Topic: Clinical Approaches with Forensic Clients

Forensic AOD clients are often involved in treatment involuntarily, presenting several challenges for clinicians. These individuals are likely to have lower self-awareness of their AOD abuse problems and are more likely to challenge or disengage from treatment, compared to community populations. Motivation towards goals and treatment is increasingly recognised as an important facet in attaining change and increasing the benefit an individual will receive from therapeutic intervention (McMurran & Ward, 2004).

Motivational interviewing is a person-centred, goal-orientated style of counselling, that aims to elicit and strengthen an individual’s own motivation and commitment towards behaviour change. This is done by attending closely to the client’s language of change, exploring ambivalence and evoking their reasons for change. Whilst the practice is not designed to coerce unmotivated individuals into change, it can help individuals resolve ambivalence towards treatment and find their own motivation needed to change their behaviour.

Motivational interviewing is a respectful and collaborative practice that uses principles of acceptance and empathy to encourage clients to talk about their reasons for wanting to change. Largely, motivational interviewing aims to elicit change talk from a client, which includes any speech that favours movement in the direction of change. Speech of this nature is often subtle, so active listening is vital when identifying and evoking change talk in clients.

Clients are more committed to change when they:

• Identify the problems they face (i.e. how their behaviour conflicts with important goals or values)
• Have feelings of discomfort towards their ambivalence
• Make a shift in attitude and decide to change (e.g. acceptance of problem, openness to change, willingness to do what it takes)
• Choose a solution and ways to achieve goals
• Have adequate internal resources to support change
• Have external resources and support available to them
• Are working towards goals that are important to themselves
• Have realistic, achievable and practical goals
• Have goals within their locus of control

Key principles of motivational interviewing:

Express empathy

Acceptance and empathetic listening is key to facilitating change and minimising resistance.
(e.g. “You feel … because …”).

Develop discrepancy

A person’s likelihood to change increases when they perceive their behaviour as conflicting with their goals. Create a conversation around change, without attempting to coerce or convince the person. (e.g. “How important is it to you to make this change right now?”, “What are the benefits and costs of staying the same?”)

Avoid argument

Work alongside the client, rather than taking an oppositional viewpoint. Information should be presented in a neutral and non-judgemental way, encouraging clients to find their own motivation and reasons for change. (e.g. “Fair enough, would you be willing to talk about your goals for the future?”)

Roll with discord

It is important to respect the client’s choices and feelings, as to avoid defensive responses to treatment. Encourage the client to find their own resolutions for the goals they have decided upon. (e.g. “Where do you want to go from here”, “Ok, so you’re not wanting to quit smoking by using nicotine patches. What other options have you heard of?”)

Support self-efficacy

Believing that change is possible and within reach can help a client develop motivation towards change. Helping a client to build confidence and highlighting their strengths can help them move towards change (e.g. “It seems like you have thought this through and have got a good plan in place).

Barriers that limit change:

• Physiological drivers such as cravings/ withdrawal symptoms
• Low motivation caused by other factors (e.g., Depression)
• Disordered thinking or beliefs
• The power of habit
• Learning difficulties
• Lack of resources or help
• Low self-efficacy

It is important to identify and discuss these barriers with clients, in an open and non-judgemental manner.

Helping clients move towards change talk:

• “What would you like to see different about your current situation?”
• “What makes you think you need to change?”
• “What will happen if you don’t change?”
• “What will be different if you complete your probation/ referral to this program?”
• “What would be the good things about changing your [insert risky/ problem behaviour]?”
• “What would your life be like three years from now if you changed your [insert risky/ problem behaviour]?”
• “Why do you think others are concerned about your [insert risky/ problem behaviour]?

References:

AIPC Article Library | Principles and Techniques of Motivational Interviewing. (2018). Retrieved from https://www.aipc.net.au/articles/principles-and-techniques-of-motivational-interviewing/

McMurran, M. and Ward, T. (2004), Motivating offenders to change in therapy: An organizing framework. Legal and Criminological Psychology, 9: 295-311

Case Notes

Case notes provide a record of the client’s interaction with your service, and in writing them it is important that practitioners are always mindful that they may be read by others (whether the clients themselves, or by legal practitioners and courts. It is the clinician’s responsibility to be aware of relevant agency and government requirements.

As with other client populations, the ultimate purpose of case notes is to assist the client. However, case notes may be subpoenaed by a Court or accessed by the clients themselves (i.e. through Freedom of Information Act requests). Case notes should always be written as though this will happen, not might happen.

Case notes serve many purposes:

• Provide professional accountability by providing evidence of services and support being provided to clients;
• Assist with treatment planning and progress review by providing a record of interactions with clients;
• Demonstrate appropriate duty of care and responses to risk;
• Meet the requirement of the funding body;
• Help jog clinicians’ memories;
• Assist in client handover.

Case note criteria:

1. Empirical and reliable
2. Relevant and targeted
3. Legible and clear
4. Recorded promptly
5. Kept in a chronological order
6. Consistent within the organisation.

Case note guidelines:

• Include only information relevant to service being provided and do not omit information that is relevant
• Report facts and observations / interpretations that have supporting evidence (“the client appeared anxious as demonstrated by…”)
• Avoid biased language, emotional language, value judgments, opinions and street language / jargon (unless quoting the client)
• Acknowledge source of information (“The client reported that …”)
• Avoid using other people’s names in your case notes (use wife, partner, brother etc. or first names only)
• If unsure about whether to include something in your case notes, seek guidance and advice from your supervisor

Adherence to these guidelines will provide protection should your case notes be subpoenaed.

What to include in case notes:

• Session details: date, time, client’s name, session number/type
• Description of client presentation based on brief MSE (highlight deviations from usual for existing clients)
• Session content:
• Disclosure of ethical obligations / confidentiality
• Main themes discussed
• Interventions used
• Progress and future goals
• Plan for next session
• Record any risk factors including detailed record of actions taken in response to risk

Writing up case notes:

• Record case notes as soon as possible after the session / event
• Type notes, or if handwritten, ensure they are legible
• General session information should be written in a concise manner with reference to important information elicited, patterns regarding presentation or content covered, and common themes
• Specific information should be provided when covering information about client risk, including risk to self and others. Emphasis should be placed on the management of risks when case noting.
• If a change is required, best practice is to record the change as a new case note, including an explanation of the error or omission in previous case note (do not alter the original case note)
• If new information comes to light after the session, it should always be included in a new case note, not added to the original case note
• NEVER use white-out on a case note. Ensure any hand-written corrections are legible (original information should still be readable), signed and dated
• The length of your case note will be dependent on the purpose and content of the session undertaken. Clinicians should endeavor to keep their case notes succinct.

Freedom of Information

The Victorian Freedom of Information Act 1982 gives clients the right to request documents held by the Department of Justice and Regulation or the Department of Health and Human Services, and allows for incorrect or misleading information held by the departments to be amended or removed.

FOI requests are usually received from current clients, from lawyers when clients receive new charges, or when clients are released on parole.

In most cases, the document MUST be provided. You can argue to restrict release, or redact aspects of the document, only if their release will pose a significant safety risk to the client or others.

FOI requests are becoming more common – therefore you should always keep this in mind in everything that is documented in a client file (including case notes, reports, assessments, etc.)

Establishing Boundaries

Although boundary setting is an important aspect of all therapeutic relationships, forensic alcohol and other drug (AOD) clients often have a history of violating personal and professional boundaries in serious ways. These populations are also likely to have had experiences of trauma and/or violations of their own personal boundaries in the past. As such, those working with forensic clients should be aware of, and emphasise the importance of firm boundaries, to ensure safety, ethical practice and good treatment outcomes.

Boundaries refer to the limits placed on behaviours and interactions between a clinician and their client, ensuring that the therapeutic relationships functions in the best interest of the client. Forensic clients are likely to display manipulative behaviours, so ensuring firm boundaries also serves as a protection to the clinician. Where crossing boundaries may at times be considered therapeutic in work with some AOD clients, the nature of forensic work means clinicians must take additional care to ensure appropriate clinician-client relationships.

Client boundary violations

Examples of boundary breaches:

• Lateness or missing appointments
• Criticising the clinician
• Asking personal questions
• Not paying attention, refusing to answer questions
• Complementing the clinician
• Giving the clinician gifts
• Aggressive or threatening behaviour
• Asking for special favours or special treatment

It is essential that the clinician is always consciously aware of what their role is within the therapeutic relationship and what actions may limit their ability to fulfil these responsibilities. Although maintaining firm boundaries is vital when working with forensic clients, some situations are not black and white, so you may need to use clinical judgement and seek supervision in times of uncertainty.

Given the client population, boundaries are likely to be challenged or crossed, and it is important that clinicians have strategies in place to manage these issues when they arise. When boundaries become blurred, clients may take advantage of the situation or begin to take control of the clinician’s role (e.g. setting appointment times, asking personal questions).

Exploring the underlying motives or reasons for a client’s boundary crossing can have important implications for treatment. For example, a client asking personal information may indicate confusion of the clinician role or alternatively may indicate deliberate attempts at manipulation.

Tips on managing boundaries:

• Discuss mutual expectations at the beginning of treatment
• Be honest and authentic in your relationships to build trust
• Maintain consistency with clients
• Avoid disclosing personal information
• Clearly define your role and its limits (e.g. “I’m sorry, but I don’t have the authority to…”)
• Seek supervision
• Follow correct organisational procedure
• Carefully document interactions with the client, especially any involving boundary beaches
• Don’t make promises that you can’t deliver and deliver on what you promise
• Advise of your response to breaches (e.g. lateness, attending substance affected etc)
• Act only within your defined role
• Maintain good social supports amongst colleagues

Professional boundary violations

Given the intensive nature of work in forensic settings, professional boundaries may be eroded over time, particularly as therapeutic relationships develop. Identifying and addressing your own professional behaviours that might indicate boundary violations, is an important aspect of ethical practice and effective treatment.

Clinician boundary violations:

• Excessive joking with the client
• Stereotyping clients who engage in certain behaviours
• A belief that only you understand the needs of the client
• Changing your behaviour during interactions with the client
• Doing favours or spending extra time with the client
• Losing hope
• Agreeing with anti-social attitudes (e.g. towards police)
• Avoiding challenging of negative behaviours
• Avoiding discussing client difficulties with peers/supervisors

Managing professional boundary crossings:

• Monitor your level of involvement with clients (e.g. over or under-involvement may indicate a blurring of boundaries)
• Ensure that the therapeutic relationship is not misread or confused with a personal relationship
• Recognise that your own behaviours provide information about the client’s presentation, and seek supervision accordingly
• Engage in self-care practices regularly to avoid burnout/compassion fatigue
• Reflect on your own practice (e.g. be aware of your own vulnerabilities and negative responses and what might be driving them)
• Always stay in role
• If you believe a boundary has been crossed, consult your supervisor for guidance

Self-disclosure

It is vital to protect your personal privacy and avoid disclosing personal information when working with forensic clients. While asking personal questions may seem benign, clients may have antisocial personality disorder and/or psychopathy and can use personal information to manipulate you.

Never disclose specific details such as your home address, phone number or details of your family members. If asked questions of this nature, seek to explore the reason for the question (i.e. lack of trust, lack of respect for privacy, manipulation) and find your own way of answering these questions that align with your therapeutic style.

Disclosing too much information can reinforce avoidance behaviours, give clients inconsistent signals of the clinician’s role, and take up time in therapy that should be devoted to the client. Additionally, over-disclosure of personal information can be a warning sign of burnout and compassion fatigue – suggesting a need for more careful consideration of your own professional boundaries.

Responsibilities of managers/supervisors:

• Model appropriate professional boundaries with clients to your supervisees
• Be open to discussing supervisee concerns
• Develop a workplace culture that allows open discussion of concerns/risk amongst team members
• Actively and regularly engage in clinical supervision
• Have an awareness of the factors that may contribute to breaches of professional-client boundaries and communicate this to your supervisees

Pro-Social Modelling

Pro-social modelling is a simple and effective technique that can contribute to behaviour change in forensic clients. It refers to the ways in which individuals working with involuntary clients can model and reinforce pro-social values to elicit similar values in their clients. This is done through the positive reinforcement of a client’s desirable thoughts and actions, while confronting pro-criminal or anti-social behaviours. Ultimately, this practice aims to move clients towards a more pro-social life. Workers who implement these practices generally show higher levels of empathy and socialisation, and have clients with improved outcomes, such as reduced rates of arrests and incarceration as well as lower rates of recidivism.

Pro-social modelling practices are based on learning theory, such that a client is more likely to replicate their positive behaviours if they understand the links between their actions and the associated rewards. Thus, it is essential that pro-social modelling is demonstrated promptly following desirable behaviours so that the client can clearly observe the link between the behaviour and reward.

Pro-social behaviours that should be rewarded/reinforced:

• Attending appointments and being punctual
• Being optimistic of progress towards goals and achievements
• Prosocial interpersonal skills (politeness, kindness, empathy)
• Accepting responsibility for offences
• Actively participating in treatment
• Following orders and directions from staff
• Participation in pro-social activities (e.g. sport, hobbies, attending classes/work)
• Attending job interviews
• Distancing oneself from pro-criminal social groups
• Associations with non-criminal peers
• Expressing understanding of the harmful effects of substance use/criminal activity
• A focus on problem-solving approaches
• Empathy for victims

Ways for workers to model pro-social attitudes/behaviours:

• Keeping appointments and being punctual
• Being reliable – don’t make promises you can’t keep
• Respecting the client’s feelings
• Ensure you are rational and fair in your interactions with the client
• Expressing negative views about criminal behaviour
• Interpreting people’s motives in a positive way (e.g. “most police are really just doing their jobs” rather than “that police officer is being unfair”)
• Being optimistic about the benefits of obeying the law
• Being non-judgemental
• Expressing empathy
• Constructively challenge anti-social or pro-criminal attitudes and behaviours
• Understand how personal or cultural factors can influence a client’s behaviours. (I.e. through talking to the client about their cultural perspective). Thus, ensuring approaches are relevant and beneficial to the client.
• Being consciously aware of your actions and the ways in which you may be influencing clients

Ways to reinforce positive behaviours:

• Demonstrate positive body language (e.g. smiling, attentive listening)
• Verbal praise
• Sharing positive information with other workers involved with a client (e.g. CCOs)
• Reducing frequency of contact
• Providing a positive report for parole or court
• Making positive comments in case notes
• Clearly indicate the attitudes/behaviours you wish to be elicited by the client
• Reinforcement should occur immediately in response to pro-social behaviours

While confrontation of undesirable behaviour is an important aspect of pro-social modelling, it must be used sparingly and amongst a wider approach of positive reinforcement to ensure it has therapeutic benefit and avoid deterioration of the therapeutic alliance. Importantly, excusing, avoiding or ignoring, rather than addressing, anti-social behaviours is associated with poorer client outcomes. Confrontation of anti-social values should involve first, identifying undesirable rationalisations or behaviours as well as the potential reasons underlying them. Then, the situation should be re-framed within a positive framework to demonstrate more appropriate responses, while still acknowledging that a client’s negative feelings may be justified.

For more information on pro-social modelling, have a look at these publications:

Cherry, S. (2010). Transforming Behaviour. London: Willan.

Chris Trotter & Tony Ward (2013) Involuntary Clients, Pro-social Modelling and Ethics, Ethics and Social Welfare, 7:1, 74-90,

Trotter, C. (2009). Pro-Social Modelling. European Journal of Probation, 1(2), 142–152.

Trotter C. 2013. Effective community-based supervision of young offenders. Trends & issues in crime and criminal justice No. 448. Canberra: Australian Institute of Criminology.

Treatment Interfering Behaviours

Treatment interfering behaviours (TIBs) refer to any client or clinician behaviours that interfere with a client’s potential to benefit from treatment. Research has found that TIBs are present in more than 50% of AOD clients (Beatson, Rao & Watson, 2010). These behaviours are typically repetitive, ongoing behaviours that prevent effective recovery.

Identifying and addressing TIBs increase the likelihood of achieving better outcomes for client recovery. Recognition of TIB warning signs can assist in early identification and management of these behaviours (e.g. history of self-harm/violence, history of repeated treatment drop out, disruptive psychosocial factors).

Common TIBs include:

• Non-attendance or late arrival
• Dramatic behaviour or extreme emotion
• Splitting
• Threats of harm (self and others)
• Critical or dismissive of response to therapist’s approach
• Presenting substance affected
• Repeatedly presenting “in crisis” (Crisis orientation)
• Deliberate disruption of therapeutic relationship
• Attempts to change the focus of sessions
• Unhelpful responses (“Dunno” or “I can’t remember” or “I’m not sure”)
• Aggression
• Providing inaccurate/misleading information
• Not identifying clear goals for treatment
• Denying problems or refusing treatment

When these signs are identified, it is important to discuss these issues in supervision and develop a plan to effectively address and reduce the presence of these behaviours.

Splitting

Splitting is a conscious tactic frequently employed by forensic clients to pit one entity against another (e.g., CCS case manager vs clinician). This behaviour can be used to help a client get what they want and manipulate those around them. Splitting is particularly harmful to therapeutic outcomes, so it should be addressed promptly at both an organisational and therapeutic level.

Some ways to manage splitting behaviours include:

• Where possible, ensure client’s interactions are with only one staff member
• Always be supportive of other staff members – never speak negatively about other staff to the client
• Communicate clearly and consistently with the client and CCS
• Communicate clearly (and unapologetically) that you are unable to get directly involved or ‘take sides’
• Ensure that everyone dealing with the client responds in a similar manner
• Be clear with the client about the best person to meet their particular needs and that it isn’t appropriate for the client to go to various people for the same thing
• Seek supervision if the client makes unambiguous claims of abuse or unprofessional behaviours

Crisis Orientation

Forensic clients often present themselves in a constant state of crisis and drama and likely have done so for some time. Clients may present in this manner for a number of reasons including avoiding underlying problems, to satisfy a need for excitement/shock, avoid negative feelings or to feel ‘alive’ rather than depressed or worthless etc.

In these cases, it is important openly discuss how the client’s behaviour is impacting their potential for recovery, and develop a collaborative plan for addressing both crises and treatment needs.  For example, you may agree to spend 10-15 minutes at the start of the session to discuss the “crisis,” and to spend the remainder of the session on broader treatment goals.

It is important not to become desensitised to client crises and recognise when these crises could lead to harm to the client or others. Appropriate risk assessment for suicidal or para suicidal behaviours/ideations should always been undertaken.

General strategies for managing TIBs:

• Provide a balanced response where the client is not invalidated, and you are not placed in an untenable situation
• Discuss the impact the client’s actions may be having on treatment
• Be clear from the beginning about your reporting requirements
• Establish expectations early (through group agreement or treatment contract)
• Identify the specific treatment-interfering behaviour and explore the possible reasons for this behaviour (e.g. avoidance, cognitive deficits etc)
• Advise the client of the consequences of continued behaviour
• Gently encourage client reflection on their interpretations of other people’s actions / motivations
• Seek supervision
• Identify strategies that could assist with the reasons for this behaviour
• Document actions
• Consider holding a case conference with the CCS case manager to discuss issues together
• Don’t buy into the behaviour!

Clinician TIBs:

Clinicians can have a range of responses to the TIBs or general behaviour of a client, some of which interfere with treatment outcomes. It is important to address both client and clinician TIBs to prevention deterioration of the therapeutic alliance and ensure effective treatment. Clinician TIB’s may include:

• Ignoring/avoiding addressing client TIBs
• Responding aggressively to the client
• Failing to recognise a client TIB
• Feeling frustrated/discouraged/hopeless
• Stereotyping clients who engage in certain behaviours
• Stigmatising clients with certain diagnoses (e.g., ASPD)
• Negative countertransference (responding or thinking in a judgmental manner due to own “stuff”)
• Positive countertransference (“I’m the only one who can help this client”)
• Avoiding challenging clients

How you can address your own TIBs:

• Avoid judgement of the client
• Monitor your level of involvement with the client (e.g. over or under-involvement)
• Seek supervision
• Recognise how your own TIBs might provide information about the client’s presentation (which can also inform treatment)
• Practice reflectively (e.g., be aware of your own vulnerabilities and negative responses and what might be driving them)
• Practice self-care regularly

For more information regarding managing TIBs, have a look at the following publications:

Clarke, M., Fardouly, P., & McMurran, M. (2013). A survey of how clinicians in forensic personality disorder services engage their service users in treatment. The journal of forensic psychiatry & psychology, 24(6), 772-787.

Wyse, K. (2016) Treatment engagement of people in forensic personality disorder services. DForenPsy thesis, University of Nottingham.

Trauma Informed Practice

Trauma refers to the experience of a real or perceived threat to one’s life or bodily integrity or that of a loved one. Trauma causes an overwhelming sense of terror, horror, helplessness and fear. ‘Single incident’ trauma involves the experience of a single event in which an individual was under threat, whereas ‘complex trauma’ refers to cumulative, repetitive and interpersonally-generated stress (e.g. ongoing abuse in the context of family or intimate relationships).

Given the nature of the forensic client population, a large proportion of clients will likely have experienced significant trauma during their lifetime, although it is often difficult to determine whether a client’s presentation is the result of complex trauma or other factors (e.g. ABI/TBI or mental health difficulties).

Children who come from neglectful or abusive backgrounds, which is relatively common among offending populations, typically experience feelings of worthlessness, apprehension, anger, fear, isolation and loneliness. These feelings can result in difficulty establishing and maintaining relationships, trusting others or engaging in meaningful and healthy affection with others.

Impacts of trauma:

• Emotional symptoms (anxiety, fear, nightmares, sadness, isolation, worthlessness, helplessness, guilt, shame, anger, sleep disturbances)
• Behavioural & cognitive symptoms (confusion, concentration difficulty, withdrawing from others, mistrust towards others, loss of interest in activities, avoidance)

Trauma informed care refers to services that are aware of and sensitive to the dynamics of trauma. Despite the prevalence of trauma in our society, many people and organisations who provide professional support often do not consider or recognise the impact of trauma, and therefore do not respond in a way which is sensitive to an individual’s experience.

In custodial settings particularly, individuals may experience identity disturbance, affect dysregulation, relationship difficulties and will often have several historical diagnoses (e.g. borderline personality disorder, intellectual disorder). Embedding a trauma-informed approach to care and facilitation is therefore highly important in the correctional context. Trauma informed practice recognises the significance of trauma to the individual, and its impact on their emotional, psychological and social wellbeing. If trauma is overlooked or not treated sensitively, there is a risk for harm or re-traumatisation to the individual and also reduces the efficacy of the current treatment.

Aims of trauma-informed practice:

• Build a sense of control and empowerment, allowing individuals to begin to heal and move forward from their past victimisation
• Creates a physically, emotionally and culturally safe environment for all involved, minimising the potential for further harm or re-traumatisation
• Assists individuals in developing pro-social and healthy ways to manage strong emotions

Five key principles of trauma informed practice:

Safety – Clinicians and clients both feel physically and psychologically safe.

Trustworthiness– Feelings of mistrust, particularly towards figures of authority, is common. So, treatment should be based on transparency and openness, with the goal of building trust and security.

Choice– Drawing from strength-based approaches, choice in treatment allows clients to bring control back into their lives. Whilst there is a limit to choice for mandated clients, clinicians should be mindful of opportunities to provide choice where possible to clients such as in appointment times, location, treatment goals, preferred treatment strategies etc.

Collaboration– Partnering with clients to understand their needs, fostering respect, efficacy and dignity. Collaboration also refers to service at an organisational level, where all policies and interactions with clients should be done so within a trauma-informed framework.

Empowerment – People who have experienced trauma may feel powerless and hopeless in their current situation. Allowing the client to take an active role in treatment based on their own strengths, can foster resiliency, recovery and healing.

Addressing trauma revealed during treatment:

• Address and validate the feelings and experiences of clients
• Acknowledge the client’s trauma directly and respond empathetically
• Avoid probing for too much detail regarding the trauma (bringing up strong feelings in an inappropriate setting can lead to re-traumatisation)
• Respect disclosures by clients (avoid minimising the significance of the experiences of clients)
• Encourage self-efficacy and empower individuals to control their present lives
• Encourage a hopeful and optimistic viewpoint of the future
• Be aware that a client’s previous experiences may influence their willingness to engage in treatment or a therapeutic alliance
• Help the client frame their challenges within the context of past victimisation

 

How to develop a beneficial therapeutic relationship:

• Approach all therapeutic relationships in a trauma-informed manner (regardless of whether the client presents themselves as having experienced trauma)
• Prioritise engagement and rapport building from the beginning of treatment (clients may try to re-create problematic relationship dynamics they are used to)
• Create a safe therapeutic environment for the client and yourself
• Be transparent, genuine, consistent and reliable
• Ensure you stay within your role and maintain boundaries (a client’s sense of urgency can lead clinicians to act in a way that goes beyond their role)
• Work through relationship ruptures (e.g. when clients attempt to sabotage the therapeutic relationship)
• Foster a calm environment in which the client can avoid stress and can access higher order functioning (e.g. use grounding/mindfulness techniques, encourage exercise)
• Try to predict periods of destabilisation and plan accordingly (this can help clients to feel contained)
• Be aware of how the treatment environment may affect clients (i.e. clients may be sensitive to sensory aspects of the room such as noise level, ability to see others or for others to see them)
• Practice self-care regularly (if you can’t regulate, you can’t help clients regulate)
• Access supervision regularly
• Ensure treatment is culturally safe (understand any factors that may influence the client’s needs/presentation)

 

Strategies for Safety

It is important to consider your safety when working with any client population, but in particular with forensic clients. This client group can present as agitated, unpredictable, substance affected, volatile, chaotic, guarded, manipulative and defensive, which can lead to displays of aggressive behavior including verbal aggression with the possibility of physical violence. Whilst incidents of physical violence are extremely uncommon, verbal aggression and generally “unpleasant presentations” occur from time to time and it is important to consider how you would manage these types of clients/situations and most importantly how to keep yourself safe when working with this population.

Factors contributing to client’s aggressive behaviour:

• Feeling powerless or helpless
• Feeling angry, frustrated or hostile
• Feeling hurt or rejected
• Feeling intimidated or threatened
• Blaming self or others
• Struggling or feeling overwhelmed
• Not wanting to engage in treatment (wanting a way out)
• Attempting to regain control: Conscious or unconscious attempts to manipulate
• Being overly sensitive or insensitive
• Being under the influence of drugs, medication or alcohol

Managing aggressive clients:

• If a client is agitated or aggressive during the session remain calm and adopt a neutral facial expression and keep your voice and tone calm and controlled.
• Allow space for the client – (both space to speak and physical space)
• Ensure others are out of harm’s way – you may need to take the client to another space away from others
• If the client is agitated/aggressive and says they are going to leave the session, allow them to leave, do not try to make them stay.
• If the client stands up, do not also stand up as this could escalate their behaviour.
• Never confront a client verbally or physically.
• Always inform your supervisor or a senior staff member if you encounter an aggressive client as the situation will need to be managed and you should access debriefing.
• You may also need to complete a “Critical Incident report”, ask your supervisor (or senior staff member) for guidance around this.
• If the session is being delivered towards the end of the day or after hours, make sure you leave the office with another staff member. Allow at least 20 minutes after session closure to leave the building – you can use this time to pack up, debrief and prepare for the next session.

 

DR LASSO technique

DR LASSO is a de-escalation technique with seven core principles. The technique can be useful in several settings, such as when interacting with aggressive clients.

Danger                        Assess risk and safety
Relocate                     Consider moving to another safe space

Listen                          Active listening, show empathy, be genuine
Ask                              Determine what the problem is, and what they need
Summarise                 Demonstrate your understanding, and validate their feelings

Set Out Scope             Explain what you can do and what they can do
Offer Options              Describe some options and the rationale for them

Staff and Client Safety

The following approaches are recommended for agencies to consider when delivering programs to forensic clients, to maximise safety:

Visible Staff Presence

In addition to the AOD worker, it is important that participants are aware that there are other people in the building. Ensure that there is at least one other staff member present for the duration of the session, such as a receptionist or another clinician, and that they are seen by clients upon arrival. This person is also then able to respond should an incident occur, such as notifying other staff or police if necessary. You may also consider starting after-hours programs at 4:30pm when there are more people around.

Building Security

Consideration should be given to controlling building access when programs are running, especially for after-hours programs. The entrance door may be kept locked if a staff member is available to let people in when they arrive (including police). However, it will also be important that an agitated client is able to leave the building quickly if necessary. Implementing access control equipment may be considered, allowing secure entry without impeding people from exiting the building.  Some agencies may consider installing CCTV cameras in public spaces such as carparks, building entrances, reception areas and corridors where clients have access.

Duress Alarms

The installation of duress alarms in reception, counselling rooms and group program spaces will ensure a timely response if a situation escalates, and provide a sense of safety to staff delivering programs.

Maintain Visibility

Whilst counselling sessions are running, ensure that the counselling space remains visible to people outside, by keeping windows free from obstructions and blinds etc, so that any incident can be observed by other staff.

Keep Others Informed

If you are aware that a client has a history of aggressive or challenging behaviour, advise reception in advance so they can be ready to respond. Also let other staff know of your whereabouts when the session is being delivered.

Minimise Exposure to Others

Keep the door closed (or locked) between the counselling areas and the general staffing area, to maximise the safety of other staff and to avoid exposing them to incidents. If an incident is occurring, ensure that any other clients who are in the waiting room are moved to a safe space away from risk and exposure to the incident.

Communicate with Local Police

It is valuable when working with forensic clients to build a relationship with the local police. Let them know that you are working with this cohort and the times you will be delivering programs, particularly after-hours. Police should be advised of the lay-out and access points to your building. This can help ensure a timely and appropriate response should an incident occur.

Ensure staff are familiar with risk-management processes

Making sure that all staff are familiar with your agency’s risk-management policies and procedures is crucial to ensuring an appropriate and consistent approach to incidents should they occur. Having a safe space where staff can retreat in case of an emergency and developing an evacuation drill will help should an incident occur.

Restrict client access to personal information

Protecting your personal details (such as home address or phone number) – E.g. through registering as a silent voter and by using an alias on social media. Social media websites often change their privacy settings and even if private, you can be found through friends of friends and sent a direct message without permission. You can block specific people on social media where they aren’t able to contact you at all- this is something you might consider doing (find your client and block them).

Remove potential weapons.

Don’t have anything that could be turned into a weapon in the room (e.g., stationery, scarves, lanyards etc.). Install chairs that cannot be easily thrown or used as a weapon.

Services for Forensic Clients

Ask Izzy

askizzy.org.au
Search for housing, food parcels, legal support, free community meals, health services, financial counselling, support & counselling in your area and specific to your needs.

Forensic Services

VACRO

1800 049 871
Range of support programs for individuals leaving prison & reintegrating into the community

Community Forensic Mental Health Service (Forensicare)

9947 2500
505 Hoddle Street Clifton Hill, VIC
Provides adult mental health services in Victoria for people involved in the criminal justice system, or who are at high risk of offending.

Melbourne City Mission

Melbournecitymission.org.au
9614 3688
Provides support for people who are homeless or at risk of homelessness, as well those recently released from prison.

Flat Out Inc.

Flat Out is a state-wide homelessness support and advocacy service for women who have contact with the criminal justice and/or prison system in Victoria. They provide individualised support for women to address homelessness, drug and alcohol treatment and a range of other support services.

Metal Health (general)

Beyondblue

1300 22 4636
Crisis support phone and online chat

Mensline

1300 858 858
Phone and online counselling for men

Lifeline

13 11 14
Crisis support phone and online chat

Suicide Call Back Service

1300 659 467
24/7 Counselling for anyone affected by suicide

The Salvation Army

1300 363 622
24/7 Telephone counselling service

QLife

1800 184 527
LGBTIQ counselling and referral service
Available 3pm – 12am, 7 days

Mental Health Advice Line

1300 60 60 24
24/7 Advice from nurse on-call

Gambler’s Help

1800 858 858
24/7 counselling and referral

Legal/Financial Services

Victorian Legal Aid

1300 792 387

Refugee and Immigration Legal Centre
9413 0100
Legal support for refugee and immigrants

Money Help

1800 007 007
Offers free, confidential and independent financial information for people experiencing financial difficulties or facing job loss

Centrelink

131 794
centrelink.gov.au
Range of payments and services to support you in an emergency or crisis situation

Family/Family Violence Services

Safe Steps Family Violence Response Centre

1800 015 188
24/7, free family violence response service

Victorian Centres Against Sexual Assault

1800 806 292
Free 24/7 crisis service for victims/survivors of sexual assault

Aboriginal Services

Timeout

1800 352 624
24/7 Indigenous Crisis Assessment and Referral Service

Victorian Aboriginal Health Service

132 660
Services such as mental health, drug & alcohol, counselling and primary health

Aboriginal Housing Victoria

9403 2100
vaghs.org.au
Narrandjeri House, 125-127 Scotchmer Street, North Fitzroy
Secures appropriate, affordable housing as a pathway to better lives and stronger communities.

Homeless Supports

Opening Doors (Housing Crisis Support)

1800 825 955
24/7 state-wide, toll-free number to speak with a housing and support worker

Northern Housing

1800 048 325
Housing and support services across Melbourne

North & West Homelessness Network (NWHN)

9689 2777
Provides access to support for people experiencing homelessness. Locations in Footscray, Sunshine, Melton & Werribee.

Mobile Laundry & Shower Services

Orange Sky

orangesky.org.au
Mobile laundry and shower service with locations around Australia including Melbourne, Melbourne South East and Geelong. Specific times and locations are available on the Orange Sky website.

One Voice

onevoice.org.au
1300 426 386
Melbourne-based shower and laundry van. Locations in Frankston, East Melbourne and Melbourne CBD.