Who’s Calling?

If there is any chance that somebody in the residence that you are going to visit speaks a language that you do not understand, it is prudent to have an interpreter along to assist. This may not seem necessary if the client speaks your language, but in times of stress and crisis, persons often resort to their language of origin. As well, the client who seems helpful and cooperative could pass instructions to another party in a language you don’t understand that may compromise your safety without you being aware of it. I recall an incident involving a pair of workers who attended at a residence to apprehend an Asian child from the child’s grandmother’s residence. When the workers arrived, the grandmother presented as cooperative and friendly. She excused herself to conduct a telephone conversation in a foreign language. She did this within sight and hearing of the workers, but as they did not speak the grandmother’s language they did not realize that what she was really doing was phoning the child’s father, a gang member, advising him to intervene. Just as the workers were getting into their car with the child several car loads of gang members armed with baseball bats pulled up. The workers were boxed in and the gang members smashed out the windows of their car. Fortunately the workers had a cellular phone and called 911. As luck would have it, they were only a few blocks from the police station and there were police units available there.  Police arrived quickly and arrested these parties just as they were climbing in the windows of the worker’s car. Fortunately these workers escaped without injury, but they were traumatized for weeks afterwards. 

If these workers had thought to take an interpreter with them in the first place, they may have escaped without incident. I recall another incident in which a client was overheard by a court interpreter. The client was threatening to “wait outside and do something to that worker.” The worker was able to notify the court sheriffs to deal with this situation.

Charles Ennis

Inter-Agency Approach to Dealing with Mentally Disordered People in the Community

Today I received a comment on my blog “Dealing Safely With Emotionally Disturbed People” from Frank, who wrote:

“You will see on my link that there is a very dangerous woman who is loose in our town who has severe mental illness. She has jumped people, stabbed people, threatened her mother, but she still manages to sneak by the cops and denies treatment. Right now she is homeless and could be anywhere hiding out, ready to pick fights with people. I have posted as many flyers, video warnings, what else can I do? The cops can’t do anything.”

I am surprised to hear that the police can’t deal with this problem. Dealing with mentally disordered people in the community is an issue all law enforcement agencies face. So I thought that I’d mention two systems developed by police to deal with such situations. First of all, here are some statistics:

 

Approximately 5% of the US population has a serious mental illness(1). The US Department of Justice reports that about 16% of the population in prison or jail has a mental illness(2). A study conducted in New York State found that men involved in the public mental health system over a five-year period were four times as likely to be incarcerated as men in the general population; for women the ratio was six to one(3).  The Los Angeles County Jail, the Cook County Jail (Chicago) and Riker’s Island (New York City) each hold more people with mental illness on any given day than any hospital in the United States(4). Inmates with mental illness in state prison were 2.5 times as likely to have been homeless in the year preceding their arrest than inmates without a mental illness(5).

 

Given the enormity of the problem, almost half of the states in the US have established special commissions or task forces to look into some aspect of their mental health systems in the last four years(6). Legislation calling for the establishment of such bodies has been introduced in an additional five states. Almost half of these commissions are explicitly charged with investigating the criminalization of mental illness(7). One of the approaches is for law enforcement agencies to enter into cooperative efforts with mental health treatment facilities.

 

One effective model for dealing with this situation was developed by the Memphis Police Department.  They found that their officers were getting stuck for 4-6 hours at the medical center for mental health admissions. That’s enough to discourage any police officer from becoming involved in mental health investigations. Once Memphis implemented their Crisis Intervention Team (CIT) model, these hospital waits were cut down to 15 minutes. The CIT model has the police agency train specially designated patrol officers to respond to mental health issues, and uses them to respond to calls involving these issues. Shortly after the CIT implementation, Memphis discovered that injuries suffered by individuals with mental illness who got into violent confrontations with police decreased by nearly 40%(8). The Albuquerque PD, which also adopted the CIT model, reports that there was a reduction of 10% in the number of mentally ill going to jail with whom their police had contact, and they were able to decrease using their SWAT team by 58%. Injuries were reduced to just over 1%(9).

 

The police department that I worked for, Vancouver PD, created the other response model in 1977. It started as an informal arrangement involving front line community mental health workers using pagers to provide an after-hours service to meet the needs of the community and police. This eventually evolved into the Vancouver Mental Health Emergency Services (MHES) unit that I worked for. In 1984 this was expanded on a trial basis as a partnership between MHES (now part of the Vancouver Coastal Health Authority) and the Vancouver Police Department. Unlike the Memphis Police Department’s CIT model, VPD and MHES created a partnership consisting of a psychiatric nurse teamed up with a police officer in a unit called Car 87. This partnership proved very successful and was formalized in 1987. MHES/Car 87 has access to an on-call physician available for consultation or call out for on-site assessments. 

 

The goal of MHES/Car 87 is to provide rapid response to mental health emergencies while minimizing admissions to hospital emergency departments. The MHES/Car 87 program aims to provide the least intrusive resolution to an emergency while maintaining the safety of mentally ill persons and the public. Our approach is to treat people with mental illnesses within their own community. Early intervention often reduces unnecessary admissions to hospital and can lead to a better over all prognosis for the course of a person’s mental illness. In 2002 MHES logged approximately 13,000 calls, leading to approximately 1,850 outreach calls, resulting in 382 hospitalizations. 

 

The current Vancouver MHES program includes a 24-hour crisis line, a geriatric nursing team, and MHES response for day shift and afternoon shift 7 days a week.

 

The strength of this unique inter-agency collaboration comes from the ability to share information between the two agencies and the way in which the legislated powers of the police officer and nurse/physician complement one another. Car 87 vehicles contain all of the special equipment (first aid kit, medical bag, medications, protective clothing, masks and goggles, WRAP restraining device, crime scene tape, etc.) necessary for them to perform their psychiatric assessments and apprehensions. The Car 87 nurse is equipped with body armor, an identification jacket marked “Nurse”, a portable radio and spare keys for the police vehicle. This permits the nurse to communicate in emergency situations and allows the nurse to drive the police car to hospital when the police officer is required to escort an apprehended client to hospital in the ambulance. 

 

The role of the Car 87 partnership is to determine the risk associated with apparent mental disorders and provide the most appropriate intervention. The police officer and nurse partnership in MHES/Car 87 works to provide the least intrusive resolution to a mental health emergency while maintaining the safety and rights of mentally ill persons and the public. The police officer assigned to Car 87 is there to exercise their authority under the Mental Health Act, conduct criminal investigations (if applicable), and to manage violence. The psychiatric nurse is there to do psychiatric assessments, interpret the mental health collateral information and provide liaison with the on-call psychiatrist. This partnership determines the most appropriate course of action for each mental health call. 

 

The Car 87 police officer has the authority under the Mental Health Act to apprehend people suffering from an obvious mental disorder who are endangering themselves or others. This is often the easiest way to get a mentally ill person into treatment.  The police officer has legal authority to force entry to a residence in emergency situations. Of course this officer has access to force options and resources to adequately contain and safely apprehend unstable and violent clients. 

 

The nurse assigned to Car 87 is responsible for conducting mental health and medical assessments, and acts as a resource to other police officers with regards to mental health issues. The nurse in Car 87 has access to an on-call psychiatrist who can attend to assess the client and certify them if necessary. As the Car 87 team has basic medical equipment and some medications with them, it is also possible for the nurse to consult with the on-call physician and stabilize the client on scene by administering medications. Thus in some cases it is not necessary to bring the client into a medical facility for immediate treatment. Follow up with the client’s Mental Health Team can be conducted the following day instead.

 

In the case of a disagreement between the police officer in Car 87 and the MHES nurse assigned to the car over the proper course of action to deal with a particular mental health assessment, they can consult with the duty doctor as to the best course of action.

 

Car 87 responds to requests for service from dispatch or police units in the field. Police units encountering people possibly suffering from mental illness in the course of their duties will forward reports electronically to Car 87 for review and possible follow up. The local Mental Health Teams forward alerts on clients of concern to them to Car 87 as well. This allows the Car 87 team to come up with a tentative action plan at the beginning of their shift. The police officer and nurse enter their reports electronically in their respective systems at the end of shift so that the agencies referring the calls can see what action has been taken the following day. This is also useful in that some mentally ill people tend to be paranoid and litigious: proper documentation makes such situations easier to deal with.

 

Through such inter-agency cooperation problems with mentally disordered individuals can be identified and addressed quickly, leading to a better prognosis for treatment. 

 

1) R. C. Kessler et al., “A Methodology for Estimating the 12-Month Prevalence of Serious Mental Illness,” In Mental Health United States 1999, edited by R.W. Manderscheid and M.J. Henderson, Rockville, MD, Center for Mental Health Services

2)  Paula.M. Ditton, Mental Health Treatment of Inmates and Probationers, Washington DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, July 1999.

3)  Judith F. Cox, Pamela C. Morschauser, Steven Banks, James L. Stone, “A Five-Year Population Study of Persons Involved in the Mental Health and Local Correctional Systems,” Journal of Behavioral Health Services & Research 28:2, May 2001, pp. 177-87.

4)  E. Fuller Torrey, “Reinventing Mental Health Care,” City Journal 9:4, Autumn 1999.

5)  Ditton, Mental Health and Treatment.

6)  See http://www.csgeast.org/programs/criminal_justice/statewide_commissions.htm

7)  Ibid.

8)  B. Vickers, “Memphis, Tennessee Police Department’s Crisis Intervention Team,” Bulletin from the Field, Practitioner Perspectives, U.S. Department of Justice, Bureau of Justice Assistance, Available at: www.ncjrs.org/pdffiles1/bja/182501.pdf.

9)  Ibid.

Dealing With Stalkers

Linda, the creator of the Fried Social Worker Blog wrote to me asking:  “Do you have any suggestions for social workers who are concerned about clients stalking them? A few days ago a colleague was telling me of her experience of being stalked by an ex-client. I started searching the web for good resources and most of the stuff out there is for victims of domestic violence, not the practitioners who work with them. It occurs to me that in the increased dialogue about social worker safety these days, stalking is an issue that’s not being addressed.”

 

I know that this is a major issue for a lot of people.  It will be no surprise to social workers that according to the Stalking Resource Center, more than one million women and 400,000 men are stalked annually in the US.  The average length of stalking is 1.3 years, although most situations last about a month. 

 

First of all, treat all stalking as a serious and legitimate threat. Involve the police and your employer right away so that they can support you.  Get the police to attach a premise history to your home and work address.  Modern CAD (Computer Assisted Dispatch) systems automatically display hazards and histories of addresses to call takers and dispatchers:  this means that if you call in and can’t say anything, the CAD will automatically list the history attached to your address.  This allows the call taker and the dispatcher to instantly see that it is you calling and that you’re having a problem with a stalker, listing his/her particulars and the address history.  This will help them to respond swiftly and appropriately even if you are unable to tell them what is happening.

 

Ensure your home phone number is unlisted with your local phone provider.  Program 911 on your cell phone to speed up emergency response.  Remember when calling 911 to always give your address first.  That way, if the police dispatcher knows nothing else, at least they will know where to send their police units.  Unlike land lines, cellular phone calls do not reveal your exact location to the police dispatcher.  All that the call taker and dispatcher sees on their screen is a display showing the location of the repeater tower the signal is coming in to and the azimuth that it is coming from.  In the US, cellular phone providers are now including a GPS locator in cell phones that helps the police narrow down your location, even if it doesn’t provide your exact location.  If you are using VOIP as a phone provider, be aware that the address that is displayed to the police dispatch is always your home phone location.  If you are using VOIP to call 911 from anywhere else you need to either temporarily reprogram the location or make sure that you tell the 911 operator where you really are.  Otherwise the police will be responding to your home address even if that isn’t where you actually are.

 

When you find yourself plunged into a crisis situation, you will fall back on whatever you have planned and/or rehearsed.  If you don’t plan for contingencies, then when things suddenly get ugly you may fall into a basic “deer in the headlights” response that isn’t a safe or effective response to the situation.  Developing safety and escape plans will help you to overcome this.  Develop and implement a safety plan which outlines to your friends and employer what you plan to do if you have to leave your home in an emergency.  Plan escape routes from your home and office and rehearse them.  Select safe destinations that you can use in emergency situations and have more than one.  Advise your friends and employer where these safe havens are located.  This will help you stay in control during an escape. 

 

Put together a “ready bag” at home packed with all of your important documents (driver’s license and registration, birth certificates, social security/SIN cards, insurance papers, extra cash, address book, prescription medications, spare clothing, cell phone, etc).  Keep it hidden in a place where you can access it quickly.  You could also leave extra money, spare keys and copies of important documents at your safe havens with people that you trust.

 

Give your co-workers, friends and family a “code word” that you can use to let them know that you need immediate assistance.  Sometimes it is difficult to talk openly on the phone in front of the abuser and you’ll want a way to tell them you’re in trouble without tipping off the stalker who is listening.  A code that my social worker and nursing partners used in the field to indicate to me and one another that we had spotted a hazard and were preparing to escape/respond was to start referring to one another by our surnames instead of our given names as we usually did.  This isn’t obvious to listening suspects and could be a useful clue to your office worker, friend or family member on the other end of the phone that you need the police immediately.

 

When you leave the office, make sure that they know where you are going and when you expect to return.  Tell them your estimated time of arrival and expected route.  Your office should have a display board on which this information can be recorded so that your movements can be monitored and a person responsible for monitoring it.  That way if you do not show up or return on time, someone can start checking up on you.  Make sure that your vehicle doors are locked at all times.  Always check in and around your vehicle before entering it.  Always check around the parking area before committing to a parking space.  Avoid walking alone, especially at night or in isolated areas.  Get police back up to cover you at problem locations.  This will help to discourage possible threats lurking in the area when you arrive.  It will also allow them to cover your departure, making sure that no one attempts to follow you.  They can also escort you to and from the place that you are visiting and escort your vehicle if necessary.

 

If you become aware of someone following you, immediately call for police assistance with your cellular phone.  Pass on the vehicle license number, description, number of persons visible in the suspect vehicle and your location and direction of travel.  Stay on well lighted and well traveled roadways and avoid stopping if you can.  Head for a place such as a police station or public building where security personnel can see you and assist you (these locations should be part of your escape route planning).  Flash your headlights and honk your horn to attract attention if necessary.

 

Maintain a journal detailing all incidents of stalking.  Include dates, times, locations and a complete description of the stalker.  Detail all that was said and the actions that you took.  List all witnesses.  You should get an answering machine at home that will not only allow you to screen incoming calls (and often identify the caller) but will also record threats made over the phone.  Use the telephone provider’s ID function (such as *57) to identify the phone number that the stalker is calling from and note this down.  Get your local phone provider to help you track the origin of unsolicited calls:  Usually they can set up a “trap line” to capture this information.  This will all be useful evidence for the police in court.

 

Get a protection order.  These vary from jurisdiction to jurisdiction and can be criminal or civil, temporary or permanent.  In most jurisdictions violation of such orders results in arrest and jail time and/or fines.  Even if the order is civil, most jurisdictions treat violations as a criminal matter leading to prosecution and incarceration.

 

In my book, The Safe Approach, I have included comprehensive safety tips and suggestions, as well as hold release techniques, when it becomes necessary to escape from a violent assailant.  In addition, the following websites contain comprehensive statistics and resources about this problem:

 

Stalking Resource Center

Network for Surviving Stalking 

AWARE (Arming Women Against Rape and Endangerment) 

AARDVARC (An Abuse, Rape and Domestic Violence Aid and Resource Collection)  

 

Charles Ennis

Document for Safety

I was reading an article “Remember Those Who Died in Social Care” on the Social Work Blog talking about social workers who had died in the line of duty.  Mike Broad, the author of this entry, said that:

“…Progressive employers are investing in training that encourages their staff to stay calm and confident, read the signs of agitation and have clear exit strategies.  They ensure that detailed records on clients are kept and shared, and risks assessed.  All incidents are reviewed and approaches planned.  Staff have access to technology such as alarms and monitoring systems.”

I couldn’t agree with this more.  Broad reported that the British government took this start in 2001 with a £2 million campaign intended to reduce violence against social workers by 25% by 2005.  Unfortunately 2005 arrived and the government had no idea whether this campaign had worked because the “detailed records” that they’d called for had never been centralized. 

One of the key pieces to the safety puzzle is reviewing all pertinent information on a client.  Workers and police that fail to document past history thoroughly are putting future workers on the case at risk.  All workers in the country should have access to everyone’s records:  Clients with histories of neglect and abuse often move around to avoid the consequences of their actions.  It’s not going to help a worker in one region if they can’t see the client’s records from another region.

Charles Ennis

Workers Want Safety Training

In “Is Social Care Work Safe?” I was reading the comments of fellow social care workers responding to the death of Philip Ellison:

Lins:  “When is something going to be done to protect workers?  In Children Services we are told not to go out alone if there is a potential for violence, but how many times, due to staff shortages, have we taken the chance?  If it was a police officer would they go out alone?”

Well said Lins.  As a former cop I would most certainly confirm that we wouldn’t go to a violent situation alone.

Anne:  “Managing conflict is essential training for any isolated worker.  As is appropriate lone working policies and procedures.  The real danger is when a violent/aggressive incident arises out of the blue.”

As they too often do.  Which is why we ought not to be having social workers out there alone if it can be helped.  The real danger is always there, even if it only seems to be coming “out of the blue”.  The fact is it rarely does.  Too often the clues are there to warn us but we don’t attend to them.

Preeta:  “The people who you see on doubled up visits have usually done or said something to warrant joint visits, it is sometimes impossible to gauge that you are walking into a high risk situation if you have had no warning that a service user is relapsing (for example).”

Most of the time there is a clue to warn you.  Safety awareness is an ongoing reassessment of your situation.  Safety is about 75 % attitude, 15 % skill, 5 % physical, and only 5 % luck.

Brian:  “It is long past the time for society to acknowledge that those of us who work in the social care profession have the right to go about our duties without the fear of abuse and assault.”

I totally agree with Brian’s assessment.  I came to that conclusion eleven years ago and went on to try to do something about safety for my colleagues in the helping professions.

A study cited in Brody’s article support’s Brian’s view.  This study, which estimated that 50,000 social care staff are attacked in Britain each year, showed that two thirds of social workers wanted some sort of self defence training.  There is certainly nothing wrong with this approach, but it requires an enormous investment in time and money to make a large group of social workers competent enough in self defence that they can rely upon this skill.  You can’t become a martial artist in a weekend workshop.  I point this out in the hold-release section of my book The Safe Approach.  Brody admits that he once argued that “self-defence training could do more harm than good, if it increased confidence without developing skills to a level where they would be useful in real life.”  There you go.  However most of the safety problem can be dealt with by recognizing the escalating situation and getting out before it turns to violence.  Basic principle from Sun Tzu’s The Art of War:  The best general is the one who wins without fighing.

Charles Ennis

Dealing Safely With Emotionally Disturbed People

I spent many years in the Mental Health Emergency Services unit of VPD getting mentally ill people safely to treatment facilities. For nine years I managed to do this without ever harming a client, at the same time always keeping the nurses and social workers that I worked with out of harm’s way. Now I’d like to share some of my experience with social workers and nurses to keep them safe in the field.

Before you leave the office, always start by reviewing all available collateral information on the person you intend to assess. This should include police history (criminal record, call history) as well as mental health/hospital records (history of treatment, behaviour when ill). Try to identify patterns and “baseline” behaviour. Do they have common delusions such as the idea that someone is projecting energy/radio waves into them? Maybe they’re paranoid? Look for precautions that they may have taken to “protect” themselves from these perceived threats. Those countermeasures may constitute a threat to your safety.

Always be looking for obvious signs of use of prescription or non-prescription drugs, as well as the use of alcohol or street drugs.  Many mentally ill people attempt to self medicate.  Many psychiatric meds should not be mixed with alcohol consumption.  Many of these attempts to self medicate only exacerbate their illness.  If you can, get the person to show you their meds.  This will give you an idea what it is they are taking, as well as how much.  If the label on the bottle containing a month’s supply of pills is dated the beginning of the month and it is now the end of the month with the bottle nearly full, it is a clear indication that they aren’t compliant with their medications.  The label on the medications also will give you an idea who the GP or psychiatrist of record is.

If the client admits that they’ve discontinued meds, try to find out why.  Many medications have side effects which cause the patient to give up on them, such as drowsiness or weight gain.  Ask if they’ve had allergic reactions. Often they’ll give you accurate information on allergies.  Many patients with a history of non-compliance will respond to my question about allergies by listing every psychiatric medication they’ve ever been prescribed.  This is a pretty clear indication that they aren’t going to cooperate with the medical plan without supervision.

Many emotionally disturbed people can pull it together for a short time in an attempt to cover their illness and avoid apprehension.  A little patience and persistence can often pay off as most of them cannot maintain this front for long.  It is a bit like asking them not to blink.  Sooner or later it will out.

I’ve always found it useful to ride in the ambulance and/or continue the assessment at the hospital.  Typically as soon as the client realizes that “the game is up”, they will drop their guard and let out all kinds of useful information and behaviours.  All this information should be carefully documented to assist people trying to follow up later.

Be direct.  Ask the client up front if they are suicidal, or having thoughts of harming themselves or others.  It is amazing how many social workers and police officers find this question so difficult to ask.  Remember, you’re there to help them and this information is vital. Ask them if the client feels safe.  Do they feel a need to protect themselves?  If so, what measures have they taken to protect themselves?  This will give you an idea if they are paranoid and, if so, how severe the paranoia is.  It also alerts you to dangerous behaviours and situations to guard against.

Ask if the client hears voices.  If so, are these “voices” telling the client to do certain things (command hallucinations)?  Does the client believe that they are getting messages from the TV, radio, or newspaper?  Ask if the client believes that they can read your thoughts and/or if they think that you can read theirs.  Watch for blocking behaviour and/or latency of response.  If they take their time responding to you, they may be responding to internal stimuli.  Do they appear to be looking at things or responding to stimuli no one else perceives? 

Safety is an ongoing reassessment of your surroundings and the persons that you are in contact with.  If you pay attention to the things I’ve listed here, you’ll be in good shape to keep yourself and your client safe.

 

Charles Ennis

 

Det. Ennis assisting an EDP in the Downtown East Side of Vancouver

Det. Ennis assisting an EDP in the Downtown East Side of Vancouver

 

 

 

Planning and Preparation

A situation that I’ve seen play out time and again in the field is where the social worker or nurse does the right thing and requests police back up.  The police arrive, the social worker and police basically introduce themselves and then everyone troops into the house.  No one stops to explain the purpose of the visit to one another.  No one explains what his or her expectations are.  No one discusses the history of the family or contingency plans should things suddenly go “pear shaped”.

Far too often when things do get violent, social workers find themselves in the line of fire.  Having the police backup there helps, but if the visit is planned properly then it is the police who deal with the violence (which is their mandate) and the social worker escapes unscathed.  I remember one case in particular from my experience at Vancouver PD, where the first thing that the police officer in the home thought of when things got violent was the safety of the child:  he picked up the child and ran out of the house.  Unfortunately this left and unarmed social worker facing an irate parent.  This shouldn’t have happened.  It should have been the social worker leaving with the child and the cop making sure that happened.

I was reminded of the potential for violence in such situations when reviewing a case from Washington state back in 2005, where a Department of Social and Health Services social worker was attacked by a male with a machete and a club (for details see memo from Anna Kim-Williams of the Governor’s Communication Office, “Attack of Child Protection Services Worker”).

Time taken to discuss and plan before entering a risky situation is always time well spent.  When things get violent you will instinctively fall back on whatever you have planned or rehearsed beforehand.  If you have done neither, then you’re going to be standing there like a deer in the headlights, and that’s not a good survival response.

Charles Ennis