural
Securing valuables
the Building
Entry – note all exits, door locked?
Use all information
Where to interview?
Health awareness and safety
a Visit
Policy and procedure
Whenever it feels unsafe
Presence of alcohol or drugs
Aggressive or hostile behavior
Vehicle - a unique environment -Safety Procedures
-Discretion not to transport
-Use alternatives

Do not transport when
-Agitated, threatening, suicidal -Under the influence
-Medical distress
-In crisis
-Attempts to exit car
In The Car
-Rear passenger seat one
of safest places in car
-Allows visual access (mirror) -Prohibits access to wheel
-Not behind driver
Assessing the Situation
Culture and Safety
When working in the field, in the agency or while traveling.
Safety depends upon maintaining an awareness of surroundings without over sensitivity
Make first observations from a safe distance.
Maintain safe space
Approach – rate, proximity, posture
Cultural Influences that Can Affect Safety
How can lack of cultural competence affect safety?What can be done to avoid problems?
-Be familiar with the culture of the recipient
-Conduct yourself appropriately
-Example: Offering of food
-Taking orders from women
Biological Factors
Underlying medical conditions
Biologically linked mood disorders
Neurological impairments
Effects of chemical substances
Psychotic symptoms
Personal space
Autonomy – need for
Privacy – letting outsiders in
Expression of emotions (anger)
Visiting another person’s neighborhood
Visiting another person’s home
Respect – how demonstrated
Authority / Gender Issues?
Interpretation of behavior? Unusual?
Beliefs about mental illness
Strength – based approach

Use supportive language

Focus on person’s strength/abilities
(I know you can do this)

Focus on positive
Making the Connection
Early Stage
Calm and reassuring- Voice: quiet, low, slow
- Take your time
- Keep it simple
- Empathy
- Interest
Early Boundaries
Include the person:

Ask the person what would be helpful

Ask for input

Offer help not control


Middle - Connection
Getting through the intensity

Voice – Mirroring .Show the behavior
you want to see.
Use the person’s name
Get to yes
-Ask simple questions that result in a positive response of yes
-When anger or hostility is present, it is
particularly useful to turn the
conversation to statements
that end in a positive response
Middle – Boundaries
Elements of good limit setting
- Clearly state behavior
- Be reasonable
- Be consistent
Late - Connection
-Anger or fear may be
reasonable responses
-Allow the person to vent
w/o increasing intensity
-Give as much as is needed
-Safe place
Late - Boundaries
Directive Statements

-Use a calm and assertive voice
-Use the person’s name
-Let the person know what you want
-Describe the behavior
-Maintain self awareness
a Crisis
First Response
Individual Worker
Assess the situation:
Call for help
Isolate – move the person to a safer space away from other people and distractions or
Move the bystanders
Establish a connection
Ask – include in problem solving
Stay at a safe distance
Responding to Weapons
Clear rules
Focus on the person
Address by name
Gain some distance
Take your time
Use “get to yes”
Emergency/crisis plans
Responding –
Under the Influence
Approach with caution
Calm, patient, slow, simple
Set limits
Drugs and alcohol effects
-Sudden mood shifts
-Sudden behavior changes
-Be prepared for crisis response
Issues Relating to
Physical Intervention
Community based program regulations
-Humane treatment
-Crisis services
Restraints can be dangerous
-Cardiac complications
-Pre-existing medical
-Asphyxia / positioning
Isolation / Seclusion problematic
Can be re-traumatizing
Not Approved for Community Settings
Earlier response w/verbal defusing

Personal crisis plans – ASK ahead

What helps

Time out

Medication (as per setting)
Event Analysis
and Debriefing
-Be thorough and specific

Review the event with staff involved

Debrief the event with the recipient and team members

Identify what worked and what may need to be changed
Psychological Factors
Displaced anger, frustration of guilt
-rejection from others
-bad news from home
-projection of self-concept
-desire to be punished
-broken promises
-threats to personal safety
-loss of autonomy
-lack of communication
Psychological Factors
Instrumental aggression
-Testing limits
-Controlling the environment

Lack of Choices
Unaddressed sexual needs
Environmental Factors
Conflicts among staff
Over/under stimulation
Temperature regulation
Changes in routine
Full transcript