Sailsbury, MD

Wednesday, July 21, 2010

It is important to be safe in the workplace. However, many professionals work with clients who have the potential to be dangerous. Risk assessment is one of the keys to preventing dangerousness in the future. Risk assessments are meant to make you, your clients, and the agency safe. Do not assume that none of your clients will hurt you because given the chance, some will. A professional needs to know who is potentially dangerous and who is not.

There are also safety precautions that one can take when working with dangerous clients. These involve:

• Being aware of where you are in your space and in relation to clients. Always be between the client and the door.

• If facing your client straight on is too threatening, move your body at an angle to the client.

• Speak softly and reassuringly.

• Ask them to take a deep breath.

• Help them problem solve.

• Get rid of any audience.

• Ask, "How do you want this to turn out?"

Data shows that dangerous clients have experienced trauma. Violence, sexual offending may be a reenactment of the violence the client experienced as a young child. Suicidality often means that the person is feeling trapped with no way out. Trauma issues must be addressed in order to reduce the risk of future violence, suicidality, or sexual offending.

Professionals that work with clients that have been traumatized and can be dangerous can experience secondary trauma, as well. They may show symptoms of PTSD or Burnout. Recognizing this can allow professionals to take care of themselves when needed. If they experience these symptoms, is important to seek help. Relaxation activities such as Yoga, meditation, and relaxation exercises can be very helpful. If it continues, counseling may be needed.

Assessing for risk is the first step in preventing future violence. However we must also understand that measuring risk is never 100% accurate. Risk means probability. There is an X% chance that someone will be violent and future. This does not tell us when in the future, under what conditions, or to whom the violence will occur. However, what it can inform is precautions for safety and treatment. Someone who is at high risk for future violence must be approached with caution and safety in mind at all times. However, we do not need to treat dangerous people any differently in terms of emotional approach than other clients. In fact, they probably need more kindness and understanding than most clients. Most have been traumatized. What we're doing is on unhooking the client's behavior of today from the past trauma.

First, one must measure the approximate level of risk that a person poses for harm to self or others. Over the years there have been several ways to measure risk. Research has demonstrated that unaided clinical judgment of future risk of violence is no better than chance. Clinical judgment aided by interview risk tools produces a result that is better than chance. Most violent risk assessment tools have ROC's (correct classification rates) from 60 to 93. Youth violence risk assessment tools include the SAVRY, CARE2, and PCL-YV. A professional must carefully choose which risk assessment instrument best suits their needs based on population being assessed, population in the standardization sample, validity and reliability, and the presence of a Manual to guide scoring.

It is necessary to measure risk for the safety all clients, coworkers, and one's self. If you are working with clients that have been referred by Parole and Probation or the Courts, public safety is also your client, too. It is important to focus on risks as well as strengths in treatment planning, so that the mix of interventions is complete.

Once risk is measured, it is important to manage or eliminate any future risk. Level of risk should determine the intensity of services needed. Youth with the highest level risk, need the highest variety and intensity of services. Types of services will be determined by the client's strengths, stressors, skills, and environment. It is important to use a holistic approach when working with high risk juveniles. Intervention should be based on a biopsychosocial/developmental/environmental approach to treatment.

Part of managing risk is communicating level of risk to the client, the workplace, and other agencies appropriately. Risk of violence, suicidality, and sexual offending must be discussed with the client. It is preferred that rapport be established between the client and a professional before attempting to communicate risk to the client. However, this is not always possible in a crisis. The reason for discussing these topics preventively is to avoid the crisis. Risk is a tough topic for the client to discuss. It is important to be calm, self assured and supportive. Don't let it be the elephant in the living room that nobody talks about. However, you must pay attention to safety before you communicate risk to the client. The professional should be closer to the door than the client. Notify staff in advance if you think there will be trouble. Be aware of the client's body language, emotional tone, and words.

In talking with the client, separate behavior from person. There is no such thing as a bad person, but there is behavior that can get you into trouble, send you to jail, or hurt your family. It is also important is separate thoughts from actions. Thinking about suicide is not the same as carrying it out. We all have thoughts and we can choose which ones act on. The use of motivational interviewing can also be useful. "Do you want to be in and out of jail (rehab) for the rest of your life or do you want something different? What you want? I can help you get something different for your life, if you want it. Let's make a plan together to make that happen."

When communicating risk to a client, be kind, but be frank. Be reassuring. Tell the client that you know he will be glad later, if he allows you to help him now. Ask the client whether he thinks he is dangerous to himself or others. Asked him why he thinks he is dangerous or not dangerous. Tell him what your assessment showed. If there are differences discuss why they are different. Tell the client, "Remember, I've told you that there is no confidentiality if you are dangerous. I can't let you hurt yourself or anyone else." Make a plan together for the next 24 hours. If he cannot cooperate, you may have to send him to the hospital. Talk softly and be reassuring, but confident.  Use these techniques to increase safety in settings where professionals work with clients that can be dangerous.

Kathryn Seifert, Ph.D.

CEO

CARE2, LLC

Sailsbury, MD

410-334-6961

410-334-6960

First Url: CARE2 online