Personal safety and self care

Personal Safety and Personal Safety and Self CareSelf Care

Molly Cowan MAMolly Cowan MA

Simone Gorko MSSimone Gorko MS

Donald McAleer Psy.D., Donald McAleer Psy.D., ABPPABPP

PPA Convention2010

Threats to Personal SafetyThreats to Personal Safety

AssaultAssault

IntimidationIntimidation

Verbal ThreatsVerbal Threats

StalkingStalking

Dr. Calmncool is in solo private practice. Her office suite is in a small building whose other tenants are mostly sales personnel, usually in and out throughout the day and gone by 5PM. Dr. Calmncool is conducting an initial interview with Mr. Narse who is employed in a mid-sized company as a department manager with a small staff he supervises. Because of his work schedule, he requested an evening appointment. The presenting complaint is that he feels undervalued by his superiors, as well as his staff. He believes they disrespect him because he isn’t “higher on the management totem pole” in a position of power. He also complains that his wife doesn’t appreciate him or even try to understand how he feels or what he is going through.

Mr. Narse states his treatment objectives as “wanting to learn how to swagger with bravado and command respect and admiration from others.” Dr. Calmncool validates his distress and discomfort, but acknowledges she does not do the kind of work he is requesting. She reframes the situation as one where they could examine his behaviors, attitudes and expectations and how he might be able to build more confidence and positive interpersonal relationships, thereby achieving his goals.Mr. Narse becomes increasingly agitated, asserting that Dr. Calmncool is “just like the others,” his superiors, staff and wife. He indicates she doesn’t understand and is unwilling to help him. He begins to berate her, demanding to know what kind of psychologist she is that she won’t help him in the way that he want, the objectives he wants. Dr. Calmncool maintains her demeanor, tries to defuse the situation and do some psycho education about what therapy and psychology are and are not. Mr. Narse lurches forward into her personal space, stares her in the eyes and bellows at her, “You don’t love me!”What should Dr. Calmncool do?What are the issues of self care here?

Safety/Self CareSafety/Self Care

Almost one in every 5 psychologists Almost one in every 5 psychologists reported having been physically reported having been physically attacked by at least one client.attacked by at least one client.

Over 80% of the psychologists reported Over 80% of the psychologists reported having been afraid that a client would having been afraid that a client would attack them. attack them.

25% to 50% reported having had 25% to 50% reported having had fantasies that a client would attack.fantasies that a client would attack.

Pope and Tabachnik, 1993


Between 10% and 25% had Between 10% and 25% had summoned the police or security summoned the police or security personnel for protection from a personnel for protection from a client.client.

About 3% reported obtaining a About 3% reported obtaining a weapon to protect themselves weapon to protect themselves against a client.against a client.

Pope and Tabachnik, 1993

Frequency of Professional Stressful Events in the Last Twelve Months

Never Once Twice Three or MoreBeen stalked by a patient 94% 5% <1% <1%

Been robbed by a patient 97% 2.3% <1% <1%

Been assaulted by a patient 97% 2% 1% 1%

Threatened with assault 88% 8% 3% 2%

Had patients assault third party 82% 9% 4% 5%

Had patients threaten to assault third party 78% 11% 4% 5%

Had patient commit suicide 86% 10% 2% 2%

Had patients attempt suicide 68% 16% 8% 8%

Had patient make suicidal gesture 46% 17% 15% 23%

Had patient threaten suicide 46% 18% 12% 25%

Been sexually harassed by a patient 94% 3% 2% 1%

Knapp and Keller, 2004


1999 Survey of marriage and 1999 Survey of marriage and family therapists residing in family therapists residing in GeorgiaGeorgia– 44% experienced a physical or 44% experienced a physical or psychological assault from a psychological assault from a clientclient

– 30% reported fearing that their 30% reported fearing that their lives might be in dangerlives might be in dangerArthur, et.al. 1999

Guy, Brown and Poelstra, 1992

AttacksAttacks

Generally younger psychologists or Generally younger psychologists or those in trainingthose in training

Inpatient / Public > Private / Inpatient / Public > Private / OutpatientOutpatient

Most attacks result in minor Most attacks result in minor injuriesinjuries

Most frequently male attackers and Most frequently male attackers and male victimsmale victims

Threats of attack more commonThreats of attack more common


Ethical and Role ConflictEthical and Role Conflict

Role as helper / doing good for Role as helper / doing good for othersothers

Role as individual / doing good Role as individual / doing good for oneselffor oneself

StalkingStalking

6-12% reported being stalked by 6-12% reported being stalked by current or former patientscurrent or former patients

Stalking often occurs in conjunction Stalking often occurs in conjunction with with harassmentharassment which is a pattern of which is a pattern of following, annoying, or alarming following, annoying, or alarming another person with the intent to another person with the intent to cause substantial emotional distress.cause substantial emotional distress.

The duration of stalking or The duration of stalking or harassment episodes varies harassment episodes varies considerably although most stalking considerably although most stalking episodes last less than one year episodes last less than one year

QuestionsQuestions

How many of you have been How many of you have been threatened by a current of threatened by a current of former patient?former patient?

How many of you have been How many of you have been assaulted by a current or assaulted by a current or former patient?former patient?

ConsequencesConsequences

Increase in personal vulnerabilityIncrease in personal vulnerability

Decrease in emotional well beingDecrease in emotional well being

Decrease in sense of competenceDecrease in sense of competence

Increase in marital / family Increase in marital / family tensionstensions

Guy, Brown, Poelstra and Paul, 1991

ConsequencesConsequences

AnxietyAnxiety AngerAnger FearFear Physiological responsesPhysiological responses

– Sleep disturbanceSleep disturbance– GI distressGI distress– PainPain

Gentile et.al., 2002

How does the Ethics Code help to guide us?

What are our obligations to clientsWhat are our obligations to clients– 4.05 Disclosures4.05 Disclosures(a) Psychologists may disclose confidential (a) Psychologists may disclose confidential information with the appropriate consent of the information with the appropriate consent of the organizational client, the individual client/patient, organizational client, the individual client/patient, or another legally authorized person on behalf of the or another legally authorized person on behalf of the client/patient unless prohibited by law.client/patient unless prohibited by law.

– (b) Psychologists disclose confidential information (b) Psychologists disclose confidential information without the consent of the individual only as without the consent of the individual only as mandated by law, or where permitted by law for a mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional services; (2) obtain appropriate professional consultations; (3) protect the professional consultations; (3) protect the client/patient, psychologist, or others from harm; or client/patient, psychologist, or others from harm; or (4) obtain payment for services from a (4) obtain payment for services from a client/patient, in which instance disclosure is client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve limited to the minimum that is necessary to achieve the purpose. the purpose.

What are our obligations to ourselves?What are our obligations to ourselves?

2.06 Personal Problems and Conflicts2.06 Personal Problems and Conflicts(a) Psychologists refrain from initiating (a) Psychologists refrain from initiating an activity when they know or should know an activity when they know or should know that there is a substantial likelihood that there is a substantial likelihood that their personal problems will prevent that their personal problems will prevent them from performing their work-related them from performing their work-related activities in a competent manner.activities in a competent manner.

(b) When psychologists become aware of (b) When psychologists become aware of personal problems that may interfere with personal problems that may interfere with their performing work-related duties their performing work-related duties adequately, they take appropriate adequately, they take appropriate measures, such as obtaining professional measures, such as obtaining professional consultation or assistance, and determine consultation or assistance, and determine whether they should limit, suspend, or whether they should limit, suspend, or terminate their work-related duties.terminate their work-related duties.

Psychologists do not automatically Psychologists do not automatically give up their personal rights when give up their personal rights when treating anothertreating another

– 10.10b10.10b Psychologists may terminate Psychologists may terminate therapy when threatened or otherwise therapy when threatened or otherwise endangered by the client/patient or endangered by the client/patient or another person with whom the another person with whom the client/patient has a relationshipclient/patient has a relationship

Issues for Early Career Issues for Early Career PsychologistsPsychologists

Lack of knowledgeLack of knowledge

Where to go for help?Where to go for help?

False expectationsFalse expectations

““It won’t happen to me.”It won’t happen to me.”

The Pregnant TherapistThe Pregnant Therapist

Physical limitationsPhysical limitations

General increased risk of General increased risk of violenceviolence

Special challenges with client Special challenges with client populationpopulation

QuestionsQuestions

How do we raise issues of safety How do we raise issues of safety and self care with ourselves, our and self care with ourselves, our colleagues, our students / colleagues, our students / trainees?trainees?

How do we address personal safety How do we address personal safety in a realistic fashion without in a realistic fashion without alarming ourselves, our colleagues, alarming ourselves, our colleagues, our students / trainees?our students / trainees?

What is to be doneWhat is to be done Research on stalking is in its infancy, and no set of rules Research on stalking is in its infancy, and no set of rules

can be applied to all situations. We urge all can be applied to all situations. We urge all psychologists who are being stalked to seek professional psychologists who are being stalked to seek professional guidance on the optimal manner in which to respond. guidance on the optimal manner in which to respond. However, here are few general comments:However, here are few general comments:– Confronting the stalker is not advised, as it may act as an Confronting the stalker is not advised, as it may act as an

intermittent reinforcer.intermittent reinforcer.

– Document the harassment by keeping tapes of home calls, notes, Document the harassment by keeping tapes of home calls, notes, letters, copies of e-mail messages, and detailed information on letters, copies of e-mail messages, and detailed information on each incident. Such actions help document the stalking needed each incident. Such actions help document the stalking needed in the event that the psychologist decides to institute in the event that the psychologist decides to institute criminal proceedings.criminal proceedings.

– Preventive actions, such as changing phone numbers or varying Preventive actions, such as changing phone numbers or varying routes to work, often thwart or discourage stalkers.routes to work, often thwart or discourage stalkers.

– Decisions to use restraining orders or criminal charges should Decisions to use restraining orders or criminal charges should be made carefully because their effectiveness varies be made carefully because their effectiveness varies considerably depending on the manner in which the police considerably depending on the manner in which the police implement them and the manner in which stalkers respond to implement them and the manner in which stalkers respond to them.them.

Knapp, Baturin and Tepper

What is to be doneWhat is to be done 1. do not see new patients alone at night, unless you have screened them 1. do not see new patients alone at night, unless you have screened them

over the phone and feel comfortable seeing them aloneover the phone and feel comfortable seeing them alone

2. obtain a history of violence and involvement with law enforcement 2. obtain a history of violence and involvement with law enforcement agencies as part of your initial assessment;agencies as part of your initial assessment;

3. screen or refer out patients with serious problems in controlling 3. screen or refer out patients with serious problems in controlling violent behavior if you do not feel capable to helping them;violent behavior if you do not feel capable to helping them;

4. structure your physical office in such a way that it increases your 4. structure your physical office in such a way that it increases your sense of protection. For example, remove objects that could be used as sense of protection. For example, remove objects that could be used as weapons (e.g., letter openers), seat yourself (not your patients) closer to weapons (e.g., letter openers), seat yourself (not your patients) closer to the door);.the door);.

5. deal with hostile behavior therapeutically; use clinical skills to de-5. deal with hostile behavior therapeutically; use clinical skills to de-escalate the situation;escalate the situation;

6. maintain professional boundaries; do not let patients know where you 6. maintain professional boundaries; do not let patients know where you live, etc.live, etc.

7. if you share offices with others or have office staff, be certain that 7. if you share offices with others or have office staff, be certain that everyone knows how to alert others when there are threats of violence andeveryone knows how to alert others when there are threats of violence and

8. Learn basic techniques for self-defense.8. Learn basic techniques for self-defense.Knapp 2008


What is to be doneWhat is to be done

Self ProtectionSelf Protection– PreventionPrevention / screening/ screening– Controlling the environmentControlling the environment– Record keepingRecord keeping

Consultation / SupervisionConsultation / Supervision– Ongoing supportOngoing support– Dealing with specific situationsDealing with specific situations

NetworkingNetworking Continuing EducationContinuing Education

Brems & Johnson, 2009

Self CareSelf Care

Getting enough sleep.Balancing work and leisure time.Keeping realistic expectations about work.

Maintaining professional contacts.

Seeking consultation for personal or professional difficulties before there’s a problem.

QuestionsDiscussion

Health & Medicine

Personal safety and self care