Monday, March 3, 2008

Client Violence: Interview with Dr. Christina Newhill

[Episode 35] In today's podcast, I talk with Dr. Christina Newhill, a nationally recognized expert on client violence and the author of Client Violence in Social Work Practice: Prevention, Intervention, and Research, published in 2003 by The Guilford Press. In today’s podcast, Dr. Newhill defines client violence, talks about why social workers should be concerned with client violence and identifies which social workers are at greater risk for violence. She discusses some ways to assess a client’s potential for violence, how to intervene with a violent or potentially violent client, and identifies some strategies for increasing worker safety. We end our interview with information about existing research and resources for social work educators.


Download MP3 [42:05]



Dr. Newhill is an Associate Professor at the School of Social Work at the University of Pittsburgh. Her primary interests are in community mental health services and the care and treatment of clients with severe and persistent mental illness, with a particular interest in the assessment of violent behavior. Dr. Newhill's articles have been published in the top social work and psychiatric journals. Her research has been funded by the local and federal agencies, including the Centers for Disease Control and the National Institutes for Mental Health.

Interview Questions
  1. Are some social workers more at risk than others?
  2. How do you assess a client's potential for violence, specifically towards the social worker?
  3. How do you intervene with a client who appears to be escalating or who is violent?
  4. What are some strategies for increasing worker safety in a solo-practice setting? in an agency setting?
  5. What are the NASW guidelines for dealing with violent and aggressive clients?
  6. What research has been conducted in this area?
  7. If a social work educator was listening to this podcast and wanted to integrate content about client violence into BSW/MSW courses, what resources or information could you provide that might help them?

Transcript

Introduction

[00:13]
Jonathan Singer: When you think of a social worker, what comes to mind? Is it an overweight middle aged woman sitting behind a desk giving out food stamps? Or callused police wannabe removing kids from innocent parents? Well, since you’re listening to the social work podcast, I suspect you have a more realistic and generous image of social workers. In fact, social workers come in all shapes and sizes and provider a greater variety of services in a greater variety of settings than any other helping professional. But the one thing that all social workers have in common is that we were trained in what we call the strengths perspective. When social workers take a strengths perspective, they look at a client’s strengths, capabilities, and resources; they ask themselves, what do these clients have going for them that will help them to successfully negotiate their current situation? The strengths perspective is one of the reasons that social workers can work successfully with so many different types of clients. There’s a downside however to taking a strengths perspective. Some social workers ignore the problems or deficits; wrongly believing that if we only look at the positives, good things will happen. Some see social workers as Pollyanna’s who ignore the realities of our client’s lives—thus perpetuating social inequalities. Putting Band-Aids on what is going on. And perhaps most importantly for this podcast, some schools of social work ignore the more dangerous aspects of social work in pursuit of training students to see the best in clients. And there are dangerous aspects of social work. The recent murder of a Boston area social worker, allegedly by her nineteen year old client highlights the problem that social work as a profession has yet to adequately address—the problem of client violence. And that’s the topic of today’s podcast. Regardless of practice setting, social workers encounter clients who are violent or have the potential for violence. When I worked at the local Community Mental Health agency in Austin, Texas, we had a code that we would use to page backup when a client was escalating or had become violent. What we would do is we would call the receptionist and ask to speak with Dr. Red. The receptionist would then make a building wide announcement that Dr. Red was needed in a particular office and everyone in the building knew that Dr. Red was a code for backup so that the escalating client or the violent client wouldn’t feel like they were about to be pounced on by dozens of angry over-protective social workers. We would mute our own phone so as not to alert the client that help was on the way. And this allowed us to continue our own intervention until backup arrived. I came to find out that this type of code or alert system was fairly common in agencies. Why? Because keeping ourselves and our clients safe is one of the most basic functions of social work. Despite the importance of this topic, there is relatively little information available to social workers. For example, the National Association of Social Workers has no guidelines for dealing with violent and aggressive clients. So, in today’s podcast, I talk with Dr. Christiana Newhill, a nationally recognized expert on client violence and the author of Client Violence in Social Work Practice: Prevention, Intervention and Research published in 2003 by the Guilford Press. Dr. Newhill is an Associate Professor at the School of Social Work at the University of Pittsburg. She received her PHD in Social Work from the University of California-Berkley. She has over ten years of mental health practice experience, primarily in psychiatric emergency and inpatient services. Her primary interests are in Community Mental Health services and the care and treatment of clients with severe and persistent mental illness, with a particular interest in the assessment of violent behaviors. Dr. Newhill’s articles have been published in the top social work and psychiatric journals. Her research has been funded by local and federal agencies, including the Centers for Disease Control and the National Institutes of Mental Health. In today’s podcast, Dr. Newhill defines client violence, talks about why social workers should be concerned with client violence and identifies which social workers are at greatest risk for violence. She discusses some ways to assess a client’s potential for violence, how to intervene with a violent or potentially violent client, and identifies some strategies for increasing worker’s safety. We ended our interview by talking about existing research and resources for social work educators. And as always, if you’re interested in more information about the topic presented in today’s podcast, just go to the social work podcast website where you will find links to newspaper articles and resources specifically on the topic of client violence. And now, on to the interview with Dr. Christina Newhill and client violence.

Interview

[05:14]
Jonathan Singer: Christina, thanks so much for being here and talking with us about client violence. I was wondering if you could start out by defining what is client violence?

Christina Newhill: That’s a good question. There are actually many different definitions of client violence that have been you know reported in the research. And I think just defining violence in general is difficulty. You know, what are the parameters? What’s considered violent and what’s considered simply aggressive? I think there are some forms of interpersonal violence that almost everyone would agree would be violence. Say one person strikes out at the other and makes contact, causing injury; most people would certainly classify that as violence. But, what would you call it if someone strikes out at someone else but they miss, you know the other person ducks? I would still consider that violence because the intent was to make contact; but you know it’s just fortuitous that the contact wasn’t made. I also include threats as violence and most investigators do. And the reason is because threats (although not all threats lead to violence) what the research has shown is that most violence is preceded by a threat. So, threats are significant on the psychological impact of being threatened is often quite significant. So, threats are usually included. Some investigators also include verbal abuse. Other people don’t. Some people lump verbal abuse and threats together. So, you know, there’s kind of a debate in the field. And then finally, some investigators, and I included this in my research, include property damage as violence because it often goes along with other kinds of aggressive behavior and is common in settings where other forms of violence are common. For example, an adolescent residential treatment center where property damage is very common but so are threats and physical violence. So, in my research, I define violence as being either an actual physical attack, and attempted physical attack, a threat, or property damage.

[07:21]
Jonathan Singer: So why should social workers be concerned about client violence?

Christina Newhill: I think that social workers need to be aware of the reality of practice today; which includes client violence. And one of the reasons that it’s important for social workers to be aware of client violence is that it is relatively common. It’s sort of like the elephant in the room often at clinical meetings; everybody knows that it’s an issue, but people really don’t talk about it because they don’t know what to do about it. In the research that I conducted, 58% of a sample of 1,600 social workers that I surveyed reported that at least 1 incident of violence at some point in their career; and the majority of them reported multiple incidents. And so, unfortunately fatalities or serious injuries are rarer; although they are occurring more and more frequently. And what I think is disturbing is that often times client violence isn’t dealt with or it’s not acknowledged until a tragedy occurs. What I would like to see is for the social work profession to be more proactive rather than reactive. So the first reason why social workers I think need to be aware of client violence is the fact that it is common. Secondly, when it occurs it can have a significant impact on both the client and the worker. Experiencing an episode of violence and those of us who work with victims of violence in general in trauma know that often times a trauma reaction occurs. And social workers have told me that they often have felt depressed, they’ve felt anxious. Many of the respondents in my study reported that it wasn’t the incident itself even that caused the trauma reaction, as much as the lack of support and responsiveness of their agency or their colleagues—that compounded things. Some of my respondents said that they left social work or left public services because of the incidents. So, it also can have the effect of losing good social workers to the profession. And I think the last reason why it’s important is that allowing client violence to occur hurts clients. I think what we have to bear in mind is that once a client strikes you, from that point on that client is going to be labeled a ‘violent client’ and their care is going to be modified. Certain services may be closed to them, there may be practitioners unwilling to see them, and they will be labeled as a violent client; so it really hurts clients. I think that to prevent violence is not just to service for ourselves, but it really serves our clients well, in addition.

[10:08]
Jonathan Singer: Are some social workers more at risk for client violence than others?

Christina Newhill: Yes, that’s what the research tells us. I might back up for just a minute and just share what my particular study involved because then I can report some specifics from that. I was concerned about the issue of client violence many, many years ago in large part because of my own practice experience where I both witnessed as well as experienced numerous incidents of client violence. Now I was working in psychiatric emergency in inpatient settings which tend to be high risk settings and so I thought well perhaps this is just an issue for our type of settings. You know, I mean is it broader than this? And what I discovered when I started to look in the literature is there really wasn’t anything out there; that no one had really studied that in this country. Now, in the UK, there had been a number of studies; but the extent to which those could be generalized to the US, I just didn’t know. So, after I went back to school and got my doctorate, one of the first studies that I conducted was a study of client violence towards social workers. And for that study, I did a random survey of 1,600 NASW members and out of the 1,600 questionnaires, I got 1,129 back—so I got a 71% return rate; so for those of you listening to this that know survey research, know that that is unusual.

Jonathan Singer: That’s unusually high.

Christina Newhill:  It’s unusually high, that’s correct. So that told me that the topic touched a button for the respondents. And so, who is more at risk than others? What I can do is share what I found out from my research and other researchers, their findings have been pretty consistent with what I found. What I found in my survey is that client violence occurred across all settings. There was no setting that was free of incidents. But, certainly the proportion of social workers in different settings that reported violence differed. And as I looked at the numbers, I divided the settings roughly into high risk, moderate risk, and lower risk. The highest risk settings included (and this didn’t surprise me too much) at the very top, criminal justice; well that’s not terribly surprising because criminal justice serves individuals who may, you know, come into the services with problems with aggression. Secondly was drug and alcohol services. Again, not terribly surprising because we know that drug and alcohol (alcohol in particular) is a disinhibitor and is often associated with violent crime. And then third is children in youth services or child welfare services. So in those three settings (criminal justice, drug and alcohol, and children welfare) 75% or more of the respondents that identified those settings as being their practice setting reported at least one incident of violence. Moderate risk settings involved individuals who reported between 54% and 75% of the respondents reported violence; and this included mental health services, developmental disabilities, school social work, and family services. And then at the bottom in terms of the lowest risk services, was services to the aged (13:12), but even there, 44% of the respondents had experienced violence. The finding that was particularly striking though from the data was the difference between male social workers and female social workers in terms of the reported prevalence of violence. Across all types of violence (property damage, threats, attempted attacks, and actual attacks), male social workers were far more likely to reports incidents of violence than females and for those who reported violence, they reported greater numbers of incidents. So, where only 27% of male social workers reported no incidents of violence; twice that number [48%] (or almost twice that number) of female social workers reported no incidents. But if we look at the numbers of incidents for actual physical attacks, on average, female social workers reported two actual physical attacks; male social workers reported nine physical attacks. Now the question is of course what could explain this? One answer that the data was able to show was that male social workers were more likely to work in the highest risk settings. So they were more likely to work for criminal justice services, drug and alcohol services, and surprisingly child welfare services (at least I found that surprising).  But I think that it goes further than that. Anecdotally, many of the male respondents told me that they were more likely to be assigned violently aggressive clients than their female counterparts. And when a client did become violent or aggressive, they were often called in to deal with the situation. So, I think what’s happening is that agencies are using male social workers as a kind of informal security force. But the disturbing thing about that is that the male social workers reported that they weren’t being given additional training nor were they given “hazard pay” for taking on this additional risk. And they really felt that they had no choice or many of them said they felt that it was their responsibility that they should take on this additional risk. So I think that’s a finding that we as professional social workers and agencies really need to think about. Is this really just—to be expecting male social workers to be doing this? So, I think that what we can conclude from this is really four things. First, is client violence towards social workers is not a rare event; rather it’s relatively common across practice settings. Secondly, risk does vary according to where one works; however, no setting is completely free of risk. Thirdly, male social workers are at significantly greater risk of experiencing client violence than female social workers. And, one issue that we have not talked about yet is that experiencing an incident of client violence exacts an emotional toll on the social worker involved. And in my research, I looked at that and asked my respondents how they felt emotionally during the incident and immediately afterwards; it was very clear that the emotional toll was significant.

[16:06]
Jonathan Singer: So how did social workers react emotionally when they experienced client violence?

Christina Newhill: Well I was very curious about this because it seemed to me that experiencing client violence is a significant event. I was wondering not only how did social workers feel during and immediately following experiencing an incident of violence; but I was also curious as to what extent the incident may have affected their feelings about their profession and changes in their practice habits. And what I found was that social workers reported a considerable variety of emotions that they experienced; and the emotions varied depending upon the type of violence that they experienced. So for example, social workers who experienced an indecent of property damage, overall, tended to feel angry. They were angry that the client had destroyed the property; but as many of the respondents said, property can be replaced, it’s not a person. So the predominant feeling was anger, some frustration. With threats, social workers predominantly felt scared, fearful and anxious. Not terribly surprising, threats left social workers feeling very anxious about what might happen. A threat implies that danger or violence may or may not occur. So social workers often left feeling very frightened, not knowing if the client was going to carry through on the threat, not knowing how to respond to it, and feeling very helpless. Clients [SWP note: we believe Dr. Newhill intended to say “social workers”] who experienced physical attacks were often angry, scared, and anxious. But they also reported three emotions that were rarely reported with property damage and threats and this included feeling shocked and shook up, helpless and inadequate, and drained and exhausted. Many of the social workers who experienced physical attacks described reactions that were very similar to trauma reactions. I mean, I did not ask about specific criteria for trauma but they often described not being able to sleep, having intrusive recollections of the incident, and often feeling very hurt that this had happened. Many of the respondents said things like “You know, I thought I had a good reaction with the client”, “I don’t understand why this happened”, “What did I do wrong” and blaming themselves for what had occurred.

[18:28]
Jonathan Singer: How do you assess a client potential for violence; specifically towards the social worker?

Christina Newhill: Well, it’s important that ahead of time that you have an adequate knowledge base; particularly regarding risk factors—what we prefer to call risk markers. And these are factors or markers that tend to be associated with violent behavior. I mean, the odds are always in the favor of the individual not behaving violently. There’s always a balance between risk markers and protective factors; that has to be taken into consideration as well. For example, one of the most powerful protective factors is good, positive social support. You may have a client that has a host of risk markers for violent or aggressive behavior but if they have people around them who care about them, who can provide them with resources and support and help them work through their problems and negotiate their difficulties, they may be able to come through whatever their crisis is without behaving in an aggressive way. That’s an important thing to bear in mind. And of course, increasing social support and helping to improve that for clients is something that social workers do very well.

[19:44]
Jonathan Singer: Now, a quick question. What’s the difference between a risk factor (which is a commonly used term) and a risk marker?

Christina Newhill: Okay, good question. In the risk assessment research and literature, risk factors suggest predictive power. So, if something is a risk factor then it means there is a causal affect; a risk marker means an associative affect. So the kinds of markers that I’m going to mention don’t necessarily predict that violence will occur with any level of certainty, but it elevates the risk level. The more of these risk markers that somebody has; they’re like red flags that you simply need to pay attention to. And, I like to think of them as divided into three spheres. As social workers we talk about the bio-psycho-social and that’s really the approach to looking at risk assessment. So we have individual clinical risk factors (which can be divided into demographic risk factors and clinical risk factors and biological risk factors), then we have historical risk factors, and environmental/contextual risk factors. There are a whole host of different things that you would look for that commonly are just part of a good psychosocial assessment but they are also things that you just want to be alert for as you’re reviewing the client’s records and information the families may give you, and so forth. Just know what to be alert for.

[21:12]
Jonathan Singer: So, if I were a clinician and I had a client that was talking to me about previous violence in their life or them being violent towards others, they might mention something that wasn’t typically considered a risk factor, but for them it would be a risk marker? Because for them it would be a red flag—this is something that has happened in the past, I should look out for this in the future.

Christina Newhill: That’s what we call a trigger.
Jonathan Singer: Trigger, okay.

Christina Newhill: So, for example—and I’m glad that you mentioned a history of violence. Because of any single risk marker, having a history of recent repetitive violence probably has the greatest predictive strength of anything. So, if somebody has recently been violent/repetitively been violent, then you want to really pay close attention to that. Now everyone has different circumstances surrounding their particular triggers for violence. And so, for one person it might be a fight with their mother, for another person it might be being intoxicated, for another individual it might be humiliating loss; and so, as you ask clients about their history and whether they’ve ever been violent or aggressive towards someone, you want to ask about the circumstances. What was the situation? Who was involved? What were they feeling at the time? So that you can get a sense of what types of circumstances for them elevates risk; and then, one of your good social work interventions would be to try to help the client into a situation that is different from that and that will protect them and help to mitigate against any aggressive urges.

[23:04]
Jonathan Singer: So could you give some examples of risk markers?

Christina Newhill: Sure, let me give you a couple of examples. In my book, I talk about these risk markers in detail, and in particular, why and how they operate as risk markers. But here’s an example—an environmental/contextual risk marker would be peer pressure from peers who endorse violence. So you might have an individual (and this is particularly important when working with adolescents) you’re working with a teen who is lonely and who wants to belong to a group. And so, there is a group that is willing to accept that teen into their group but that teen has to show that they’re going to be part of that group by behaving violently and that violence is endorsed as a way of gaining power and gaining status. So here you have a kid who under other circumstances might not behave violently but engages in that because the group endorses that and really supports and reinforces that behavior. Another example of an environmental/contextual risk marker would be potential victims that are accessible. What I often tell my students is that I think that all of us have the potential for violence given the right or wrong circumstances. I think most of us might behave violently to defend ourselves or to defend our child if our child was being hurt by somebody or attacked by somebody. For many of our clients, interpersonal violence occurs only in certain interpersonal contexts. So you may be working with a client who is only violent toward a particular family member because they have a longstanding animosity with that family member. As a social worker, then what you would do if you want to prevent violence from occurring, is you don’t suggest that that client go home and live with that particular family member—you have them live with somebody else. Or you have a client who has maybe made a threat to hurt their mother; then what you would want to do is try to separate that client and that mother and have the client go somewhere else until you can work with the client and the mother and try to sort out what is going on. So those are just a couple of examples of what we would call risk markers; and they differ from individual to individual in terms of what the particular factors are that are involved in that particular marker.

[25:28]
Jonathan Singer: So you mentioned there were differences between risk factors and risk markers; and you also said that there were/you said that a good assessment (biopsychosocial assessment) is really the best thing to do. Are there any guidelines?

Christina Newhill: Yes, there are guidelines; and I have rather detailed guidelines in my book. Let me just share in a very summary fashion what some of them are. The first guideline is you want to (before you meet with the client—and this is just kind of good clinical practice) find out as much background information as you can because many of these so-called risk markers are going to be present in the history of that client (in the psychosocial history). So you want to review available documents, any clinical records, and history of past hospitalizations. Why would that be important? Well, because of our civil commitment criteria; which are danger to self or others. So someone has been in the hospital, particularly involuntarily, that is a red flag. What landed that person in the hospital? Were they a danger to others? Or even a danger to self? You want to pay attention to that as well. You want to see if there are any criminal justice records, any history of arrest or incarcerations. Is there any history of violence towards others? You don’t just want to know if there is a history or not, but you want to know what those circumstances are. Is there any history of your client being a victim of abuse? Because many times people who are victims of violence and abuse, they may learn that violent behavior is a way to solve problems. It’s a way to get your way. Maybe they have been a victim, but then they may then turn that around and become a perpetrator. Then I have a number of guidelines for the clinical assessment of the client. I will just mention one of them. When you are assessing a client, under all circumstances, use all of your senses. Use what you see, what you hear, what you smell. Often times you can tell if someone is intoxicated because you smell alcohol or you smell marijuana, and so forth. So you want to notice anything significant about the client’s physical appearance suggestive of a risk of violence. For example, does the client show any scars or any tattoos that may have particular significance or may suggest that the client has been in fights? You want to pay attention to that. I know when I was working in California, if I saw a client that had a teardrop tattooed in the corner of his or her eye—what that meant in California was that you spent one year in the California Youth Authority. For an adolescent to be in the California Youth Authority there was inevitably a history of violent or aggressive behavior. Now in other parts of the country, that that teardrop means that you have killed somebody. You have to be cognizant of the meaning of dress patterns and tattoos and so forth as you begin to go about your assessment.

[28:28]
Jonathan Singer: So Christiana, when I worked at the crisis intervention unit, it would not be uncommon for the mental health deputies to bring in a kid who had a known history of psychiatric illness. They’d bring him into the mental health center as opposed to the detention center because they’re trying to be sensitive of this kid’s psychiatric disorder. So my question for you though is: how do you intervene with a client who appears to be escalating or who is actually violent?

Christina Newhill: That can be a very anxiety provoking situation for a clinician. In those kinds of situations you may have been there from the beginning or maybe as your suggesting, an incident happened out in the community and the individual is being brought in. I think it’s important to approach the situation in a calm and relaxed kind of way and to open up attempting to engage the client by simply commenting on the obvious—“you seem really upset”. That sounds very simple, but the purpose of that is that it lets the client know that you’re trying to understand their feelings. And I think that one of the most powerful tools that you can use in such a situation is empathy. Many clients who have problems with aggression and violence don’t get much empathy from others, because of their behavior. And so, you’re going to give them a different experience. You’re going to give them the message that you’re not going to reject them because of what they’ve done. You want to understand where they’re coming from. After you sort of comment on the obvious, then it’s very important that you introduce yourself. They may not know where they are, they may not know who you are, they may have been sort of brought in a very strong-armed kind of way; so, they’re entitled to know who you are, what your position is, and what you’re going to do. It’s very important to let them know your reason for being there, explain what they’re rights are, be very honest in their communication, and then invite them to tell you what happened/what brought them in here—and listen to them. And it is clients that have problems with violence also have problems with expressing themselves verbally. If they were facile in expressing themselves verbally, they might be able to resolve their problems that way. And so, the client may struggle a little bit; it’s real important that you be patient, and you listen, and allow them to tell their story. Empathizing with the client does not mean that you are condoning what they did; it simply means that you understand they’re frustrated, they’re angry, or whatever the feelings seem to be. And after they’ve had a chance to tell their story, then you can tell them your understanding of the situation and explain to them where things sit now and what’s going to happen next. I found that simply listening to people/empathizing with their feelings can go a long way in helping someone deescalate. If people feel that their welfare is really what you’re concerned about and you’re there to really support their best interest, often times they will respond in kind. This is not to say that you don’t want to take precautions. Let’s say that a client is brought in by the police and they are in restraints. And very often what the individual will say is “can you tell the police to take the restraints off”. You may want/you think, well I’m going to need to do that in order for the client to trust me. And I think you have to think first, are you going to feel safe if those restraints are removed? And it’s perfectly fine to say no. And what you can say to the client is, “I understand that it feels awful to be restrained. Right now, I don’t know enough about the situation to make that decision. So, why don’t we talk a little bit first, and then we can talk later about removing the restraints”. And if the client hears that you empathized with their situation and that this is something that can be revisited, often times they will accept that.

[32:42]
Jonathan Singer: I know that in children’s services, one of the things that we would do is we would end up having to restrain/we the clinicians would have to restrain kids who were getting violent. And one thing that we would say is, “I am going to need you to not fight for a minute and then we will start to let go.” Basically, we will get off you or we will loosen the basket hold or whatever it happened to be. And in part we did that because it showed some self-control. It wasn’t that there was any magical thing about the minute marker (that I know of) but it was a way to demonstrate the ‘you can control yourself for a minute’; and for a kid, a minute is an eternity, especially if you’re being restrained by six guys. Is that similar to what you’re talking about in terms of somebody coming in restraints that says “release me”, and then you say, “well let’s make sure that you’re not at risk right now for lashing out?”

Christina Newhill: Right, it’s very similar. And one of the things that I have always been impressed with as I have worked with people is that often times clients are quite honest about their ability to control their behavior. So, I would sometimes as a client, “If the restraints are removed, are you sure that you’re going to be able to control your behavior?” And many times, clients would say, “I don’t know” or “I don’t think so.” So then I would say, “Well maybe it would be best to leave them on for now”; with the implication that we will just take this one step at a time.  One last point I want to make is, never make promises that you cannot keep; and I’ll explain why I say that. You may encounter a client who will say, “Well I’ll talk to you if you promise that I won’t be given any medication or if you promise that I won’t have to go into the hospital.” It’s tempting to say, “Oh I promise that”, because the client is saying that then he or she will talk to you. But it’s important not to do that, because at that point at the beginning of the interview, you don’t know what’s going to happen; and you don’t want to be in a situation where you promise the client ‘no you won’t be hospitalized’ and then you have to hospitalize the client. Because not only will that rupture the trust that the client may have built with you, but you represent the mental health system or the health care system or the child welfare system and that client will lose trust in not only you, but services in general. That may undermine the probability that the client will be engaged and will receive services. What you can say instead is, simply that: “I don’t know what the outcome of our interview is going to be and I don’t want to make a promise to you that I’m not able to keep. Let’s talk more about the situation and then you and I can discuss what the options might be”—so that you take a collaborative approach. And if the client realizes that they are going to have a say in things or at least they’re going to be listened to, then often times you can move forward.

[35:53]
Jonathan Singer: So my last question is, if a social work educator was listening to this podcast and wanted to integrate content about client violence into either Bachelors of Social Work or Masters of Social Work courses, what kinds of resources or information could you provide that might help them—and this can even include some of the research that has been conducted in the area. 

Christina Newhill: There hasn’t actually been a lot of research. In the 1980’s, the British Association of Social Workers sponsored a number of studies in Great Britain that sort of opened up the conversation about this issue. Studies in the U.S. up until the early 80’s were pretty much confined to Psychiatry. There were studies about client violence, especially on psychiatric units, that were published in psychiatric journals. But then in about the mid 80’s/early 90’s there were a number of studies in the U.S., predominantly in child welfare because the issue of risk assessment and safety in home visits is very central to child welfare work. Child welfare services have really been ahead of the game in terms of not only doing research but creating risk assessment protocols. However, much is left to be done in terms of testing the validity of these protocols. I think here’s where the research needs to go. I think we know by now that client violence is relatively prevalent, it’s an issue for practice and it’s something that we need to address. We have come up with a lot of clinical strategies and a lot of practical strategies for increasing safety. What we don’t know is how effective these strategies are and I think that’s where the research has to go next. That’s not going to be easy because it’s going to require some kind of a longitudinal design that can follow and get a baseline assessment of the incidents of violence, employ some strategies, and then follow over time the extent of which those strategies seem to be working—but I think that’s where we need to go. Hopefully in the future and perhaps through an organization such as OSHA because there’s increasingly a concern about workplace violence in general and the business community has taken that very seriously. So I think it may be a multidisciplinary kind of research agenda and hopefully that will occur because I think that’s where we need to go.

[38:25]
Jonathan Singer: And so, if I were an instructor in a BSW course (I was teaching a BSW course) and I wanted to integrate information other than the research findings (because it doesn’t sound like there are many), what sort of resources are out there for my students/for designing a whole course about it or just putting a little bit of information into a foundation course?

Christina Newhill: Right. I think that there are several junctures in the curriculum where information on safety and risk assessment can go. I think that some information should go in the foundation curriculum in terms of just making students aware that safety is an important issue and basic strategies for safety when working with clients and going out in the field. More advanced clinical strategies for working with involuntary clients/working with violent and aggressive clients/clients who may have problems with substance use and severe mental illness might go in more advanced practice classes. I think that one could also develop a very interesting course in this area. In fact, in my book, at the end of the book I talk about that and have a model syllabus in the back of the book that can walk the reader through how such a course might look. One could actually pick and choose the various modules and kind of plug them in. And I have (in the book) case analysis exercises, discussion questions, readings, and so forth. I think that the important thing is just have the material somewhere. I know that when I first started out in this, sometimes social work educators would say, “Well are you sure you really want to talk about this because this might frighten students”. I really think that it’s the opposite, that it empowers students. I think that students become frightened when they’re not prepared and they go out and then they encounter a client who is making a threat and they don’t know what to do. The student and the practitioner who is prepared to meet the unexpected is in the best position to not just protect themselves, but protect their clients as well and provide the best services.

[40:46]
Jonathan Singer: Sounds like your book is an excellent resource. Not just for the research, but also for educators who might be teaching; as well as of course for students who want to learn—or for clinicians out in the field, actually. And so, if it’s okay with you, we will put a link onto the Social Work Podcast website where listeners can get a copy of the book.

Christina Newhill: Sure, that would be great. And I also can post some summary material on the website that I use in my workshops that might be useful to the listeners.

[41:20]
Jonathan Singer: Okay great; well all of that information can be found at the Social Work Podcast website, at socialworkpodcast.com. And Christina, thank you so much for taking the time to talk to us today about this really important topic of client violence.

Christina Newhill: It’s been a pleasure, thank you for having me.

—End—

[41:34]

Transcription generously donated by: Natasha Bancroft, LMSW (Licensed Master Social Worker), QMHP (Qualified Mental Health Professional), CMHP (Child Mental Health Professional). Currently employed with Community Mental Health for Central Michigan as a clinical social worker and Youth Intervention Specialist. She is passionate about providing preventative clinical services to at-risk youth and families in her rural community. 

Links and Resources
APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2008, March 3). #35 - Client violence: Interview with Dr. Christina Newhill [Episode 35]. Social Work Podcast [Audio podcast]. Retrieved from http://socialworkpodcast.com/2008/03/client-violence-interview-with-dr.html
Posted by Jonathan B. Singer, Ph.D., LCSW at 7:00 AM
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