Managing Difficult Behaviors of Clients with HIV and Mental Illness

1. Managing Difficult Behaviors of Clients with HIV and Mental Illness Columbia University HIV Mental Health Training Project, a regional resource for the NY/NJ AIDS Education and Training Center

2. The more you know, the more prepared you can be • Criminal History • History of Past Violence (clients with dementia sometimes have no history) • Substance Abuse History

3. Staying Safe in Unsafe Places • Often in this work we must do things which are unusual or go to potentially dangerous places. • It is important to think out in advance how you can both meet the needs of your client and avoid putting yourself in danger.

4. Be aware of the environment in which you work • Is there someone in an adjacent office you can contact in an emergency? • If you are in an individual’s room, know who you can call for help. • You should be able to get out of a room in an emergency. Is your desk or chair close to the door or are you pinned in? Are you closer to the door than the client? • Don’t go into a closed room with a high-risk client.

5. Responding to Threatening Behavior • In talking with clients, use your instincts. If you feel threatened, have someone sit in with you, keep your door open, maintain a distance, or terminate the interview immediately. • Use a lot of people to calm clients down (sometimes a show of force enables a client to muster reserves of self-control). Don’t feel “you are ganging up.”

6. Responding to Threatening Behavior • Be aware of your own emotions, often not an easy task . • Be appropriate at all times. The client is the one who is sick. If you are feeling afraid, you should remove yourself from the situation. • Remove other clients and visitors from the room where agitated client is. • When on a home visit, never try to deal with a threatening client, just leave.

7. Substance Use and Threatening Behavior • Harm reduction does not mean you can come to your appointment drunk as a skunk. • Clear policies about substance use and/or intoxication at your program site may help prevent incidents.

8. Cognitive Impairment and Threatening Behavior • Advancing HIV illness is associated with cognitive impairment. • Confusion is frightening for the client and can result in agitated behavior. • Providing reassurance and orientation (date, time, place, your role with the client) are helpful and calming.

9. Mental Illness and Threatening Behavior • Most people with mental illness who are not using substances are not interested in hurting anybody. Threatening behavior among people with mental illness is often a response to feeling threatened. • Do not argue about the clients’ voices or delusions. • Psychotic clients do not react well to confrontational interventions. Instead, allow for some supervised quiet time.

10. After an Intervention • Clients usually appreciate efforts to calm them down. Later, they often thank you. • Encourage your agency to create a neutral forum where threatening behavior can be openly discussed. • Avoid blame. • Report and review all incidents in order to improve future responses.

11. Be Aware of Non-Verbal Cues • Signs of Physical Agitation – e.g. pacing • Angry Facial Expression • Staring Behavior • Clenched Fists