Dealing with Abusive Behavior and Difficult Situations

1 Contra Costa AIDS Program Final June 2009 XII/1 G:\CSGA\CM Working Group\MODULES\2007-08 Module REVISIONS\Final Modules\Module 12 Difficult Situations MODULE TWELVE Dealing with Abusive Behavior and Difficult Situations Contra Costa AIDS Program Final June 2009 XII/2 G:\CSGA\CM Working Group\MODULES\2007-08 Module REVISIONS\Final Modules\Module 12 Difficult Situations Policy Occasionally medical case managers will need to address Abusive behaviors and Difficult client Situations . In each instance, safety must be balanced with serving clients, many of whom have histories of violence related to substance abuse, mental health, and other circumstances. What follows are definitions of abuse and Difficult Situations and methods of assessment and possible interventions.

2 Case conferencing and team approaches work best in these Situations . Programs may suspend or terminate a client if the client has threatened violent Behavior or bodily harm to the medical case manager or any member of the agency staff. Medical case managers must discuss this action with the supervisor and document it in the case notes. Clients with substance abuse problems must not be terminated from medical case management solely for active substance use. Programs must identify a back-up plan for client services when using a suspension plan, "cooling off period, which allows a client who acted in a violent or threatening manner the opportunity to continue services with improved Behavior .

3 Clients can be terminated from the programs if they have made fraudulent claims about their HIV status or have falsified documents. Procedure Abusive Situations Abusive Situations are defined as acts that involve physical, sexual, or verbal abuse, and/or other types of abuse. Examples include the following: Physical Abuse: Hitting, punching, kicking, grabbing, spitting on orotherwise striking an individual. Sexual Abuse: Sexual assault or sexual harassment of either a staffmember or another client. Examples include rape, lewd conduct,creation of a hostile environment through sexual innuendos,advances, etc. Verbal Abuse: Verbal assault including belittling, screaming,threatening, blaming, or using sarcasm in an Abusive manner.

4 Other Abusive Situations : Includes acts of violence such as threatening someone with or without a weapon, displaying aweapon, and/or using a weapon on the premises or aroundclients/staff. Medical case managers (MCMs) have a variety of behaviors to pay attention to in the course of delivering services. It is the MCM s responsibility to do their best to ensure their own safety and the safety of others through assessment and prevention of Abusive Situations or through knowing how to respond to Abusive Situations . Clients may engage in violent Behavior in response to real or perceived rejection or confrontation by the MCM or as a result of their active drug use.

5 When a MCM is in the position of setting a limit or denying access to a service because of non-compliance with the care plan or another protocol, the MCM may become the target of the client s entire frustration. Sometimes this limit setting will remind a client of other Difficult or rejecting Situations in their lives, and they may react from that place. Responding to these Situations requires assessment to determine the best course of action. Contra Costa AIDS Program Final June 2009 XII/3 G:\CSGA\CM Working Group\MODULES\2007-08 Module REVISIONS\Final Modules\Module 12 Difficult Situations Assessment While we can never fully predict when someone may behave in an Abusive manner, we can minimize those times when a medical case manager might be surprised by an Abusive or dangerous Behavior .

6 The key to prevention of Abusive Situations is thorough and ongoing assessment. Assessment in our service delivery system includes a comprehensive initial assessment and an ongoing assessment. Initial Assessment: In Module 3 the Initial/Needs Assessment process was reviewed. The questions from the Needs Assessment most connected to assessing risk around abuse are the mental health and substance abuse questions. It is important to know how the client handles anger, disappointment, frustration, and other Difficult feelings. It is also important to know if they have ever injured or been accused of injuring someone . It is helpful to know if they are being or have been treated for mental illness, since some illnesses can be connected with Abusive Behavior .

7 These questions will give you some idea about their propensity for being Abusive . It is also important to know if they are actively using substances and, if so, which ones. Their use/abuse may alter their disposition, resulting in an Abusive situation related to their level of intoxication. A past history of violence or Abusive Behavior prior to seeking case management will not necessarily disqualify the client from case management services. However, such a history will influence how you will work with the client ( meeting at the office when others are present, making referrals to substance abuse treatment or mental health services, assessing social supports, etc.)

8 Assessing Client s Potential for Violence Indicators of potential violence are illustrated below. Indicators of Potential Violence Prior history of violence Low frustration tolerance Having a history of perpetrating violence on others or beingthe victim of violence History of serving time in jail or prison for a violent offense High level of agitation History of threatening others in a violent manner Mental illness related to acts of violence: A diagnosis ofBorderline Personality Disorder, Anti-Social PersonalityDisorder, Conduct Disorder in youth, etc. No demonstrated understanding between cause and effect Active chemical dependency, detox , or early sobriety Possession of weapons In Dealing with potentially violent clients, it is critical for the medical case manager to trust their instincts.

9 If the situation seems uncomfortable, leave, and make other Contra Costa AIDS Program Final June 2009 XII/4 G:\CSGA\CM Working Group\MODULES\2007-08 Module REVISIONS\Final Modules\Module 12 Difficult Situations arrangements. In such instances, medical case managers should record assessment information in the case notes and consult with their supervisor. It is important to develop a plan of how this client will be served to prevent client abandonment. Use of cooling-off periods, boundaries regarding when and where services are rendered are tools to consider using in these Situations . Ongoing Assessment: As the medical case manager continues to work with clients, he or she will need to continually watch for and assess changes in attitude or disposition that may lead to a client behaving in an Abusive manner.

10 By identifying the issues early, the MCM may be able to de-escalate the situation or make a referral for additional support that may prevent an Abusive episode. Sometimes clients surprise us despite our best efforts to identify and intervene in potentially Abusive Situations . There are a number of Situations that may present themselves in the moment when meeting with clients. Possible Triggers for Client Abusive Behavior towards the Case Manager Medical case managers serve as the center of many of the services within the system of care. Some clients are very new to the system of care and others have been a part of the system for some time. MCMs may need to set limits with clients.