By Dr. Krystyne Mendoza, Ph.D., LPC
Colorado Christian University, Associate Professor, MA in Clinical Mental Health Counseling

In a culture of increasing violence, counselors in practice must consider their own safety, in addition to ensuring the safety of their clients. In a study published by Stephens (2019), violence against healthcare workers is a rising phenomenon. According to this report, “75% of nearly 25,000 workplace assaults occur annually in healthcare settings…” (para. 1). While this specific report highlights the risk against nurses and emergency department physicians, counselors are not immune to such perils, and are often placed at a higher risk of receiving such threats (Davenport, 2009; Wilson, 2012; Winer & Halgin, 2016). Policy makers have taken action and supported the Workplace Violence Prevention for Health Care and Social Service Workers Act, which introduced the need for proper provisions and legislation geared towards keeping emergency departments safe (Stephens, 2019). However, there is little research that speaks to safety policies and practices of solo practitioners.

A study by Phillip (2016), identified four types of workplace violence. The first type identifies a perpetrator who has no identifiable affiliation with the workplace or with an affiliated employee. The second type names a perpetrator who is a patient of the workplace or employee. The third type of violence names an assailant who was a former patient or employee. And the fourth type responds to the occurrence of when an assailant has a personal relationship with an employee, though not necessarily with the workplace. While the second type of workplace violence is the most commonly identified category of violence that occurs against healthcare workers (Phillip, 2016), it is clear how counseling practitioners can be vulnerable in all categories through their work with clients.

Mental health practitioners often work with people who are experiencing severe mental health problems, like depression, anxiety, mood disorders, and post-traumatic stress disorder. Such disorders can predispose clients to having thoughts of violence, including suicidality, homicidality, and other non-specific violent ideations (American Psychiatric Association, 2013). In light of recent events and the rise of mass shootings, homicidality has become a paramount concern for counselors (Davenport, 2009). Thus, protecting practitioners and clients is of utmost importance and should be given appropriate consideration.

Safety Policy Tips

Counselors, whether the sole practitioner, or working with a group, should establish a solid plan and develop strategies to address threats to safety (Wilson, 2012). While larger healthcare facilities and universities typically have such plans in place (Stephens, 2019; Wilson, 2012), it is important that the solo practitioners and small counseling practices also create similar policies. Such plans and policies reduce the risk of harm and legal liability (Nolan et al., 2011). While therapists often discourage clients from asking catastrophic “what if” questions, it is important that counselors engage in hypothetical discussions related to safety concerns and how they would respond in such situations (Wilson, 2012). Thought experiments conducted in this way may serve as a guide should an emergent situation arise. Here are some elements that could be useful when developing safety policies and procedures:

• Outlining a Plan: OSHA’s Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers (2015) provides broad guidelines to consider in assessing for safety in practice settings.
• Office Aesthetic: Counseling can occur in many different locales, but a primary place is usually within the practitioner’s office (Sanders & Lehmann, 2019). The office space is dynamic in presence as research indicates how the environment can impact client’s thoughts, feelings, and behaviors (Pearson & Wilson, 2012; Sanders & Lehmann, 2019). There is a great deal of research that speaks to the idea of how office space impacts clients’ perceptions and elicits a feeling outside of those who inhabit it (Sanders & Lehmann, 2019; Widgery & Stackpole, 1972). The organization of desks, chairs, couches and other office furniture has an effect on the psychological and physiological comfort for both clients and practitioners (Lecomte et al.,1981; Shepherd, 2001; Widgery & Stackpole, 1972). However, beyond aesthetic, the element of safety should also be introduced within this context. Furniture arrangement can be one aspect of the therapeutic experience that introduces proper boundaries and can serve as a physical framework for what a healthy therapeutic relationship should look like (Anthony, 1998; Anthony & Watkins, 2007). With this in mind, practitioners should consider ways of fostering an open environment to facilitate rapport promoting psychological safety, while also creating protective personal boundaries that foster security. Should there ever been a need for a therapist to urgently leave their office, it is important to consider the proximity to the nearest exit. Furniture should be arranged so that the practitioner is the one who is first able to leave the room, should the need arise (Wilson, 2012).
• Creating a Code Word: If a dangerous situation arises and the need to be discrete occurs, creating a safety code word is invaluable (Wilson, 2012). Such a word can be communicated with other staff, clinicians, or other nearby personnel to indicate a need for help in a discrete way.
• Awareness of Risk: Some clients present more risk than others (Winer & Halgin, 2016). Taking this into consideration, therapists should weigh the need, aligning with confidentiality requirements, to notify another clinician when they are working with a client who might be more at risk to react in violence. This is not limited to the client themselves, but also should be considered in other potentially volatile situations, such as custody battles, child protective service cases, or in high conflict divorces. Contacting a colleague before and after a session as a safety check-in, provides a communication line should something go awry.
• Assessing Threat: Within the context of assessing threats, Winer and Halgin (2016) indicate there are three waves of assessment; relying on clinical intuition, administering assessments, and utilizing clinical judgement. In assessing threat, counselors should be prepared with determining how they should move forward to protect both themselves and the client as well as understand the different types of threats that can occur, in addition to considering the severity of such threats (Winer & Halgin, 2016). Both physical and cyber threats are relevant, as well as the physicality of both internal and external office features (Wilson, 2012).
• Self-Defense & Protection: While each State has particular laws around self-defense, it is important to consider how one might defend themselves should a client become violent or if a person outside of the office engages in violent behavior. Counselors should consider both internal and external threats, having well formulated action plans for several different scenarios (Wilson, 2012; Winer & Halgin, 2016). Additionally, having a handheld panic alarm or similar security device could be of value (Wilson, 2012).
• Connecting to Local Law Enforcement: Establishing a connection with local law enforcement may prove valuable (Wilson, 2012). Counselors need to identify the thresholds that trigger when they would need to contact security or law enforcement (Wilson, 2012). Often times, police officers will perform courtesy check-ins, especially if there is a heightened risk. Such check-ins are typically available upon request. Additionally, counselors might consider having a formal safety report conducted by law enforcement or a private security agency (Wilson, 2012).

Conclusion

A safe therapeutic space is of utmost importance in treating clients to promote healing (Geller & Porges, 2014; Pearson & Wilson, 2012). Safety measures are present in physical, psychological, and elemental forms within the office setting. However, the safety of the practitioner is an equally important aspect to address. As therapists continue working with those in most need, proper consideration to our own wellbeing should be reflected upon to promote health and safety for all participants within the therapeutic setting.