Self Defence for Mental Health Professionals

1
Self Defence for Mental Health Professionals

• Graham Martin, Ed Heffernan, James Scott,
• Rod Martin, Malwina Martin, Sarah George

Li Tieh Kuai (Iron Crutch Li), most ancient of
the 8 Immortals Born 2nd Century AD (Han
Dynasty)
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Disclaimer

• Today I am not trying to teach Karate the focus
  is on quick and dirty ways of defending yourself,
  prior to running away.
• None of what we work on today should be too
  physically arduous we will protect you from
  injury we want you to be able to enjoy the rest
  of your Congress.
• However, we cannot accept liability for any loss
  or any personal injury

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We live in dangerous times

• Before Grade 1, the average child has seen over
  8,000 murders on television and over 100,000
  violent acts. By schoolies week, the numbers
  will double (American Academy of Child and
  Adolescents Psychiatry, 1995)
• An average TV program contains 5 acts of violence
  per hour, the average kids program shows 25 per
  hour. (Center for Media Public Affairs)
• Lyrics from Michael Mather (Eminem) talk about
  sticking nails through eyelids and slitting
  parents throats.
• Children have access to video games like Doom,
  Diablo, and Kingpin (multiplayer gang bang
  death and see the damage done including exit
  wounds)

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Team Sports may not help much
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Why I wanted to do this presentation

• We have a responsibility to ourselves and to
  others to have reflected on our experience and
  prepared for the future as well as we can.
• Christopher L.
• Mary K.
• Dr. Nandadevi Chandraratnam, who died on 3rd
  December 1992
• Dr. Margaret Tobin, who died on 15th October 2002

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Factoid

• Health care workers experience close to 40 of
  non-fatal assaults on employees in the United
  States.

7
Victims of Patient Assault

• Physicians
• Nurses
• Social workers and other allied health personnel
• Other patients
• Visitors
• Emergency team members
• Administrators
• Police
• Staff in Corrections

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005 . Available at http//www.emedicine
.com/neuro/topic713.htm. Crilly, et al. Violence
towards emergency department nurses by patients.
Accid Emerg Nurs 2004 12 67-73
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• Staff members who have developed a systematic
  approach to the treatment, understanding and
  management of assaultative behaviour are less
  likely to injure or be injured during an
  assaultative incident than those who havent.

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Gun Deaths in Australia
Results In the 18 years before the gun law
reforms, there were 13 mass shootings in
Australia, and none in the 10.5 years afterwards.
Declines in firearm-related deaths before the law
reforms accelerated after the reforms for total
firearm deaths (p 0.04), firearm suicides (p
0.007) and firearm homicides (p 0.15), but not
for the smallest category of unintentional
firearm deaths, which increased. No evidence of
substitution effect for suicides or homicides was
observed. The rates per 100 000 of total firearm
deaths, firearm homicides and firearm suicides
all at least doubled their existing rates of
decline after the revised gun laws.
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Categories of Workplace Violence (US)

• Type I- Stranger vs. Employee - (examplearmed
  robbery)
• Accounts for 60
• Type II- Client vs. Employee
• (example social worker attacked by client)
• Accounts for 30
• Type III- Employee vs. Employee
• Accounts for 10 of workplace attacks and/or
  homicides

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Small Group Workshop Exercise

• Your Personal Experience

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Is there a profile?
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Dr. Tobins killer(prevention may not have been
possible)

• In his closing argument in the SA Supreme Court,
  Prosecutor Peter Brebner said there was too much
  evidence linking Jean Eric Gassy with the victim
  for it to be discounted as a coincidence. Gassy
  owned pistols like the one used. And Gassy had
  travelled to Adelaide in October 2002. Gassy
  also harboured resentment towards Dr Tobin for
  the role she played in having him deregistered in
  1997. Gassy, 48, was diagnosed as suffering a
  delusional disorder prior to his deregistration
  (The Age)

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• I remember the time he gave to my Dad.
• He would come around at the drop of a hat.
• He was a marvelous GP
• apart from the fact that he killed my father

Quote from Christopher Rudo -son of a victim
killed by mass murderer Dr Harold Shipman
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Dr. Chandras killer (prevention may have been
possible)

• "There is no doubt that Mr. Tzeegankoff has a
  history of impulsive behaviour with violence
  which ante-dates the onset of his psychotic
  illness in the mid 1980s. The psychotic illness
  has at times been difficult to delineate, but on
  balance it would appear that he has a paranoid
  schizophrenic illness. (Prof. Robert Goldney)
• There is little evidence before me about whether
  there was a specific treatment plan formulated in
  relation to his illness. (Coroner Wayne Chivell)

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Principle 1
Most criminal violence is not committed by the
mentally ill

• most mentally ill are not violent
• violence committed by the mentally ill may be due
  to reasons not directly related to their
  psychiatric impairment

The next 5 slides courtesy of Dr. Ed Heffernan
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Principle 2
Mental illness alone is a modest risk factor for
violence

• mental illness COMORBID with substance abuse and
  personality pathology dramatically increases risk
• more disorders higher risk
• subs abuse gt psychosis gt neurotic

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Principle 3
Shared risk factors

• predictors of violent recidivism in any mental
  illness are strikingly similar to those of
  offenders without illness
• violence committed by the mentally ill may be due
  to reasons not directly related to psychiatric
  impairment
• Hx of violence
• Hx of criminality
• Younger age, male, lower SES
• substance use

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Principle 4
Victims are more like to be known

• That is
• more likely to be family or acquaintances

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Principle 5
Active symptoms increase risk

• individuals with mental illness alone are most
  likely to be violent when acutely unwell
• non-compliance with therapy may be a factor

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Relevant History to alert you

• Previous history of violence to self or others
• History of family violence
• Substance abuse and/or dependence
• Antisocial personality disorder
• Borderline personality disorder
• Bipolar disorder
• Dementia
• Head injury (with history of disinhibition)
• Impulsivity
• low frustration tolerance
• inability to tolerate criticism

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Relevant History (2)

• Male gender
• Single
• Learning disability or Intellectual Disability
• History of physical and/or sexual abuse
• Violence at home
• Lower socioeconomic status
• Lower income
• Homelessness
• Poor social networks
• Sex offender
• Fire setting and other history of Delinquency (eg
  torture of animals)

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Current Status which may be important

• Acute confusional state
• Acute organic psychosis
• Alcohol intoxication
• Delirium
• Delusional
• Grandiose
• Agitation
• Anger

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Factors increasing your suspicion of likely
violence

• Deep belief that they are the victim of the
  organization
• Self centered moral righteousness
• Access to guns and other lethal weapons
• Participation in gangs
• Tattoos and old scars
• Recklessness or Risk-taking
• Verbalization of command auditory hallucinations
  to perform violence
• Verbalization of intent to kill
• Verbalization of plan to take revenge

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Assessing for ve history

• Brief Psychiatric Rating Scale (BPRS) (Overall
  and Gorham, 1962)
• Hostility Scale
• (hostility, suspiciousness, and
  uncooperativeness)
• Negative Symptom Scale
• (flat affect, emotional withdrawal, and motor
  retardation)
• Positive Symptom Scale
• (concept disorganization, hallucinatory behavior,
  and unusual thoughts)
• Empathy Tasks (Abu-Akel and Abushualeh, 2004)
• Modified Overt Aggression Scale (Kay et al,
  1988)
• Maudsley Violence Questionnaire (Walker, 2005)

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Times when things can go wrong

• Seasonal variations (High Summer, Early Spring
  and Deep Winter)
• Temporal variation (eg, evenings, nights,
  weekends)
• Staff variation (eg, students, new staff, temp
  staff)
• Nursing unit variation (eg, admission, maximum
  security, violent patients)
• Copycat or Clustering Effects (Impact of Media or
  Local Events)

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Triggers for Violent Episodes

• Job loss
• Relationship Breakdown
• Long wait to be assessed
• Anxiety
• Fear
• Frustration
• Hunger
• Noise
• Pain
• Sleep deprivation

• Denial of patient request for admission
• Involuntary hospitalization
• Disrespect, actual or imagined
• Lack of privacy

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Contexts Associated with Violence

• Absence of escape routes
• Inadequate staff
• Malfunctioning equipment
• Portable furniture
• Portable objects
• Unobserved patients
• Untrained protective services

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Know your environment

• Exercise Draw your rooms or where you work.
• Where could you get trapped?
• Where are the escape routes?
• How do you let people know you are in trouble?

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Signs of Impending Violence

• Flushed facies
• Hostility
• Impulsivity
• Loud outbursts
• Name calling
• Obscene or Profane language
• Opening and closing the fist
• Pacing
• Pointing
• Pulling out a weapon

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Signs of Impending Violence

• Tension
• Restlessness
• Smell of alcohol on breath
• Pushing furniture
• Staring or widened eyes
• Sudden movements
• Slamming or throwing objects
• Uncooperativeness

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Sometimes you are certain you can manage
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Other times you just know you are in trouble
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Assessing Risk

• Take all threats of violence seriously.
• If you feel apprehensive, tense or afraid in a
  clinical situation, then follow your instincts
  and guard your personal safety. Take steps to
  either remove yourself or get help.
• Experienced clinicians follow their gut reactions
  that something serious is imminent.

35
Create a Safety Plan(personal or system based)

• Exercise
• What will you do when you get back?

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In the Office

• Always keep your purse, wallet or valuables with
  you (or secure them)
• Check the identity of any strangers who are in
  your office
• Always let someone know where you will be
  (lunch, restroom, late for work)
• Be discreet. Dont advertise you or your
  coworkers social life and vacation plans to
  visitors or callers

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On the Road

• Plan your trip, have a map, use it
• Carry a cell phone, know your location
• Doors locked while you drive
• Car runs well, maintenance up to date
• Stop or park in busy, well lighted
• areas, close to entrances.
• Have keys ready, inspect area, interior
• Conceal maps, rental info, luggage
• If you are bumped, remain in vehicle, call
  police

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Hotel/Motel Security

• Travel light - never leave luggage unattended
• Keep doors and windows closed and locked
• Protect your room assignment and room keys
• Locate most direct route to fire escapes,
  elevators and telephones
• Leave valuables, jewelry and excessive cash at
  home (or use the house safe)
• Always verify who is at your door - before you
• open the door (use peephole or call the
  desk)

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Administrative Approaches

• Make it clear to patients, clients, and employees
  that violence will not be tolerated or permitted
• Establish face to face liaison with local police
  and ask them to review your premises for
  problems.
• Require employees to report all assaults and
  threats
• Consider setting up an emergency response team

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Technology to prevent violence Awareness,
Vigilance, Communication, Action

• Closed circuit television monitoring
• Panic buttons in all clinical areas
• Two-way communication systems

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Context Monitoring

• Establish a violence reporting system and regular
  review of reports
• Review staff meeting reports on safety issues
• Analyze trends in illness/injury or fatalities
  caused by violence
• Measure improvement based on lowered frequency
  and severity of violence

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Staff Training and Education

• Ensure that all staff are aware of potential
  security hazards and ways of protecting
  themselves
• Train in recognition of risk factors that cause
  or contribute to assaults, and
• Early recognition of escalating behavior or
  warning signs
• Workplace violence prevention policy
• Ways to prevent volatile situations
• Standard response action plan for violent
  situations
• Location and operation of safety devices

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Tips Staff Protection

• Tuck ties in shirt.
• Dont wear necklaces or earrings.
• Dont divulge personal information about
  yourself.
• Give yourself access to exit.

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Tips Alternative Devices

• Name badges can be on break-away clips. Dont use
  around-your-neck lanyards.
• Stethoscopes can be clipped to the belt instead
  of around the neck.
• Scissors can be used as a weapon. Be aware of
  where they are in relation to your patient.

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Prevention is better than something unexpected
and nasty happening
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Personal Strategies to avoid violence

• Do not interview or examine patients in your
  home.
• Do not interview dangerous patients in offices
  without a security guard.
• Install windows in the doors of examination
  rooms.
• Avoid furniture that can block exits from rooms.
• Equip examination rooms, offices, and nursing
  stations with panic buttons.
• IN THE FUTURE WE MAY HAVE TO CONSIDER
• Requiring patients (and ? even staff) to pass
  through metal detectors before entering clinical
  areas.

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Defusing Techniques

• Attend to client before things get out of hand
• Walk/Stand confidently
• Maintain eye contact
• Avoid arguing or defending previous actions
• Avoid threatening body language (dont stand with
  arms crossed).

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Defusing Techniques (2)

• Calmly but firmly state the limits.
• Communicate information about any delays etc.
• Give some choices.
• Seek a family member or friend to support
• If situation continues to escalate, with louder,
  more agitated verbalizations, reduce stimulation
  from settingeg. bring from waiting room to exam
  room.

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Your Personal Safety Depends On.

• Two Rules!
• React quickly.
• Make a decision.
• Two Questions!
• My situation?
• Best options available?
• Two Objectives!
• Survive.
• Escape.

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Acting in Self Defence
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Confronting an Attacker

• You are walking in a dark alley when you find
  yourself in a bad situation. Standing in front
  of you is a male figure. Without warning he
  moves quickly towards you.
• What do you do??

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Confronting an Attacker

• Recent studies show that females who fight back
  are less likely to be killed or seriously hurt.
• A majority of attackers are seeking an easy
  target. The harder you make it for them, the
  better chance you have to survive.

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Fighting Back

• Everything you do should be setting up to allow
  you to escape (ie run away)
• Its not what you can do thats important, but
  what you are willing to do.

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Behaviour to Abort Violence

• Keep an attacker in your visual field.
• Maintain eye contact
• Do not turn your back on an attacker.
• Make sure that an attacker does not invade
• your personal space within 4 to 6 feet
• Be prepared, but not provocative

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Short Video

• Taken from 100 Techniques of Self Defence, these
  2 segments can give you some ideas

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RESPONSE

• Question
• When we are responding to a person who is
  threatening or attempting to injure, will we be
  able to match our response to the level of injury
  threatened?

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Definition of Reasonable Force

• A reasonable amount of force is just enough
  force for effective protection of self and others
  and no more than is absolutely necessary
• (Smith, P., 2004. P.A.R.T. Trainers Manual)

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Selecting a self defense strategy

• What is my goal?
• If you decide to fight back, what is the best
  technique for you?

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Selecting a self defense strategy

• Am I willing to get physical?
• Can I bring myself to hit someone?
• Could I deliberately and knowingly cause damage?

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What might you need to know?

• Martial Arts and self-defense are not synonymous.
• Traditional martial arts have skills that are not
  designed, nor are they realistic for a
  self-defense situation.
• The idea that someone can do a high kick to a
  persons face on an icy street is not realistic.
• In this workshop we seek to teach what is simple,
  direct, and uses gross motor skill moves.

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Key Points to Fighting Back

• Dont panic
• Dont freeze-up, react quickly
• Do start yelling, make lots of noise !
• Commit and go hard
• Recognize and utilize escape opportunities
• Do whatever it takes!

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Key Points to Fighting Back

• Never
• ever
• give
• up!

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Active Demonstrations

• 1. Someone pointing and shouting abuse
• Maintain eye contact
• Move sideways on
• Keep hands up, but do not provoke
• ESCAPE.

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Active Demonstrations

• 2. The Wrist Grab
• Pull away (reinforced)
• Offer food
• Wave at your Mum
• Pull arm across body and push shoulder
• ESCAPE.

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Active Demonstrations

• 3. The lapel grab (single hand)
• Same hand over top to cover, grab and turn hand
  over
• Try the same thing with pressure on elbow
• Turn in and push under jaw
• ESCAPE.

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Active Demonstrations

• 4. The Lapel Grab (2 hands)
• Bowling Arm
• Goal Umpire
• Strike to Brachio-Radialis
• ESCAPE.

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Active Demonstrations

• On being strangled from in front
• Grab hands (natural) and turn to side
• If up against a wall sweep with 1 arm and twist
• Turn and push away (or strike to throat)
• Hit to ear or ears with cupped hand
• Knee
• ESCAPE.

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Active Demonstrations

• The Hay Maker Punch
• Cover up
• Wave at your Mum
• Body weight Dinosaur
• ESCAPE.

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Active Demonstrations

• The Strangle from Behind
• Head Butt
• Twist head to give an airway, grab the hand,
  strike and pull your head through
• Groin Strike
• The Wrist Grab
• ESCAPE.

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Active Demonstrations

• 8. Bear Hug
• Breathe in, Drop down
• Bum Strike
• Strike to the Groin
• ESCAPE.

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Active Demonstrations

• 9. On the Ground
• Hands on head and roll away
• Strike to the groin
• Kicking with legs
• ESCAPE.

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Active Demonstrations

• The attack with a knife
• No Illusions - this is hard.
• Cover up an arm and try to block
• Groin kick
• Grabbing the wrist
• Escape.

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Active Demonstrations

• 11 The attack with a gun
• Its all too late
• Chance
• ESCAPE.

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Confronting an Attacker

• You are walking in a dark alley when you find
  yourself in a bad situation. Standing in front
  of you is a male figure. Without warning he
  moves quickly towards you.
• Did you change what you might do??

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After the Event
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Once you have escaped, report.

• Your location/situation
• Weapons
• Hostages
• Injuries
• Suspect description
• Statements
• Direction of travel
• Vehicle description
• Stay on the phone (safety first) and in contact
  with police

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After something horrible happens.
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Adverse Consequences of Violence

• Feeling upset
• Feeling irritable
• Headache
• Anger
• Blaming self
• Fear of caring for isolated patients
• Insecurity

• Refusal to identify self to patients
• Lost time from work
• Career change
• Low worker morale
• Poor job satisfaction
• Poor worker retention

79
Coping and Survival Strategies

• Denial
• Hiding
• Calling police
• Seeking advice or help from others
• Fighting back / self-defense
• Leaving
• Self-medicating

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Post-Incident Response

• Provide comprehensive treatment for victimized
  employees and employees who may be traumatized by
  witnessing a workplace violence incident
• Critical incident stress debriefing
• Trauma-crisis counseling
• Employee assistance programs to assist victims