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

 

 

Who Is That?

I came across these articles by Sarah Ovaska and Thomasi McDonald about a social worker hurt in an office attack in Raleigh, NC, last February (Social worker hurt in attack: Security a concern at Wake building and Wake County Social Worker Assaulted on the Job).  It reminded me of some office incidents that motivated us to write about office safety in our book The Safe Approach.

In this incident, a 28-year-old male walked into the social worker’s place of employment and basically had freedom of access to the entire building.  Apparently there is no visible security checkpoint at the entrance: just a sign taped to a desk asking visitors to sign in with security.  The suspect went straight up to the victim’s fourth-floor office, where he repeatedly punched and kicked the victim, sending her to hospital.

People wandering around an office can be a great threat to personal safety and security.  At the very least there ought to be a locked gate or door separating the reception area from the offices.  The client should be signed in and given temporary visitor identification.  They should then be escorted to and from the interview.  The best set up is to have a designated interview room with separate doors for the client and worker. Display signs in the waiting area should indicate zero tolerance for violence. Any staff member who notices a stranger wandering about the office should politely question them as to their business there. You should never assume that the stranger that you see walking past has signed in or has permission to be there. 

Having the client sign in at reception also gives the reception staff an opportunity to assess the visitor’s demeanor.  If they are agitated and/or aggressive it is a good idea to keep them out and ask them to return when they are calmer.  If they cause a scene you can summon appropriate assistance to deal with this in the reception area.

Charles Ennis

Check the History and Take Cover

How many of you have been faced with this task: trying to get a decompensating mental patient to return to treatment?  It is a task that I am very familiar with, having spent many years as a police officer working in the Mental Health Emergency Services unit of the Vancouver PD.  Many of these clients were resistant to such efforts, since they had no insight into their condition, were paranoid, and often were self- medicating with street drugs.  One of the things that motivated me to write The Safe Approach was to help social workers and nurses to deal with this sort of scenario.

I was reminded of all this when I reviewed an older article from the UK’s The Independent newspaper, “Frenzied Attack on Social Worker“.  This told of dedicated social worker, Jenny Morrison, 50, who went alone to try to convince Anthony Joseph, a schizophrenic male, that he needed to return to psychiatric hospital.  This schizophrenic killed her, stabbing her more than 100 times, breaking the first knife and calmly walking back to the kitchen in the halfway hostel to get another to continue the attack.

Apparently Morrison had gone there alone, and although some other workers had arranged to be there to cover her, they had not shown up.  This demonstrates the paramount importance of taking adequate resources to cover the situation that you expect to face upon arrival.  Going alone to see an unstable and possibly violent client is never a good idea.  Having fellow workers accompany you is better, but in such situations it is always best to have the police with you.

Another incident which underscores the hazards of going to dangerous dwellings alone, is the case of a West Virginia social worker who was murdered when she conducted a solitary home visit, as reported in Tony Rutherford’s article “Social Worker Attacked, Sexually Assaulted, Murdered, Burned”.

Checking collaterals is another issue I covered in The Safe Approach. Before attending to see the client, you need to check any and all sources of information to get as clear an idea as possible of the risks that you are likely to face. The author of the Independent article, Terri Judd, reports “Mr Joseph had not picked up his medical prescription for five months and had told fellow residents at the social services hostel that he was selling his pills to “clubbers”, while taking a cocktail of heroin, crack cocaine and ecstasy himself. Three weeks before the attack, care staff were well aware that he had stopped taking his medication, yet he remained free to come and go as he pleased, the court heard.” The staff had specifically asked for assistance, because Joseph’s behavior had deteriorated dramatically since his release from the psychiatric hospital. He was described as abusive, as having paranoid delusions about being pursued by fascists, as being “tortured by dark spirits”. Joseph made no secret of the fact that he did not believe he was mentally ill and that if returned to the psychiatric hospital, he would be tortured. All of these behaviors are ‘red flags’ that should have led to the police being brought along to the scene for back up.

Usually safety problems result from a combination of factors. Training may fail to accurately reflect reality. Perceptions of the true risk may not match the actual risks involved. A study by Carmel and Hunter in 1990 found that frequent training can improve the likelihood of avoiding assault.

Yet workers may receive no training in safety considerations at all (*). More often than not they are expected to pick up whatever they need to know on the job. Workers become complacent in the knowledge that most people in the profession reach retirement without ever being in a potentially dangerous position. Day in and day out, workers investigate situations where nothing happens and complacency sets in. They may approach a situation casually, hastily, and with over-confidence, as “nothing ever happened before”. They begin to assume that “nothing ever will happen”. And then it does.

Charles Ennis 

(*) US Dept. of Labor, Occupational Safety & Health Administration; (1996) Guidelines for Preventing Workplace Violence for Health Care & Social Workers OSHA 3148-1996. pg 9.

 

 

 

 

 

Injuries to Social Workers from Client Assault

Robin Ringstad Ph.D, LCSW, has an interesting CSWE APM power point presentation showing statistics on client violence to social workers.

Safe Approach Introduction

It is amazing how little effort has been expended by some agencies to train field workers how to survive violent encounters with clients they encounter in the field. Proper training, planning and preparation can prevent many violent incidents from occurring and can enhance their ability to survive violent encounters. Depending on luck is a poor substitute for taking constructive measures to prevent a violent encounter. The current state of knowledge of safety procedures makes your ability to stay safe in the field greater than ever. Yet more effort is likely to have gone into the counseling and support that a worker receives after an assault than that worker or that worker’s agency devoted to worker safety before the assault.

When we first started doing safety training for social workers and public health nurses in 1996 there were concerns from the field administrators the material being presented might incite fear in the workers, resulting in them never leaving their office. One of the first things that we do in our sessions is to ask the attendees to take a moment to write down past work situations where they found themselves in dangerous or violent situations. Many of them come up with personal accounts of risk and injury. In other words, these people have already experienced the dangers of the job. They are attending classes like ours because they wanted strategies and techniques that allow them to overcome the fears and anxieties that they already have experienced on the job so that they can continue to do those valuable jobs.

You can’t make yourself safe unless you have a true appreciation of the risks involved. Only then can you adequately prepare for them. The best defense for any field worker is to be prepared before violence happens. This often makes it possible for you to avoid potential violence altogether, and can substantially reduce the number of incidents that escalate to the point of violence. The old adage ‘An ounce of prevention is worth a pound of cure’ certainly applies here.

Your body will often react to impending danger before you become consciously aware of it. When suddenly confronted with violence, your body will automatically revert to an instinctive “fear-fight-flight mode.” It has been our experience that workers often dismiss the physiological symptoms they are having when they begin to feel unsafe and attempt to continue their interview or assessment. They fail to trust their instincts. If you become aware that you are experiencing these symptoms you should begin looking for the cause. If you ignore them, you may end up being surprised by the client’s violent outburst. Under these circumstances you will instinctively revert to the way you have trained. If you have neither rehearsed nor planned a response, you will be left with a basic “startle response” which is rarely an appropriate response to a violent outburst.

Yet most social workers have nowhere near the training and equipment that a police officer has when responding to such situations. A client can decide when, where, and whom to attack, on grounds that may be totally irrational and indiscriminate. On the other hand, moral and psychological considerations that inhibit quick, impulsive action usually influence the worker.

Clients know you won’t make the first violent move. You may not want to use violence. You may find violence morally distasteful. Nevertheless, it is very likely that the client will not share your views. Faced with arrest, hospitalization, or with the removal of their children, clients may feel that they have nothing to lose. They may accept violence as a natural risk of their lifestyle. When they act, they are only thinking of themselves.

Usually there will be some clue or danger sign warning of violence. Something about the client’s behavior will indicate his or her intent. Learning the body language of violent clients is essential to your safety. You should watch for displays of pre-assaultive behavioral that will warn you of an impending attack. 

Safety is a matter of on going assessment of your surroundings and making timely decisions based on that assessment. Safety is a matter of constantly reviewing your actions to learn from your mistakes. The first step toward greater personal safety in the field is knowing where to draw the line. Violent behavior on the part of the client may be understandable, but it is never acceptable.

The Safe Approach

The Safe Approach