Client Violence toward Social Workers: The Role of Management in Community Mental Health Programs

Beginning of article

   Fear gripped me. This routine psychotropic
   medication delivery and in-home assessment
   visit had gone terribly wrong. The look I saw
   in my client's eyes indicated to me that he had
   lost control of himself and that he was intent
   on killing me. We were alone in his house.
   While in the kitchen I listened to him describe
   in great detail how he was going to slowly kill
   me by dismembering me piece by painful
   piece, shoot me in the stomach, decapitate me
   and bury me in the backyard. What were
   probably only minutes felt like hours. It was
   clear to me that the client I had worked with
   for one year was not his usual self and was
   decompensating. I tried to remain calm as I
   scanned the room, looking for a way to escape.
   Somehow I came to the decision to slowly
   back out of the house towards the front door,
   while continuing to talk calmly to my client as
   he described his murderous plans. In my mind
   as I was halfway to the front door, I thought I
   was on my way to safety. Suddenly, he
   grabbed my arm and swung me into the living
   room, effectively cutting me off from my exit.
   Out of the blue, my captor became distracted
   with the collection of videos on the other side
   of the room, while continuing to describe
   deadly scenes from each movie. Seizing the
   moment I turned and ran out, sprinting to the
   car. Safely I got in my car, locked the doors,
   and sped off back to my office.

   My life was significantly disrupted for
   months after this incident. Nightmares interrupted
   my sleep. I was overwhelmed with feelings
   of shame and doubt. I began to question
   my judgment at every turn. Should I quit?
   Maybe I'm not cut out for social work? My
   reactions altered the work patterns of my coworkers.
   Because I no longer felt comfortable
   going alone to a client's home, I requested a
   coworker accompany me on my outreach visits.
   The responses amongst my colleagues were
   mixed--some acknowledged the event as traumatic,
   others overtly and covertly expressed
   sentiments such as, "This is part of the job so
   just deal with it" and "If you are too afraid to
   deal with clients' needs, you do not belong in
   this type of work."

   I didn't quit. In fact, since this incident I
   was promoted to a supervisory position and
   continue to work diligently with clinicians and
   agency administration to develop a comprehensive
   staff safety policy that goes beyond
   current policies dealing primarily with facility
   issues. My ability to cope with this traumatic
   incident was certainly impacted by my enjoyment
   of the challenge of the work and core
   belief that I am a conscientious and competent
   mental health professional. However, it was
   the knowledge and supportive presence of my
   supervisor that was key in helping me return
   to my previous levels of professional and personal
   sense of confidence.

Client violence toward social workers is not a rare occurrence. In a study of licensed social workers in a western state, Rey (1996) found that violence against social workers occurs across settings. Griffin (1995) reported that social work cases have become more complex (for example, substance abuse and mental illness and homelessness) and that treatment is provided in a societal context fraught with greater violence. Community-based social workers face greater peril than their office-based counterparts because they often provide services in unsafe neighborhoods and have limited to no immediate support available if something should go wrong. Key indicators of potential violence include positive symptoms of schizophrenia, medication noncompliance, active drug or alcohol use, mandated clients, and a history of violence (Shergill & Szmukler, 1998; Weinger, 2001). Even in the midst of writing our final drafts of this article, we sadly read that Nicole Castro, a 23-year-old social worker in Maryland was murdered while serving a mentally ill client during a "routine visit" (O'Neill, 2002).

The introductory vignette is an actual account of the first author's experience of a serious threat to her physical safety at the hands of her client. Unfortunately, it is merely one among the many scenarios that social workers face daily in providing services to clients.

Overview

During the middle of the 20th century, the focus of mental health treatment shifted from large psychiatric hospitals to community programs (Okin, 1995; Witkin, Atay, & Manderscheid, 1996). Since the advent of psychotropic medications in the 1950s (Kelly, 2000) and subsequent deinstitutionalization, the number and types of community mental health programs has grown substantially. The focus of treatment has expanded to include outpatient counseling and case management services provided at clinics, group homes, vocational programs, and in clients' homes (Fisher et al., 1996). Not only is community treatment the current trend for mental health professionals, patients, and their families, the 1999 U.S. Supreme Court decision Olmstead v. L.C. (1999) ruled that states must provide appropriate community mental health treatment.

Although community mental health treatment has become more prevalent, the consequences for social services workers have become increasingly dangerous. One state program that exemplifies national trends is the New Jersey Redirection Plans (State of New Jersey Department of Human Services, 2000, 2001), designed to shift treatment from psychiatric hospitals to home-based mental health treatment. In 1998 one New Jersey state psychiatric hospital was closed; currently another is designated for closure. Comprehensive outreach mental health treatment programs that serve clients in vivo (for example, within the general community such as client's home, vocational setting, homeless shelters, streets) have been created. Changes in laws requiring more stringent civil commitment criteria (Occupational Safety and Health Administration [OSHA], 1998) have also contributed to an increase in the psychiatric acuity levels of clients. Although the majority of individuals with severe and persistent mental illness are not inherently dangerous, the potential for danger exists because of the pervasive and unpredictable nature of the condition. Patients who were previously considered too ill and or violent to be released from the hospital now live outside of hospitals, and tasks that were previously under the auspices of state psychiatric hospitals are now frequently carried out in the community. Although 53 percent of people with a mental illness in prison are incarcerated for a violent offense, mental health professionals in the community often serve those individuals before and after incarceration (Ditton, 1999). Despite the many advantages of community-based care for clients (for example, least restrictive environment) and workers (for example, intervening with clients in vivo), community-based social workers perform functions at an elevated risk of danger--clients are sicker and communities are more dangerous.

Unfortunately, client violence against social workers has received little attention by our profession. Despite social work's history of home visits with society's most vulnerable clients who are often at risk of dangerous and unpredictable voluntary and involuntary episodes of violence, the shift from hospital to community psychiatric care, and the increase in home visitation programs, few agencies have appropriate safety policies in place. Because it is in the client's own environment that social workers may be most vulnerable (Breakwell & Rowett, 1989), …