Dealing with Potentially Violent Clients

Identifiable Risk Factors

After multiple instances of mass violence in the past year (Dallas, Orlando, San Bernardino, Colorado Springs, and Charleston, to name but a few), the ability to identify and treat individuals who are predisposed to violent behaviors is more vital than ever. Unfortunately, even mental health professionals are not very good at predicting future violence.

Before discussing the few risk factors that may be visible and identifiable, I think it is important to note that research tells us, very clearly, that the link between mental illness (by itself) and violent behavior is minimal. In reality, the overwhelming majority of mentally ill people (who do not display one of the risk factors I’ll discuss momentarily) are able to live peacefully in society as productive and loving family members, neighbors, employees, and citizens. This is especially true if/when these individuals receive proper interventions and treatment.

Conversely, mental illness coupled with substance abuse issues and/or a history of violence greatly increases an individual’s propensity for external expressions of violence. For instance, a study looking at bipolar disorder found that 4.9% of people with bipolar disorder but no other mental health diagnoses had been convicted of a violent crime, which is approximately the rate for the population as a whole. However, bipolar disorder coupled with a substance use disorder (an addiction) more than quadrupled that number, to 21.3%. Research looking at schizophrenia shows a similar increase in rates of violence, from 8.5% to 27.6%, when alcoholism and/or drug addiction enters the picture.

Another very strong indicator of future violence is a past history of violence, with or without a diagnosed mental illness. For instance, research shows that people who’ve been arrested for past violence are much more likely than others to be violent in the future. Similarly, things like fire-starting and other “conduct disordered” behavior extensively exhibited in childhood and early adolescence should always be noted and taken seriously, regardless of the client’s current age. Meanwhile, mentally ill people with no history of violence (and no other prominent risk factor, like a substance use disorder) are unlikely to be violent in the future.

What Therapists Should Look For

There are several relatively common signs of mental illness. Certainly many mentally ill people can hide these signs for periods of time, including during therapy sessions, but they cannot manage this 24/7/365. Eventually the cracks will show, if not in the therapy space then elsewhere, witnessed by family members, neighbors, employers, and even total strangers. Moreover, these indicators will usually manifest (or be brought up for discussion by the client) during therapy. These general signs of mental illness include:

• Confused thinking
• Inability to cope with daily life
• High emotional reactivity and mood lability
• Ongoing social withdrawal
• Excessive fears and/or anxiety, perhaps to the level of paranoia
• Prolonged depression/sadness
• Prolonged irritability
• Drastic changes in eating and/or sleeping habits and other areas of self-care
• Delusions (believing in things that are not real)
• Hallucinations (seeing and/or hearing things that are not real)
• Self-harm or thoughts/threats of self-harm (cutting, burning, suicidal ideation, etc.)

As stated above, these possible signs of mental illness do not automatically signify the potential for violence. The primary elevating risk factors for violence are substance abuse and/or a history of violent behavior. Unfortunately, these are both problems that mentally ill clients tend to not bring up in therapy. Rarely will addicted clients fess up about their drinking, using, and other addictive behaviors unless they are directly confronted with evidence of use and related consequences. And a past history of violence may be covered up and denied even when clinicians directly address the issue.

If a client does not seem overly forthcoming about previous behaviors, possible signs that should evoke concern include:

• Extreme anger directed at specific people, institutions, or situations
• Ambient (generalized) anger
• Frequent bursts of anger (either directed or ambient)
• Threats of violence (toward self or others)
• Excessive brooding about perceived hurts combined with a stated desire for revenge
• Externalizing and justifying rage related behavior
• Little to no ability to accept blame or responsibility
• Ongoing petty crimes (theft, vandalism, and the like)
• Consistent defiance of authority
• Pacing in sessions or in the waiting room (indicating an inability to self-regulate when upset or angry)
• Refusing to end sessions, or to leave when sessions are over
• Coming to therapy drunk and/or high

Generally speaking, many of the people at risk for violence are treatable. However, it is not always easy to convince these individuals to participate in their own recovery, especially emotionally painful trauma therapies, substance abuse treatment (when appropriate), taking medications as prescribed, and participation in peer support groups.

NOTE: As a psychotherapist, if a client gives you reason to believe he or she might imminently engage in an act of violence toward self or others, you are legally obligated to report this.

Safety First

I am grateful to have had several years of basic mental health training while working as a tech in locked mental health wards. In those environments I learned quickly, from both peers and clients, how to watch my back when dealing with potentially violent people. In short, this work taught me some basic protective responses that I now turn to when working with potentially violent clients. These responses may or may not apply to you and your client base, but I think they are good to keep in mind. Take what you like and leave the rest.

• Don’t do the session in your closed office. Instead, take it outside. Agitated clients can feel trapped in a small room. Taking potentially violent clients on a walking/talking session allows them to “walk it off” while simultaneously keeping you safer than you would be behind closed doors.
• Put the session on hold until the client calms down, or postpone the session altogether. If the client asks why, be honest. Sometimes your response will actually calm the client down.
• Sit by the door during the session (even if you have to wheel your desk chair into a new and seemingly odd position). You can also leave the door open during the session. Again, if the client asks why, be honest. This intervention will often rein in a client.
• Keep your phone handy.
• Make sure another person (or, preferably, several people) are within shouting distance and can help you if need be.
• Get supervision/consultation. A potentially violent client with whom you have a solid clinical relationship may not seem like a person who will clobber you with a paperweight, but the possibility is nevertheless there. This is why professional feedback is so very important.
• Pay attention and trust your instincts. If a client suddenly seems unsafe, summon assistance or exit the situation immediately.

If there is nothing that suggests imminent violence but you nonetheless see risk factors for potential violence, your next step might be referring your client to a psychiatrist or program where he or she can be more fully assessed and treated, possibly with prescription medications that can help with the worst of the client’s symptoms (including the potential for violence). If you fear for your safety at any time, you are under no obligation to continue working with a particular client, though you do have an ethical responsibility to refer the client on to useful help.

Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he founded The Sexual Recovery Institute in Los Angeles in 1995. He is author of Cruise Control: Understanding Sex Addiction in Gay Men and Sex Addiction 101: A Basic Guide to Healing from Sex, Porn, and Love Addiction, and co-author with Dr. Jennifer Schneider of both Untangling the Web: Sex, Porn, and Fantasy Obsession in the Internet Age and Closer Together, Further Apart: The Effect of Technology and the Internet on Parenting, Work, and Relationships. For more information you can visit his website, www.robertweissmsw.com.