Safety: In The Office and In Safety: In The Office and In The FieldThe Field

UNC- CH School of Social WorkUNC- CH School of Social Work

Matthew J. Sullivan; JD, MSWMatthew J. Sullivan; JD, MSWEmergency Management Coordinator; Town of Emergency Management Coordinator; Town of Chapel Hill, N.C.Chapel Hill, N.C.919-968-2814919-968-2814 msullivan@townofchapelhill.orgmsullivan@townofchapelhill.org

Initial Questions and Initial Questions and ConcernsConcerns

What are your thoughts about safety in What are your thoughts about safety in field?field? Have you thought about it previously?Have you thought about it previously? What are your concerns in this area?What are your concerns in this area?

What have you heard about this issue?What have you heard about this issue? What do you know or experience do you What do you know or experience do you

have in this area?have in this area? What specific areas or questions would What specific areas or questions would

you like to address prior to the end of this you like to address prior to the end of this program? program?

ObjectivesObjectives Participants will articulate multiple risk Participants will articulate multiple risk

factors that might lead to violent or factors that might lead to violent or hostile behavior.hostile behavior.

Participants will identify the Participants will identify the components and the significance of a components and the significance of a Personal Safety Plan (PSP).Personal Safety Plan (PSP).

Participants will be familiarized with the Participants will be familiarized with the pattern of escalation that is associated pattern of escalation that is associated with violent behavior. with violent behavior.

Participants will learn multiple safety Participants will learn multiple safety strategies that may be utilized when strategies that may be utilized when practicing within the multiple practicing within the multiple dimensions of human service practice dimensions of human service practice inside and outside the office.inside and outside the office.

Participants will articulate the Participants will articulate the importance of utilizing proficient clinical importance of utilizing proficient clinical skills as it relates to practitioner safety.skills as it relates to practitioner safety.

NC Mental Health NC Mental Health “Reform”“Reform”

In 2001 the NC Legislature approved a In 2001 the NC Legislature approved a comprehensive plan aimed at improving public comprehensive plan aimed at improving public mental health services.mental health services.

This plan resulted in significant changes in delivery This plan resulted in significant changes in delivery of mental health services.of mental health services.

Two Main OutcomesTwo Main Outcomes Creation of Local Management Entities (LME)Creation of Local Management Entities (LME) Divestiture and PrivatizationDivestiture and Privatization

Orange County ExampleOrange County Example OPC Mental Health became the OPC Area LMEOPC Mental Health became the OPC Area LME

2010 to present: “Consolidation” Managed Behavioral Healthcare

Organizations

Effects of the “Reform”Effects of the “Reform”

The LME becomes a HMO type entity The LME becomes a HMO type entity that authorizes and pays for services that authorizes and pays for services delivered to individuals in its delivered to individuals in its catchment area. catchment area.

Multiple for profit and not for profit Multiple for profit and not for profit entities are created to provide entities are created to provide services in the LME catchment areas.services in the LME catchment areas.

The state, and therefore the LME, will The state, and therefore the LME, will only pay for specific services provided only pay for specific services provided to certain “targeted populations”.to certain “targeted populations”.

The Bottom LineThe Bottom Line

Services in communities are more Services in communities are more difficult to access and are being difficult to access and are being provided by less qualified mental provided by less qualified mental health professionals.health professionals.

The most limited and highest risk The most limited and highest risk individuals are not receiving needed individuals are not receiving needed services.services.

These two factors coupled with These two factors coupled with downsizing at state mental hospitals downsizing at state mental hospitals results in more unserved mentally ill results in more unserved mentally ill individuals in our communities.individuals in our communities.

LocallyLocally

Closing of mental health regional Closing of mental health regional offices.offices.

Services restrictedServices restricted

Two Case StudiesTwo Case Studies AA/M “IE”AA/M “IE” W/F “NC”W/F “NC”

What is Workplace What is Workplace Violence?Violence?

““Workplace violence is violence or the Workplace violence is violence or the threat of violence against workers. It can threat of violence against workers. It can occur at or outside the workplace and occur at or outside the workplace and can range from threats and verbal abuse can range from threats and verbal abuse to physical assaults and homicide, one of to physical assaults and homicide, one of the leading causes of job-related deaths.” the leading causes of job-related deaths.”

US Occupational Safety and Health US Occupational Safety and Health AdministrationAdministration

Workplace Violence in Workplace Violence in the U.S.the U.S.

Almost 1.5 Million “violent victimizations” occur Almost 1.5 Million “violent victimizations” occur in the workplace each year, most of these in the workplace each year, most of these incidents are simple or aggravated assaults.incidents are simple or aggravated assaults.

This number has been declining over the past This number has been declining over the past several years, however shootings are increasing.several years, however shootings are increasing.

Over ½ of all incidents are not reported to the Over ½ of all incidents are not reported to the police even though most have been reported to police even though most have been reported to management.management.

Of the physically violent acts: Of the physically violent acts: 16.8% Aggravated Assaults16.8% Aggravated Assaults2.3% sexual assaults2.3% sexual assaults

Workplace Violence Workplace Violence ContinuedContinued

State and Local agencies far outweigh private State and Local agencies far outweigh private industry in the percentages of agencies industry in the percentages of agencies experiencing incidents. experiencing incidents.

Violence Rates: Mental HealthViolence Rates: Mental Health Professional 20.5 workplace, 17.2 non-workplaceProfessional 20.5 workplace, 17.2 non-workplace Custodial Care 17 workplace, 12.8 non-workplaceCustodial Care 17 workplace, 12.8 non-workplace

30% Coworker/Supervisor30% Coworker/Supervisor Males perpetrate more oftenMales perpetrate more often Estimates are that workplace violence was the Estimates are that workplace violence was the

cause 1,751,000 (3.5 per incident 500,000 people) cause 1,751,000 (3.5 per incident 500,000 people) lost work-days at cost of 55 Million.lost work-days at cost of 55 Million.

Injury Cost 6.5 to13.5 Billion DollarsInjury Cost 6.5 to13.5 Billion Dollars

Why Worry ?Why Worry ?

Incidents of violence perpetrated against Incidents of violence perpetrated against human service professionals are human service professionals are increasing.increasing.

These incidents are greatly underreported.These incidents are greatly underreported. 3 of 4 human service professionals may be 3 of 4 human service professionals may be

assaulted at least once in their career.assaulted at least once in their career. In service training has been shown to In service training has been shown to

decrease risk and the severity of injury. decrease risk and the severity of injury.

INDIVIDUALS TEND TO IGNORE OR INDIVIDUALS TEND TO IGNORE OR DISCOUNT THE WARNING SIGNS.DISCOUNT THE WARNING SIGNS.

It Should Also Be Noted It Should Also Be Noted That…..That…..

Most mentally ill clients are no more Most mentally ill clients are no more dangerous than the general population.dangerous than the general population.

Those who are “More Dangerous” (10%) Those who are “More Dangerous” (10%) target family members predominately.target family members predominately. Mother living with schizophrenic adult childMother living with schizophrenic adult child

The “More Dangerous”The “More Dangerous” History of Violent BehaviorHistory of Violent Behavior Substance AbusersSubstance Abusers Report Command HallucinationsReport Command Hallucinations Non-compliant With Prescribed MedicationNon-compliant With Prescribed Medication

RISKRISK

““The chance of The chance of injury damage or injury damage or loss.” loss.” --WebsterWebster

Three DimensionsThree Dimensions DesireDesire OpportunityOpportunity AbilityAbility

Field TacticsField Tactics

Skills utilized by the Skills utilized by the Human Services Human Services Professional to minimize Professional to minimize risk within his or her risk within his or her discipline.discipline.

Global ConceptsGlobal Concepts

The Personal Safety/Defense Plan The Personal Safety/Defense Plan (PSP/PDP)(PSP/PDP)

Self Awareness & Personal Self Awareness & Personal AppraisalAppraisal

Personal EvaluationPersonal Evaluation Chart Evaluation/Case Load Chart Evaluation/Case Load

AnalysisAnalysis DocumentationDocumentation

Internal Crisis ResponseInternal Crisis Response

BONUSBONUS Improved Sensory Improved Sensory

Ability Ability Increased StrengthIncreased Strength Improved Reaction Improved Reaction

TimeTime Increases Alertness Increases Alertness

and Focus (narrow)and Focus (narrow) Increased EnergyIncreased Energy

ALTER IMPACTSALTER IMPACTS Increases Error Increases Error

PotentialPotential Decreases JudgementDecreases Judgement Decreases Attention Decreases Attention

SpanSpan Decreases Ability To Decreases Ability To

Discriminate Between Discriminate Between Trivial and DangerousTrivial and Dangerous

Tactic 1: Recognize the Tactic 1: Recognize the Pattern of EscalationPattern of Escalation

TriggeringTriggering EscalationEscalation CrisisCrisis RecoveryRecovery

(Kaplan and Wheeler, 1983)(Kaplan and Wheeler, 1983)

TriggeringTriggering

AnxietyAnxiety MiscommunicationMiscommunication Non-communicationNon-communication Nonverbal CuesNonverbal Cues

pacingpacing clenched fists/jawclenched fists/jaw posturingposturing too much or no eye too much or no eye

contactcontact angry affectangry affect

EscalationEscalation

Client exhibits a loss of rationality Client exhibits a loss of rationality and/or increased anxiety.and/or increased anxiety.

Begins to test limits or issue Begins to test limits or issue challenges, makes unrealistic challenges, makes unrealistic demands upon the worker.demands upon the worker.

Increased hostility, verbal Increased hostility, verbal abusiveness, insulting abusiveness, insulting communication and use of profanity.communication and use of profanity.

Defusing Escalation Defusing Escalation

Re-Direct ConversationRe-Direct Conversation SLOW DOWN- Initiate Helping SupportSLOW DOWN- Initiate Helping Support Help The Client To Nonviolent AlternativesHelp The Client To Nonviolent Alternatives Take Away AudienceTake Away Audience Make Mental Notes Of This Incident’s Make Mental Notes Of This Incident’s

Impact On Bystanders, Other Clients & Impact On Bystanders, Other Clients & Staff.Staff.

DO NOT PARTICIPATE IN A POWER DO NOT PARTICIPATE IN A POWER STRUGGLESTRUGGLE

CrisisCrisis

Loss of ControlLoss of Control Physical Action/ViolencePhysical Action/Violence Release of energy that Release of energy that

has been building.has been building. Usually not Usually not

premeditatedpremeditated

PROTECTION OF SELF PROTECTION OF SELF AND OTHERS IS YOUR AND OTHERS IS YOUR

FOCUSFOCUS

Recovery Recovery

Reduction of anxiety.Reduction of anxiety. Perpetrator becomes remorseful and Perpetrator becomes remorseful and

apologetic.apologetic. Worried about consequencesWorried about consequences Proactive Stress ManagementProactive Stress Management Do Not Rush the situation by attempting Do Not Rush the situation by attempting

to process with perpetrator or moving to process with perpetrator or moving past the situation. CALL FOR HELPpast the situation. CALL FOR HELP

Should An Incident Should An Incident OccurOccur

CALL APPRORIATE PUBLIC SAFETY CALL APPRORIATE PUBLIC SAFETY SERVICESSERVICES

Initiate immediate treatment for staff Initiate immediate treatment for staff victim and other effected personnel.victim and other effected personnel. Caring social supports and a sense of mastery.Caring social supports and a sense of mastery.

Evaluate any needs for debriefing.Evaluate any needs for debriefing. Levy consequences on the perpetrator.Levy consequences on the perpetrator. Use the incident as a planning/ training Use the incident as a planning/ training

tool.tool. DocumentationDocumentation

Hostile Behavior: Risk Hostile Behavior: Risk FactorsFactors

PhysiologicalPhysiological SleeplessnessSleeplessness HungerHunger Chronic Pain or Chronic Pain or

IllnessIllness Drugs or AlcoholDrugs or Alcohol Medication Medication

InteractionsInteractions HeatHeat Organic PathologyOrganic Pathology Low IQ, Head InjuryLow IQ, Head Injury

Research ProvenResearch Proven Deprivation of Low Level Deprivation of Low Level

Basic NeedsBasic Needs Poverty and Poor HousingPoverty and Poor Housing Negative Behaviors Negative Behaviors

Documented at 8-10 Yrs.. Documented at 8-10 Yrs.. Harsh DisciplineHarsh Discipline EmbarrassmentEmbarrassment No Family StabilityNo Family Stability Parental FactorsParental Factors

Supervision/DisciplineSupervision/Discipline

HOMICIDAL TRIANGLEHOMICIDAL TRIANGLE

BED WETTERBED WETTER

FIRE STARTERFIRE STARTER

ANIMAL ANIMAL CRUELTYCRUELTY

Warning Signs of Potential Warning Signs of Potential ViolenceViolence

Past History of Violent BehaviorPast History of Violent Behavior Weapons or Threats of WeaponsWeapons or Threats of Weapons Substance AbuseSubstance Abuse Bizarre or Violent Bizarre or Violent

Thoughts/ObsessionsThoughts/Obsessions Extreme ParanoiaExtreme Paranoia Major Behavior or Belief ChangesMajor Behavior or Belief Changes Psychosis, Hallucinations, DelusionsPsychosis, Hallucinations, Delusions

Other Important Other Important ConsiderationsConsiderations

The probability of violence escalates with each The probability of violence escalates with each act. act.

The most important risk factors are:The most important risk factors are: Alcohol Abuse & History of Violent BehaviorAlcohol Abuse & History of Violent Behavior

Cognitive Interpretation By PerpetratorCognitive Interpretation By Perpetrator It is important to always assess current stress.It is important to always assess current stress. The most likely victims are:The most likely victims are:

Objects of FantasyObjects of Fantasy Family MembersFamily Members Members of Target Groups (Hate Crime) Members of Target Groups (Hate Crime)

Tactic 2: Develop Personal Tactic 2: Develop Personal Safety PlansSafety Plans

Pre-plan situations or occurrences in Pre-plan situations or occurrences in an attempt to become familiar with an attempt to become familiar with response prior to the crisis.response prior to the crisis. HomeHome WorkWork CommunityCommunity

When Crisis Occurs, It Is Too LateWhen Crisis Occurs, It Is Too Late

Personal Safety Plan Personal Safety Plan ConsiderationsConsiderations

In The Field:In The Field: Communication MeansCommunication Means Pairs Visit Designated Clients/NeighborhoodsPairs Visit Designated Clients/Neighborhoods Personal Protective Gear Personal Protective Gear

Pepper Spray w/Training & Bullet Proof Pepper Spray w/Training & Bullet Proof Vests Vests

Neighborhood AssessmentsNeighborhood Assessments Vehicle MaintenanceVehicle Maintenance The Home Visit…….. The Home Visit……..

The Home SettingThe Home Setting

Leave itinerary at work with times, clients and Leave itinerary at work with times, clients and return return

Drive by, do not park directly in frontDrive by, do not park directly in front Upon approach listen, do not stand in frontUpon approach listen, do not stand in front Make mental note of door knob and swingMake mental note of door knob and swing At first contact assess individuals and activityAt first contact assess individuals and activity Keep everyone in your line of visionKeep everyone in your line of vision Position yourself for easy and quick departurePosition yourself for easy and quick departure Remember: Guns in Bedroom, Knives in KitchenRemember: Guns in Bedroom, Knives in Kitchen If all else fails, “A good retreat is better than a If all else fails, “A good retreat is better than a

bad stand.”bad stand.”

In An Office Environment In An Office Environment

Work Alone?Work Alone? Secured Access AreasSecured Access Areas Verbal Distress CodeVerbal Distress Code Consider Physical Plant ArrangementConsider Physical Plant Arrangement What’s on your desk?What’s on your desk? What is the case load?What is the case load? Friendly/Welcoming Office Friendly/Welcoming Office

Environment?Environment? HOT ROOMSHOT ROOMS

Office IIOffice II

Warning/Help Lights or BuzzersWarning/Help Lights or Buzzers Multiple Access Points?Multiple Access Points? Survey Office Space and Survey Office Space and

Arrangement Arrangement (aka. security survey)(aka. security survey)

DocumentationDocumentation Flag RecordsFlag Records Eliminate Weapons of OpportunityEliminate Weapons of Opportunity FORMAL SAFETY CRISIS PLANFORMAL SAFETY CRISIS PLAN

Car Safety SkillsCar Safety Skills

Keep car lockedKeep car locked Keep car well maintainedKeep car well maintained Keep car door key in handKeep car door key in hand Look around and under upon approachLook around and under upon approach Keep fuel level at least ¼ tankKeep fuel level at least ¼ tank Carry a cellular telephone, don’t stopCarry a cellular telephone, don’t stop Park in busy and well lit areasPark in busy and well lit areas

Street Safety SkillsStreet Safety Skills

Walk in well lit areasWalk in well lit areas Walk in groupsWalk in groups Know your surroundingsKnow your surroundings Walk facing trafficWalk facing traffic Be alert watch those watching youBe alert watch those watching you Walk away from buildings and shrubberyWalk away from buildings and shrubbery Keep valuables on your person not in Keep valuables on your person not in

bagbag

Practitioner Practitioner ConsiderationsConsiderations

Promises PromisesPromises Promises The RelationshipThe Relationship TAXI????TAXI???? Work ScheduleWork Schedule Take Responsibility For Take Responsibility For

Your Mistakes.Your Mistakes. Do NotDo Not Use Humor Use Humor

ClinicallyClinically Allow SilenceAllow Silence Change Pace and RhythmChange Pace and Rhythm

For The Difficult For The Difficult IndividualIndividual

Friendly GreetingFriendly Greeting Identify Yourself ClearlyIdentify Yourself Clearly Ask For ComplianceAsk For Compliance (If refused ask a second time with (If refused ask a second time with

reason)reason) Present OptionsPresent Options Confirm RefusalConfirm Refusal Take ActionTake Action

Tactic 3: Non-Clinical HazardsTactic 3: Non-Clinical Hazards“Environmental Occupational “Environmental Occupational

Hazards” Hazards” Personal Protective Equipment?Personal Protective Equipment?

Bio-HazardsBio-Hazards Bloodborne and Vectorborne DiseaseBloodborne and Vectorborne Disease Resurgence of TB in the homeless Resurgence of TB in the homeless

populationpopulation Personal Defense Weapons?Personal Defense Weapons?

Drug House ConsiderationsDrug House Considerations CampsitesCampsites MethlabsMethlabs

Tactic 4: Agency Safety Tactic 4: Agency Safety PolicyPolicy

Agency develops a formal policy that Agency develops a formal policy that addresses employee safety and addresses employee safety and workplace violence.workplace violence.

No tolerance for violence with No tolerance for violence with strong consequences for violation.strong consequences for violation.

Development of a Safety CommitteeDevelopment of a Safety Committee Practice PlanPractice Plan

Defensive Tactics?????Defensive Tactics?????

““Walk Like a Champion”Walk Like a Champion” SeatedSeated Arm or Hand AggressionArm or Hand Aggression Use Head to Put Off BalanceUse Head to Put Off Balance Infra-Orbital Pressure PointInfra-Orbital Pressure Point Ground Defense and “Snow Angel”Ground Defense and “Snow Angel” Bear HugsBear Hugs Choke HoldsChoke Holds

Legal Issues In Self Defense Legal Issues In Self Defense CasesCases

North Carolina’s Castle DoctrineNorth Carolina’s Castle Doctrine Self Defense Requirements:Self Defense Requirements:

NecessityNecessity ProportionalityProportionality FaultFault

““Norris Test”Norris Test” Honest Belief Honest Belief Reasonable BeliefReasonable Belief Not the AggressorNot the Aggressor Must Not Have Used Excessive ForceMust Not Have Used Excessive Force

What About Personal Defense What About Personal Defense Weapons?Weapons?

Biohazard Protective GearBiohazard Protective Gear Bullet Proof VestBullet Proof Vest Pepper Spray or MacePepper Spray or Mace Noise Making DeviceNoise Making Device Blunt ObjectsBlunt Objects Non-TraditionalNon-Traditional Firearms ?Firearms ?

Cautions With Personal Cautions With Personal WeaponsWeapons

Training is a necessityTraining is a necessity Cost and Upkeep AssociatedCost and Upkeep Associated AccessAccess Will you be able to deploy when Will you be able to deploy when

needed?needed? They can be used against you.They can be used against you.

Finally……Finally……Social Worker Know Thy Social Worker Know Thy

SelfSelf It is important to trust your It is important to trust your

instincts.instincts. What are your strengths …???? ANDWhat are your strengths …???? AND What are your limitations….?????What are your limitations….????? ““Am I in over my head” Am I in over my head” Pre-Plan Pre-Plan Every Every EncounterEncounter Collaboration is keyCollaboration is key Professional SupervisionProfessional Supervision

And…. Take Care of And…. Take Care of YourselfYourself

Effective social workers must develop Effective social workers must develop and maintain a keen sense and and maintain a keen sense and maintain clear strong boundaries.maintain clear strong boundaries.

Maintain BalanceMaintain Balance Utilize formal and informal social Utilize formal and informal social

supportssupports Nutrition, sleep, rest ect.Nutrition, sleep, rest ect. Seek and ask for assistance if indicatedSeek and ask for assistance if indicated Keep each other “in check”Keep each other “in check”

Some Final QuestionsSome Final Questions

Where do you go from here?Where do you go from here?

What will you apply from this What will you apply from this afternoon’s presentation to your afternoon’s presentation to your field practice?field practice?

What will you implement in the next What will you implement in the next 48 hours?48 hours?