Case Management Work with Crisis, Violence and Abuse

SW 611 Class Notes (FA04: Rossman)

BASIC CRISIS INTERVENTION

Identifying Crisis

When a person is not able to use coping behaviors and is faced with stress, a crisis state will generally evolve. Often the subjective distress, such as anxiety of grief, overwhelms the individual and the coping behaviors are not functioning. It is no wonder that the person’s functioning level in a variety of areas will be affected. When such individuals realize they can no longer function at work, at home, socially or emotionally, they may not be able to identify their own coping strengths/skills or resources.

Indicators
  1. A precipitating event occurs
  2. the perception of this event leads to subjective distress
  3. usual coping methods fail, leading the person experiencing the event to function psychologically, emotionally, or behaviorally at a lower level than before the precipitating event occurred.

Direct questioning
  1. Specific, clear and non-judgmental questions can be asked in a confidential, non-judgmental manner.
  2. "What happened that made you call or come for help today?"
  3. If it is an ongoing problem that has suddenly caused a crisis, "What is the ‘straw the broke the camel’s back’?"
  4. Eliciting the client’s frame of reference regarding the crisis situation. Explore meanings, cognition and perceptions "Put everything together for me from your perspective?", "What does it mean to you when this happens/ed?", "What goes through your mind when you picture this event?".
  5. "Everyone responds differently to life events, tell me what your days looked like before this happened?" "How did you feel about _____ before this happened?"
  6. If precipitating event happened before, "what is different about this time that caused this to be a crisis in your life," and/or "how did you get through this last time this happened?"

Procedure
  1. Client identifies that they are in crisis or an event is causing them to be unable to use regular coping mechanisms.
  2. Triage for immediate danger, medical crisis, psychological functioning.
  3. Danger to self and/or others should be evaluated.
  4. Social worker/Case Manager:
    • ABC Model of Crisis Intervention
    1. Attending Skills
    2. Basic Identification of Problem and pre-crisis level of functioning
    3. Coping strategies (using strengths and supports)
    • Client should leave with a plan based on previous coping skills used (in daily life), client’s own strengths, informal and formal supports, referrals to further services (basic needs, mental health, support groups, etc).
    • Re-evaluation or Assessment in follow-up appointment

 

DOMESTIC VIOLENCE

Domestic violence is a pattern of coercive behaviors that involves physical abuse or the threat of physical abuse. It may involve repeated psychological abuse, sexual assault, progressive social isolation, depravation, intimidation or economic control.

Domestic violence is a frightening, traumatic event for the victim. As a care provider, your response to the crisis is of essential importance to the victim’s present and future well being. Providing proper care at this critical time may be complex and difficult. Those guidelines are designed to guide you to the best and most complete practices to meet the needs of these patients and their families.

It is essential for a clinician to approach these patients in a non-judgmental, emphatic and reassuring manner, validating the experience while providing safety and privacy. It is critical to understand that patients who have been abused have experienced a loss of control. By asking for consent and explaining each step of the treatment, decision making is returned to their control. Violent trauma also leads to ambivalence and confusion. Stay with the patient for as long as your duties permit. Remember that a healthcare provider may be the first person a victim of domestic violence approaches to reveal their problem.

Identifying Domestic Violence

Domestic violence is a pattern of coercive and violent behavior that may include physical, psychological, and sexual attacks that adults and adolescents inflict upon their intimate partners, of the opposite or same sex. This behavior often produces physical signs on the victim. Occasionally, there are ambiguous or unclear physical signs.

Indicators
  1. Injury to head, neck, torso, abdomen, breasts or genitals.
  2. Bilateral or multiple injuries or repeated visits.
  3. Delay between the onset of injury and seeking medical treatment.
  4. Explanation by the patient which is inconsistent with injury.
  5. Any injury during pregnancy, especially breasts or abdomen.
  6. Prior history of trauma.
  7. Chronic pain symptoms without apparent etiology.
  8. Psychiatric distress, depression, anxiety, suicidal ideation, sleep disorder.
  9. A partner who seems overprotective or won’t leave partner’s side during clinical exam or interview.
  10. Suicide attempt/overdose.

Direct questioning

Specific, clear and non-judgmental questions can be asked in a confidential setting. The examiner must be alone with the patient in a private room. Opening questions can include:

  1. "Because violence is common in so many people’s lives, I’ve begun to ask about it routinely. At any time has your partner ever hit, kicked or in some other way hurt of frightened you?"
  2. "I know that you said you fell on your left side, but you have injuries on your other side as well. I’m concerned that someone hurt you."
  3. "Many people come in with injuries like yours and often they are from someone hurting them. Is this what happened to you?"

Procedure
  1. Patient comes to ER
  2. TRIAGE clinician sees bruised or other indicators and suspects abuse.
  3. Patient taken to exam room.
  4. All persons accompanying the patient are asked to leave.
  5. Clinician conducts screening.
  6. If abuse is revealed or suspected, patient is referred to a social worker.
  7. Social worker/Case Manager:
    • Makes referrals to shelters, hotlines, other community resources.
    • Help patient develop a safety plan if needed.
    • Stays with patient throughout her ER visit.
    • Assists the patient in notification of law enforcement if required
      or requested by patient.

 

CHILD ABUSE/NEGLECT STANDARD OF CARE

Child abuse and neglect are frightening, traumatic events for their victims and for their families. Each state has clearly defined statutes and regulations governing the reporting and management of abused and neglected children. Clinicians need to provide safe and private time for examination and interview of the child and the responsible adults.

Identifying Child Abuse

The spectrum of child abuse includes inflicted injuries resulting in bruises, welts, cuts, burns, fractures, poisoning, drugging, etc. Sexual abuse is the subjection of a child by a person responsible for the child’s care, by a person who has a significant relationship to the child, or by a person in a position of authority, to any act regarding criminal sexual conduct, prostitution or solicitation, or child pornography. Sexual abuse includes threatened sexual abuse. Neglect of children may involve nutritional deprivation, withholding of appropriate medical care, abandonment, lack of supervision, lack of provision of appropriate shelter, and significant inattention to normal childhood emotional or developmental needs.

Indicators


1. Family Indicators

  • Domestic Violence
  • Physical or mental health problems
  • Alcohol and substance abuse
  • Isolation
  • Delay or failure in seeking medical attention
  • Homelessness
  • Prior history of abuse

2. Physical Abuse/Behavioral Indicators

  • Unexplained bruises, welts and/or bite marks
  • Unexplained burns
  • Unexplained fractures or dislocations
  • Unexplained lacerations or abrasions
  • Afraid to go home
  • Will not cry when approached by examiner
  • Indiscriminately seeks attention
  • Reports injury by parent(s) and/or caretaker(s)

3. Physical Neglect/Behavioral Indicators

  • Underweight, poor growth patterns, failure to thrive
  • Consistent lack of supervision
  • Abandonment
  • Alcohol of drug abuse
  • Aggressive behavior, delinquency
  • Depression/Regression
  • Significant decline in school performance
  • Domestic Violence Observed by the Child

4. Sexual Abuse/Behavioral Indicators

  • Difficulty walking or sitting
  • Torn, stained or bloody underclothing
  • Pain, swelling or itching in genital area
  • Bruises, bleeding or laceration in external genitalia, vaginal or anal areas
  • Venereal disease
  • Pregnancy
  • Hypersexual behavior, reports of sexual acts on other children
  • Prostitution
  • Suicide attempts or self-injurious behaviors
  • Running away

Direct Questioning

Specific, clear and non-judgmental questions can be asked in a confidential setting. The child and the caretaker(s) must be interviewed separately.

Procedure
  1. Any suspicion of abuse or neglect should be communicated to appropriate personnel.
  2. The child should be medically examined by appropriate clinicians.
    If abuse is revealed or suspected, the situation is referred to a social worker.
  3. The social worker/Case Manager:
    • Assesses the situation (interviewing the child and caretaker(s) separately).
    • Provides counseling.
    • Reports the situation to appropriate city, county and/or state authority.
    • Ensures the child’s safety and arranges for alternative living arrangements, if indicated.
    • Assesses the safety of other children in the home and ensures a safe plan for them.
    • Ensures follow up coordinated care for the children and caretaker(s).

 

ELDER ABUSE/NEGLECT STANDARD OF CARE

Introduction

Elder abuse and neglect are frequently occurring incidents which render the older adult vulnerable and helpless. Each state has regulations and policies governing the reporting of cases of elder abuse. Elder abuse is a frightening, traumatic event for the victim. As a care provider, your response to the crisis is of essential importance to the victim’s present and future well being. Providing proper care at this critical time may be complex and difficult. Those guidelines are designed to guide you to the best and most complete practices to meet the needs of these patients and their families.

It is essential for a clinician to approach these patients in a non-judgmental, emphatic and reassuring manner, validating the experience while providing safety and privacy. It is critical to understand that patients who have been abused have experienced a loss of control. By asking for consent and explaining each step of the treatment, decision making is returned to their control. Violent trauma also leads to ambivalence and confusion. Stay with the patient for as long as your duties permit. Remember that a healthcare provider may be the first person a victim of elder abuse approaches to reveal their problem.

Identifying Elder Abuse

Elder abuse is a pattern of coercive and often violent behavior that may include physical, emotional and financial exploitation that caregivers inflict upon older adults. Neglect includes failure or omission by a caregiver to supply an older adult with reasonable and necessary food, clothing, shelter, health care or supervision.

Indicators
  • Physical Abuse
  • Hitting, pushing, shaking
  • Emotional Abuse
  • Harassment, intimidation, verbal insults
  • Financial, cons, scams, theft of monthly checks and/or other assets

Signs and Symptoms

  • Sudden inability to pay bills, buy food or medicine
  • Unexplained injuries or bruises
  • Changes in mood, depression, or tiredness
  • Lack of contact with family and friends

Direct Questioning

Specific, clear, and non-judgmental questions can be asked in a confidential setting. The examiner must be alone with the patient in a private room. Opening questions may include:

  1. Because violence is common in so many people’s lives, I ask about it routinely. At any time has anyone living with or caring for you ever hit, kicked or in some other way hurt you or frightened you?
  2. I know that you said you fell on your left side, but you have injuries on your other side as well. I’m concerned that someone hurt you.
  3. Many people come in with injuries like yours and often they are from someone hurting them. Is this what happened to you?
  4. It seems you haven’t been eating well lately/not taking your medications. Has someone taken money you would use for food or medications?

Procedure
  1. Patient comes to Emergency Department.
  2. Triage clinician sees bruises or other indicators and suspects abuse.
  3. Patient taken to the exam room for clinician to conduct screening. All persons accompanying the patient are asked to leave.
  4. If abuse is revealed or suspected, patient is referred to a social worker.
  5. Social Worker/Case Manager:
    • Performs a complete psychosocial assessment
    • Reports cases of suspected abuse to the appropriate agencies.
    • Provides immediate, on site counseling.
    • Makes referrals to shelters, hot lines and other community
      resources.
    • Assesses the support network to ensure a safe and appropriate
      discharge.
    • Provides follow-up counseling and assistance with Police and
      Crime Victims reporting.


Some text adapted directly from Society for Social Work Leadership in Health Care Standards.

Sources:

Hones, W. (1968). The ABC Method of Crisis Management. Mental Hygene, 52, 87-89.

Kanel, K. (1998). A Guide to Crisis Intervention. California: Brooks/Cole Publishing Co.

Standards of Care on Violence and Abuse. [electronic version] (2000-2004) Society for Social Work Leadership in Health Care. Retrieved 2004 from http://www.sswlhc.org/html/standards.html