Safety First: Paying Heed to and Preventing Professional Risks

by Barbara Trainin Blank

In light of the murder of social services worker Boni Frederick in Kentucky earlier this week (October 2006), we are posting Barbara Trainin Blank's article on social worker safety from the Summer 2005 issue of The New Social Worker. Ms. Frederick's death is a terrible tragedy and is of concern to all social workers and social service workers.

In August 2004, Teri Zenner, a case manager with the Johnson County (Kansas) Mental Health Center, was a newlywed who was getting her MSW degree. Then she was stabbed to death while visiting the home of a client. The 17-year-old client, diagnosed with a mental illness, has been charged with the murder.

The previous January, Greg Gaul, a licensed private clinical social worker in Johnson, Iowa, was apparently killed by a troubled 16-year-old client. The young man previously had killed his house sitter and later committed suicide during a police chase. Are these isolated events? Unfortunately not. But such incidents lend renewed emphasis to client violence and the need for social workers (and the agencies they work for) to protect themselves.

“It’s an open secret, really; social work is a dangerous profession,” declared the newsletter of the North Carolina Division of Social Services and the Family and Children’s Resource Program.”

Just how dangerous? A survey by NASW’s Committee for the Study and Prevention of Violence Against Social Workers, with the support of the Massachusetts Chapter (see http://www.naswma.org/about/default.asp?

topicID=99), revealed that 51.3% of the sample reported feeling unsafe in their jobs. Nearly one-third have experienced some form of violence, including verbal abuse, at least once in the office. Nearly 15% reported at least one episode in the field.

According to OSHA, only one more setting is more dangerous, and that’s working at night in a retail store, notes John Weaver, a social worker with the Northampton County in Bethlehem, Pennsylvania.

Nor is client violence a “new issue,” says Christina Newhill, an associate professor of social work at the University of Pittsburgh and author of Client Violence in Social Work Practice (Guilford Press). “I can say that client violence has been like the elephant in the room no one is talking about. We were just managing it. But now, we’re talking about it more—because of deaths (occurring) close together.”

Probably few social work students or new practitioners realize when they enter the field that they may be a target for assault. Yet threats of violence and actual violence occur more frequently than even experienced social workers care to admit, according to several studies.

A National Survey of Violence in the Practice of Social Work, Srinika Jayaratne, et al., reported in Families in Society: The Journal of Contemporary Social Services (October-December 2004), for example, indicates that verbal abuse is quite common, whereas threats of assault and actual assault are less common—but still problematic. For example, verbal abuse is pervasive across all settings—22.8% of agency workers reported being physically threatened.

Being young and male places a worker at higher risk, and public and nonprofit agency practitioners report many more incidents than workers in private practice. Within institutional settings—where much of the available data have been gathered—73% of psychiatrists in a 1999 study reported threats violence.

OSHA announced in 1996 that “more assaults occur in the health care and social services industries than in any other,” but social work is not separated out. According to a 1998 study (Guy & Brady), usually the violence is not premeditated, and the weapon is frequently an object found in the immediate surroundings.

Newhill found in a 1995 survey of MSW students that client violence is one of the top three practice concerns in their field placements. A large study of mental health workers in Georgia (2003) showed 61% had been victimized either psychologically or physically, and 29% had feared for their lives during their professional careers.

There are a number of reasons client violence seems to be on the rise. One is the “sea change,” as one executive of a social work agency put it, from seeing clients in the office to seeing them in the community. Other factors are the availability of guns and a population adept at using them; the rise in violence in general, including in schools and other work places; and deinstitutionalization.

Add budget cuts to social service agencies, a growing substance abuse problem, and exposure to higher-risk situations on the part of social workers, and increased rates of client violence might be expected. Still another factor is an increased disparity of income in the population, leading people to feel helpless and more desperate.

“In my own practice with inpatient social work and then psychiatric emergency services, colleagues had received no training, and the problem was not even acknowledged in MSW programs,” says Newhill.

But the attitude of social workers is also a factor. They often resist thinking of clients as potentially threatening, or, conversely, assume that danger is intrinsic to the field and shouldn’t be overemphasized.

“We’re not oriented toward seeing clients as perpetrators,” agrees Susan Weinger, an associate professor of social work at Western Michigan University and author of Security Risk: Preventing Client Violence Against Social Workers, published by the NASW Press. “The overwhelming majority of clients are nonviolent. But if an incident of violence occurs, the agency gets more focused.”

Unfortunately, continues Weinger, not every case receives national recognition, so “each area (of the country) gets aware on its own. And if a social worker is aware of certain surroundings and nothing has happened, that person tends to feel safe. We’re supposed to be able to handle these problems. Otherwise, it may seem you don’t know your job.”

The experts also agree that many cases of violence go unreported or underreported. This may be because workers don’t want to bother filling out reports; assume such violence is routine, and therefore report only extremely severe incidents; or believe reporting such an incident would reflect badly on their job performance.

Some agencies, in fact, don’t have a systematic way of reporting incidents of violence, or a standardized form. That sends out a message that client violence is not taken seriously or that the social worker may be “blamed” for trying to report it, rather than receiving sympathy.

“Most of us have developed a comfort level with the profession and don’t want to be fearful,” says Weaver. “So we have denial. A lot of people tell horror stories about the places they left. Only recently have we begun to think in terms of ‘zero tolerance’ toward a client who’s violent.”

During workshops he has conducted, Weaver conducts informal surveys—and has found that as many as 50% of social workers have witnessed some kind of violence, to them or a co-worker. Ten to 15% have been pretty seriously threatened themselves. Some have been stalked by parents whose children they have removed from their homes.

But, unfortunately, it sometimes takes a tragedy for agencies to really focus on what can be done to make social workers safer.

“People are starting to look at policies (regarding safety), which is great,” says Matt Zenner, who had been married to Teri Zenner for only three months at the time of her death. “There was extremely little in place before Teri’s murder. There was no GPS on the phone, and no training as far as how to get out of situations.”

Since then, Johnson County has reevaluated policies and implemented some changes.

“Teri’s death has caused us to take a step back and reassess everything we had been doing and ought to be doing,” says David Wiebe, the agency’s executive director. “We tried embedded GPS chips, but the technology was not as advanced as it needs to be for fail-safe reliability, so we didn’t proceed with it. We’re focusing on keeping schedules up to date, so we know where everyone is, and on retraining staff on an ongoing basis. We’re going to give staff knowledge and resources about the anticipatory part of safety, rather than just the reactive part.”

The agency is also offering social workers self-defense training given by local experts, as well as a personal safety presentation sponsored by the

Sheriff’s Office. Yet another focus will be helping workers assess the risk of a new client or of going into a new situation.

“The vast majority of mentally ill people are not dangerous,” says Wiebe. “But a small slice possess a risk. We have to figure out who they are and how to handle it. Some clients we will see only in the office, or we will send two people. The problem is always there, because that’s where the profession is.”

So, what can you do to minimize your risks?

If you’re starting out in a practicum or in an agency after graduation, ask some questions. Be sure you are comfortable with all safety matters and with emergency procedures. It is advisable to sign an Assumption of Risk statement, a copy of which is kept in students’ permanent files. Discuss what agency policy and recommended courses of action are if a client becomes agitated, hostile, or threatening during an interview.

Safe agencies talk about and act on safety concerns. This begins the first day on the job—when safety skill training is part of the orientation. Ask if the agency has a “violence plan,” like a fire drill.

Determine if the agency has an incident reporting system and written procedures. Ask about cell phones for workers, especially in rural areas. And don’t forget to inquire about policies for following up victimization and trauma suffered by staff, especially in serious incidents.

Never take risks with a client who becomes threatening. Leave the room and seek assistance. Eliminate objects in your office that can be thrown or used as weapons. Check the physical layout of the office, to see if there are such precautions as silent alarms, limited access to staff work areas, even the arrangement of furniture in your office—so you have easy access to the door.

In an institutional setting, it is acceptable to request that your supervisor or another staff member accompany you when meeting a client whose behavior may be unpredictable.

If attending an activity at a social service setting after hours, be aware of the location or neighborhood: note street lights, open spaces, shrubs and other growth that might impair your vision. When going to a car after dark, request being accompanied by a supervisor or someone else.

If you believe you are not adequately prepared to provide a service or intervention, address the concern with your agency field instructor or supervisor.

Use “street smarts”: plan home visits for early mornings; lock car doors; travel without a purse or briefcase, if possible; and take on an assertive “I know where I’m going” demeanor.

If you’re a social worker in private practice or considering that option, suggests Sheila Peck, a social worker in Long Island, you should ask yourself such questions as: Is the parking lot well lit? Is the neighborhood violent? Do you want to work with domestic abuse cases?

You might want to consider a panic button, connected to the police or someone else’s office, or you might want to share offices.

On the other hand, Peck says, “Know yourself.” Some social workers work well with clients with a history of violence.

If preventive strategies haven’t worked, and the client seems to be getting violent, what do you do?

You have to find a way not to be afraid. And sometimes it’s advisable to “stop behaving like a therapist.” In other words, drop the “What do you mean by that?” kind of questions. Treat the client “like a human being,” advises Peck.

If you’re a young social worker just starting out, acquire a supervisor or consultant before you go into private practice. Often new practitioners may not pick up on warning signals of impending violence. Experienced clinicians may spot things you don’t.

You might also want to form a link with a psychiatrist. Some patients require medication, and psychiatrists also offer admission privileges and evaluation. Beyond that, you’ll want to educate yourself about psychopharmacology. If the drug or dosage is wrong, this can have negative effects on the client.

Whether you work for an agency or not, take extra precautions when dealing with survivors of domestic violence. Although most batterers focus only on their partners, some also turn against people they see as a threat to their control over those partners. You might consider keeping your last name from becoming known to the batterer, having your phone number unlisted or unpublished, and never giving your home address or phone number to the survivor or allowing that information to be on a document or list the batterer might see.

The NASW Committee recommends several strategies for social workers, including: learning the indicators of violence; never carrying risk alone or putting yourself knowingly in a risky situation; understanding the dynamics of addictions, mental illness, and other issues associated with acting-out behaviors as well as how to recognize signs of agitation; following your gut and assessing your safety at all times; and learning nonviolent self-defense, physical evasion, force deflection, and disengagement skills.

Above all, never let your guard down—and stay out of denial. And remember: the best predictor of violent behavior is prior violence.

Before a home visit

Have a safety plan in place. This should include precautions to avoid danger as well as strategies to help you manage a confrontation if one occurs.
Start with a safety assessment: learn all you can about the family’s history—have they had violent encounters with the police, schools, or social services? Is there a history of mental illness in the family? Some of these details will be noted in agency records. For others, you may have to consult informal sources, such as your supervisor, co-workers, or colleagues from other agencies.

Home visits should be made with the full knowledge of your agency supervisor—time of departure, time of return, other activities while on the trip, and so on. Do not conduct a home visit when you feel uncomfortable or threatened, and return to the agency and report your experience.

Give serious consideration to the street, neighborhood, or area where the family lives. You might want to exercise extra caution.

Identify potential safety risks while in the home. Remain alert and observant. Listen outside the door for any disturbances, such as screaming or fighting. When knocking on the door, stand to the side, not in front of it.

Note if the people you’re speaking with are intoxicated. Scan the environment for any weapons and note any drug paraphernalia.

What can agencies do?

Acknowledge client violence toward human services workers as a real and legitimate practice concern.
Implement specific safety precautions in the office and field.• Establish a worker safety manual that explains policies and procedures, and establish cooperative safety protocols with other organizations you work with.

Affirm to all staff it is okay to ask for help.

Establish a worker safety committee.

Develop a team approach or buddy system in cases in which a client has a history of violent behavior.

Give a clear consistent message to clients that using violence to solve problems is not acceptable, and help clients learn nonviolent strategies to resolve their problems.

Establish a firm protocol regarding possible filing of criminal charges against violent clients.

Some tips on de-escalation techniques

Appear calm, centered, and self-assured even if you don’t feel it.• Use a modulated, low, monotonous tone of voice.
Do not be defensive. Even if the comments or insults are directed against you, they aren’t about you.

Be respectful, even when setting limits firmly or calling for help.

Never turn your back for any reason. Always be at the same eye level, but do not maintain constant eye contact. Allow extra physical space between you. Keep your hands out of your pockets.

Do not get loud or try to yell over a screaming person. Wait until he or she takes a breath; then talk.

Empathize with feelings, but not with the behavior. Do not interpret the client’s feelings in an analytic way; do not argue or try to convince.

Trust your instincts. If you feel the de-escalation isn’t working, STOP! Tell the person to leave, call for help, or leave yourself.

Additional Reading

Children’s Services Practice Notes.

http://sswnt7.sowo.unc.edu/fcrp/Cspn/vol3_no2.htm

Grobman, L. M. (2002). The field placement survival guide. Harrisburg, PA: White Hat Communications.

Newhill, C. E. (2003). Client violence in social work practice: Prevention, intervention, and research. New York: The Guilford Press.

Stanley, J., & Goddard, C. (2002). In the firing line: Violence and power in child protection work. West Sussex, England: John Wiley & Sons.

Wenger, S. (2001). Security risk: Preventing client violence against social workers. Washington, DC: NASW Press.

Barbara Trainin Blank is a freelance writer in Harrisburg, PA.