In our last blog, we discussed the fact that the tragedy that occurred at an affordable housing program in Westerly was not an isolated incident. We listed a month by month accounting of murderous assaults and murder-suicides that have occurred in senior housing around the country, with at least one deadly incident occurring monthly in 2019. These incidents did not include a list of assaultive behaviors, sexual assaults or other forms of acting out. The bottom line is that violence in senior housing and affordable housing programs for seniors and the disabled is a problem that continues to grow.
We also discussed the fact that staff at some of these programs are assaulted and injured at higher rates than other workplaces. But these dangers are not always from within as there exist external threats as well.
In this week’s blog, we are going to look at these external threats, some red flags indicating a potentially dangerous resident, some examples of problem residents, and using a biopsychosocial assessment to assist in screening for the best possible resident.
Last week, we detailed the plethora of internal threats present for staff and other residents of these facilities, but there are also a number of external threats.
External Threats to Staff
Assaults on Staff or residents – In assisted living or nursing homes, family visits are a welcome and necessary part of providing the resident with autonomy and assists in normalizing the transition into a new living environment. However, family members can create problems as well. There are a plethora of reports of domestic violence situations between residents and family members where violence is the end result. In these cases, staff are the first line of defense and must intervene. Of course, calling the police or facility security is the recommended policy, but one of the old axioms we used at our treatment facilities was “when seconds count, police are just minutes away”. You get my point. Staff must have training to address an immediate crisis. But it’s not just domestic family violence that occurs in these facilities. Often, family members become extremely upset at a perceived lack of caring by program staff leading to emotionally filled interactions that turn into arguments and can lead to assaults. In affordable housing for seniors and the disabled, more freedom exists meaning that often residents have visitors from the outside who are not always there with the best of intentions and may bring in unwanted items like drugs, weapons, etc. The risks in affordable housing environments are much higher than in most assisted living and nursing settings for obvious reasons.
Theft and Exploitation – while visitors are a wonderful thing, too many outsiders in these settings can leave residents vulnerable to acts of theft and exploitation. When I say visitors, I am including other residents as well. Although such actions can occur in any senior housing situation and do, affordable housing programs are more prone to this given the level of freedom and some of the backgrounds of those living there. Staff must engage residents and teach them the importance of safeguarding their documents and valuables.
Armed Intruders – an armed intruder or active shooter, as in the Westerly incident, can push the ethical thinking of program staff. The normal training that is taught consists of Run, Hide, Fight. But many staff and healthcare providers can not do this given the limitations of those they care for who are unable to run and hide, leaving clients and staff vulnerable to such acts of violence. When training for such possibilities, it must be taken into consideration that the "standard" training may not work in these settings.
Can We Predict Violence?
This is the million-dollar question. Theoretically, we can predict what types of people and personalities are prone to violence, but can we predict violence with one hundred percent certainty, unfortunately not. But what we do know is that certain personality types can create havoc within congregate living situations and just one person can upset the balance of an otherwise healthy community.
I have had spirited discussions with other administrators that a single individual cannot damage a strong and vibrant group of people but through my own experiences and knowledge of the experiences of others, I certainly beg to differ. In fact, just one individual terrorized an entire town and it's people some forty years ago until someone murdered him in a crime that remains unsolved to this day. That town is Skidmore, Oklahoma.
The Skidmore Bully
His name was Ken McElroy, a 47-year-old bully who kept the town of Skidmore living in terror until someone shot him as he sat in his pick up truck outside a local bar in 1981. McElroy was a problem since his teen years, a high school dropout who drank heavily and stole from the town's citizens, seemingly at will. He had been married three times by his early 40s and his last wife, named Trena, was impregnated by him at the age of 14.
McElroy was known as a sweet talker and master manipulator, if that didn't work, he would resort to intimidation. Local police charged him with crimes ranging from theft to assault but nothing seemed to stick. In one case, a farmer caught him leaving his property with stolen merchandise but withdrew the charges after McElroy smashed his face with the butt of a rifle.
Even police were intimidated by McElroy. A Missouri State Trooper named Dan Boyer related that one night he pulled over the town bully for speeding with his truck. Boyer stated that "just the way he looked at me scared me to death." Boyer then stated that a few days later outside his home, a pickup truck fitting the one owned by McElroy, drove up and down outside his house and then parked for a good period of time, just waiting -- and intimidating a trained law enforcement officer.
In 1980, McElroy was involved in an argument at a local grocery store after trying to take a candy bar without paying for it. When the owner's young daughter tried to stop him, he became physical with her. When the owner came from the back, McElroy shot him in the neck. He was arrested, charged with assault.
A short time after, the arresting officer's wife was on her way to church when McElroy stalked her, cut her off and "put a shotgun in my face." She was able to get away but he followed her until police showed up and scared him off.
But McElroy wasn't done with the store owner he shot. He continued to stalk the victim and sat outside the store on a daily basis, saying nothing but terrorizing the family and the citizens to a point that the store could no longer maintain business. During the assault trial, McElroy testified that the owner attacked him with a knife and he acted in self-defense. Although he was found guilty of second-degree assault and sentenced to two years in prison, he was released on bond, pending appeal. He was shot to death a few days later.
As angry as the townspeople were about McElroy, they were even angrier at the police for not keeping them safe and resentment boiled over when they began investigating the murder.
Trooper Boyer remembers one of the town officials confronting him during the investigation, “what are you doing here?” Boyer said he was asked. “Why are you doing this now? You know what he was like. You know how he oppressed and threatened us. I don’t believe you’re coming now—after we needed your help all this time.”
The point of the story is that if an entire town can be affected by one person, a senior living community surely can. And as in any congregate living setting, the staff's inability to keep the residents safe will result in resentment, anger, and chaos.
In the case of Ken McElroy, it appears that he meets the criteria for a diagnosis of an anti-social personality disorder. As a clinician and administrator, it was certain personality types that concerned me the most when decisions were being made for admission into housing or other programming. As a result, we tried to focus on four key pieces of the applicant and be as thorough as possible in gathering the information we needed to make a decision.
The Four Core Categories
1. Poor Impulse Control
There were always two main concerns here – did the person react disproportionally to situations out of their control and did this reaction occur in the absence of concern for the consequences involved. An example of this would be someone with a drug addiction or gambling addiction who spent their social security check without any concern for the rent, utilities or food. The inability to postpone gratification or remove a problem so as not to create anxiety for them is a telltale sign of a risky resident.
2. Emotional Instability
We see this in small children who have tantrums over the most innocuous things, and we chalk it up to childlike behaviors, but what happens if it is an adult, especially when it comes to anger and anxiety? These adults let their negative thoughts and feelings control their behaviors. They often lack the ability to tolerate social settings and are not emotionally flexible enough to delay spontaneous reactions.
These are people who act out in settings over the smallest slights or when a desired outcome from a behavior is not achieved. These are the people who become easily frustrated, slam and stomp around or become loud. Unfortunately, others tend to give in to them to avoid such acting out and only serve to reinforce future inappropriate activities (think about one of the most common rule violations in housing, smoking. Staff see a resident smoking and then look the other way. When another staff confronts the behavior, there is a reaction often out of context to the situation because he had "gotten away with it" before). If you suspect this during an interview, challenge them and watch their reaction. If they act frustrated, exhibit a negative or aggressive body language, or even become angry, there may be a problem.
3. Narcissistic Presentation/History
A narcissist has an inflated sense of their own importance and place in the world. They crave attention and desire admiration while lacking empathy for others. However, despite this façade of a highly confident person lies a fragile self-worth that boils and bursts at the slightest criticism. Research has shown a correlation between insult and narcissism that leads to high levels of aggression. People with narcissistic personality disorder or traits may be generally unhappy and disappointed when they're not given the special favors or admiration they believe they deserve.
4. The Presence of Paranoid Thinking
Individuals who exhibit constitutional paranoia do not normally confide in other people and frequently misread others, redefining innocuous statements and behavior as malevolent. Because of this, they may view themselves as victims which they use to justify acting out and abuse towards others. For instance, a group of residents may be laughing and innocently look over at such an individual, it will be misinterpreted and trigger a response which could be problematic.
When any of these four concerns are present with someone who has a history of alcohol or drug abuse, frequent homeless episodes, generalized anxiety or other mental health issues, has been incarcerated or has a history of multiple arrests, then it is advisable to dig deeper into their past. They are a problem waiting to happen.
Let me share with you a few true stories of individuals who were not vetted properly accompanied by the failings of staff boundaries and refusing to follow policy. The presence of these residents led to chaos until they were removed from the community. In other words, we learned the hard way.
Ron the Perfect Resident
Ron came in more than willing to help the staff, talking up the fact that he had a bachelor’s degree in Psychology. He offered to assist staff in any way possible, from co-facilitating groups to volunteering to assist in cleanup after activities at the program. He would relish being allowed to sit in staff offices, often giving his "clinical opinion" on the issues about other residents.
Ron was a tall man with a deep voice and his presentation was one of extreme confidence and as a result, was capable of intimidating not only other residents but many staff as well. This program was a non-smoking residence and doors were secured after 10 pm, with access only given through a buzzer controlled by program staff. Smoking was permitted outside until 10 pm, but after activities, leaving the building was not permitted. Staff who smoked, however, would go outside and smoke before writing notes and closing out their shifts.
Ron, who had volunteered, began sharing in the staff 'after hour' smokes. It didn’t take long for some of the staff to share personal stories with Ron, something that was considered a boundary violation, and he soaked it all in. Ron soon began smoking in his room and when confronted by staff, he would remind them of just how much help he is to them and a little smoke by himself "isn’t such a bad thing, after all." And if staff objected to this, Ron had a way of raising his voice and standing over them that forced staff to swallow hard and walk away.
As time went on, Ron began to violate other rules and exploit staff boundaries more and more. Among residents, he was "borrowing" their ATM cards and buying coffee, food and even clothing. When they objected, he would attempt to intimidate them either with his physical presence or by the knowledge he had about them, threatening to take this information to the administration.
When I would confront him, it was clear he knew that I was aware of his behavior but would often ask me "name what I am doing wrong", which I couldn't as he always knew just where to stop. I then decided to assign him to a seasoned social worker named Fran.
Fran did not buy into Ron’s 'charitable' offerings and told me about the things she had heard, including the manipulation of staff and residents. Fran had worked in the prison system prior to taking this position and was considered "a tough cookie". A plan was made with her where I would sit down with staff and discuss the boundary issues and she would confront Ron and remind him of his role at the facility, thereby removing his 'power'.
During the first discussion, Fran told me that Ron became visibly angry when she challenged him and took away his staff "assistant" role, but he managed to hold his temper. But, “his act is wearing thin,” Fran told me. Several days later, she came to my office in tears.
Earlier in the evening, Ron went into Fran’s office and said to her, “There’s a good movie on tonight about a social worker who created problems for a resident at a housing program and he kills her. All she had to do was leave him alone but she got what was coming to her.” When Fran asked him if he was threatening her, he stated, “No, I’m talking about a movie.” He left her office laughing.
Two nights later, Ron knocked on her office door and gave her a piece of paper he said he "found" by the resident computer. When Fran read the paper, it had her address on it and the names of her children. "People shouldn't leave this information around, you never know if some nut might get it and decide to hurt these poor people. Do you know who they are, Fran?" he said laughing and left the office.
Unfortunate for Ron, he made the mistake of signing in to the computer using his password and the searching that was done to find her personal information came up under his name. He was discharged immediately.
After more digging was done into his background, it turned out that he had been arrested for sexual assault on more than one occasion, but the charges had been dropped or lowered to lesser offenses.
In following up on this, it appeared Ron was telling other male residents how to succeed at "picking up women". He would brag about his “ability” to pick up women whenever he wanted, "making the cost of my degree in psychology worth it," he would brag. He told them that the best place to find “the easy woman” was at the bookstore. He stated he would watch which women went to the self-help section of the store and he would make his move. "It never failed, they are the most vulnerable" he shared.
Individuals like Ron always look for the weakest link, whether in the community or among staff. Once found, they will use them to whatever means is necessary.
Carl, the 'Loving Grandpa'
In another case, a male resident named Carl befriended a new staff member, “sharing” his history with him including his deep love for his grandchildren. At one point, Carl told the staff that his grandchild’s birthday was coming but because he was on a fixed income and spent all his money on medication, he had no money to buy him a present. He convinced the staff to buy a stereo system that he had in his room, "a very good stereo, but my grandson is more important right now."
Such activity was against program policy, but the new staff person was so smitten by Carl's story that "bending the policy" so he could buy his grandson a gift "wasn't the worst thing in the world." Within a week, it was discovered that the stereo system that was in Carl's possession and had been sold to the staff had been stolen the previous week from Carl’s brother and sister in law and, by the way, he had no grandchildren.
Apparently Carl had quite a cottage industry going with other residents, often offering to walk to the local donut shop to buy coffee for them with their debit card and skimming off a few dollars each time. Once he was found out, the residents were too afraid of Carl to tell staff about the theft and chose instead to isolate in their rooms and avoid activities.
Gretchen, the Appreciative Thief
We had strict rules against transporting residents in personal cars for reasons of liability and boundary concerns. Gretchen was a sweet-talking, late-middle-aged woman on SSI with a history of drug addiction and prostitution who had a way of endearing herself to program staff. One morning, a staff member was leaving work when Gretchen approached her and asked for a ride to a medical appointment because "it looked like rain." Even though the staff knew it was a policy violation, she felt sorry for her given the weather (Gretchen chose to walk and had the money for a bus).
When the staff agreed to do so, Gretchen jumped in the car and expressed her thanks over and over. Sitting in the front seat, Gretchen nonchalantly opened up the glove compartment and deposited her keys inside. Once they got to the doctor's office, Gretchen opened the glovebox again and rummaged through it until she found her keys. Several days later, while the staff was a work, her house was broken into and several valuable electronic items and pieces of jewelry were stolen.
A few days after that, Gretchen was seen wearing a ring that belonged to the staff. What Gretchen did was get the staff's address off her registration when "looking" for her keys in the glove box. Because the staff had shared personal information with Gretchen, including the fact that she lived alone, she was a perfect target for someone like her. When the police were called, she threatened the staff with violence, stating, "if I get locked up, I know people who will kill your ass!"
These are extreme but true examples of what can happen when boundaries are violated and policies are ignored. But there are warning signs of a potential problem within the residence should someone "slip through" the screening process. In these cases, immediate interventions need to occur, both clinically and behaviorally.
Does the person(in the absence of a dementia diagnosis):
Attempt to intimidate staff either overt (outright forcefulness) or subtle (using knowledge or previous experiences)
Have a bossy style and tone when speaking to others
Appear to be very critical of others and things
Complain about others in a dramatic and outraged style, saying they are being “picked on” (seeing themselves as victims)
Show little or no remorse
Lead others in turning public spaces into private areas, like gang behavior of “territory”
Form cliques and exclude others from participating in positive social events and activities
Harass others, make mean comments, racial slurs, insults, gossip, ethnic slurs, body shaming
Physically intimidate or verbally abuse others.
While administrators work on addressing the disruptive individual, staff can assist other residents by:
Providing groups and skill development to assist them in standing up for themselves
Encourage and support them to come forward when targeted
Foster their self-worth and dignity through unconditional self-acceptance
Provide de-escalation skill training
Provide Communications skill training
Encourage them to continue to report and provide reinforcement when they do ss
Teach Coping Techniques
And for staff and administrators, focus on the following:
Prevent intimidating or inappropriate behaviors through education and training and stay connected with what’s happening in the milieu or community
Create, implement and disseminate a zero-tolerance policy on intimidating or inappropriate behaviors and safe ways for targets to report it
Confront the individual(s) involved and inform them that their behaviors will have consequences – and follow up
If anyone sees aggressive or intimidating behaviors, it must be confronted and reported
Offer support to the target
All staff must be on the same page when implementing a behavioral plan
The administration must support staff and residents when they report these behaviors – no matter how minor it may seem
There is one truth here, we can never stop every person who has evil intent, but we can prepare ourselves to be ready to respond to such a situation. Following policy, observing boundaries, being aware of the environment and the residents, abiding by security procedures and appropriate screening of applicants can go a long way in avoiding the kind of violence that took the life of a staff member in Westerly and in keeping ourselves and residents safe.
Below is an example of a biopsychosocial assessment that covers all the areas of concern. Please click on the form to download a copy.