Managing Difficult Managing Difficult Behaviors of Clients with Behaviors of Clients with

HIV and Mental IllnessHIV and Mental IllnessColumbia University HIV Mental Health Training Project,Columbia University HIV Mental Health Training Project,

a regional resource for thea regional resource for the

NY/NJ AIDS Education and Training CenterNY/NJ AIDS Education and Training Center

The more you know, the more The more you know, the more prepared you can beprepared you can be

1.1. Criminal HistoryCriminal History

2.2. History of Past Violence (clients with History of Past Violence (clients with dementia sometimes have no dementia sometimes have no history)history)

3.3. Substance Abuse HistorySubstance Abuse History

Staying Safe in Unsafe PlacesStaying Safe in Unsafe Places

Often in this work we must do things Often in this work we must do things which are unusual or go to which are unusual or go to potentially dangerous places.potentially dangerous places.

It is important to think out in It is important to think out in advance how you can both meet the advance how you can both meet the needs of your client and avoid needs of your client and avoid putting yourself in danger.putting yourself in danger.

Be aware of the environment Be aware of the environment in which you workin which you work

Is there someone in an adjacent office you Is there someone in an adjacent office you can contact in an emergency?can contact in an emergency?

If you are in an individual’s room, know who If you are in an individual’s room, know who you can call for help.you can call for help.

You should be able to get out of a room in You should be able to get out of a room in an emergency. Is your desk or chair close to an emergency. Is your desk or chair close to the door or are you pinned in? Are you the door or are you pinned in? Are you closer to the door than the client?closer to the door than the client?

Don’t go into a closed room with a high-risk Don’t go into a closed room with a high-risk client.client.

Responding to Threatening Responding to Threatening BehaviorBehavior

In talking with clients, use your instincts. In talking with clients, use your instincts. If you feel threatened, have someone sit If you feel threatened, have someone sit in with you, keep your door open, in with you, keep your door open, maintain a distance, or terminate the maintain a distance, or terminate the interview immediately.interview immediately.

Use a lot of people to calm clients down Use a lot of people to calm clients down (sometimes a show of force enables a (sometimes a show of force enables a client to muster reserves of self-control). client to muster reserves of self-control). Don’t feel “you are ganging up.” Don’t feel “you are ganging up.”

Responding to Threatening Responding to Threatening BehaviorBehavior

Be aware of your own emotions, often not Be aware of your own emotions, often not an easy task .an easy task .

Be appropriate at all times. The client is Be appropriate at all times. The client is the one who is sick. If you are feeling the one who is sick. If you are feeling afraid, you should remove yourself from afraid, you should remove yourself from the situation.the situation.

Remove other clients and visitors from the Remove other clients and visitors from the room where agitated client is.room where agitated client is.

When on a home visit, never try to deal When on a home visit, never try to deal with a threatening client, just leave.with a threatening client, just leave.

Substance Use and Substance Use and Threatening BehaviorThreatening Behavior

Harm reduction does not mean you Harm reduction does not mean you can come to your appointment drunk can come to your appointment drunk as a skunk.as a skunk.

Clear policies about substance use Clear policies about substance use and/or intoxication at your program and/or intoxication at your program site may help prevent incidents.site may help prevent incidents.

Cognitive Impairment and Cognitive Impairment and Threatening BehaviorThreatening Behavior

Advancing HIV illness is associated Advancing HIV illness is associated with cognitive impairment.with cognitive impairment.

Confusion is frightening for the client Confusion is frightening for the client and can result in agitated behavior.and can result in agitated behavior.

Providing reassurance and Providing reassurance and orientation (date, time, place, your orientation (date, time, place, your role with the client) are helpful and role with the client) are helpful and calming.calming.

Mental Illness and Threatening Mental Illness and Threatening BehaviorBehavior

Most people with mental illness who are Most people with mental illness who are not using substances are not interested in not using substances are not interested in hurting anybody. Threatening behavior hurting anybody. Threatening behavior among people with mental illness is often among people with mental illness is often a response to feeling threatened.a response to feeling threatened.

Do not argue about the clients’ voices or Do not argue about the clients’ voices or delusions.delusions.

Psychotic clients do not react well to Psychotic clients do not react well to confrontational interventions. Instead, confrontational interventions. Instead, allow for some supervised quiet time.allow for some supervised quiet time.

After an InterventionAfter an Intervention

Clients usually appreciate efforts to Clients usually appreciate efforts to calm them down. Later, they often calm them down. Later, they often thank you.thank you.

Encourage your agency to create a Encourage your agency to create a neutral forum where threatening neutral forum where threatening behavior can be openly discussed.behavior can be openly discussed.

Avoid blame.Avoid blame. Report and review all incidents in Report and review all incidents in

order to improve future responses.order to improve future responses.

Be Aware of Non-Verbal CuesBe Aware of Non-Verbal Cues

Signs of Physical Agitation – e.g. Signs of Physical Agitation – e.g. pacingpacing

Angry Facial ExpressionAngry Facial Expression Staring BehaviorStaring Behavior Clenched FistsClenched Fists