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When trust is broken

section identifier imagethe front cover of a crosscurrents magazine- the main image is a vase with bold coloured flowers

Home visit staff need strategies to ensure their safety

By Abigail Pugh

Summer 2004, Vol 7 No 4


Providing health care to clients with mental illness involves much more than psychiatry appointments, hospitalization or finding and maintaining an appropriate drug regimen. Psychosocial support is key to a good outcome, and for many, home visits by social workers, nurses, occupational therapists and other community workers represent a regular, positive encounter that facilitates recovery. That’s because people with mental illness face a far higher risk of social isolation and poverty than the general population, in addition to the everyday challenges of unpleasant symptoms and drug side-effects. A home visit with a health worker with whom the client has a good, long-term rapport might mean the difference between a week of loneliness and debilitating symptoms and one of success and better health.

Yet homecare, with its one-on-one dynamic, brings occupational hazards for workers. Violence against homecare workers may include verbal abuse, harassment with a weapon, property damage, harassing phone calls, stolen property, physical assault and murder. A 1998 study published in the Journal of the American Medical Association found that among public health workers, 38 per cent had experienced violence. A 1997 study published in Social Psychiatry and Psychiatric Epidemiology found that among field-based community mental health researchers in the United Kingdom, 51 per cent had experienced at least one verbally violent incident. An Australian study published in 2002 in the International Journal of Mental Health Nursing revealed an even bleaker picture: among community mental health workers, 96 per cent had experienced some form of aggression in the course of their work. A full quarter of the sample felt that their lives had been threatened, and seven per cent had in fact sustained physical injuries.

Assaults and threats on workers may be more prevalent than is suggested by the academic literature. Incidents may be underreported, for several reasons: officially reporting a minor incident may involve time-consuming paperwork, and it may involve implicating a vulnerable client with whom the worker has a strong emotional bond. The worker may choose not to discuss the incident for fear of being labelled incompetent or inexperienced. In their article in a 2003 issue of Social Work, Patricia Spencer and Shari Munch argue that many social workers hold the “perception that violent incidents are an inevitable part of their work and that social workers should be able to take care of themselves.” Too often, management gives low priority to violence issues and neglects workers who are victims.

Not only is fear a major occupational stressor and a cause of burnout and “compassion fatigue” – both topics well-publicized in the case of mental health workers – fear compromises client care, as well. “If the worker does not feel safe, then the therapeutic relationship and quality of care provided will suffer,” says Karen Rebeiro, an occupational therapist in Sudbury, Ontario. “If I am fearful for myself, then it is difficult, if not impossible, for me to attend to my client’s needs and remain focused on caring.” Patricia Spencer is a social worker in Somerville, New Jersey, who was herself threatened with torture and murder while visiting a client’s home in 1999. “If a practitioner is threatened or hurt, he or she may suffer some symptoms of ptsd,” she says. “The person may call in sick, may quit, may have his or her clinical judgment affected.”

Anita McNeil, an occupational therapist in Winnipeg, Manitoba, believes that trust is a cornerstone of therapeutic success, and that when a worker feels intimidated, trust is compromised, sometimes beyond repair. “In some cases, change to a different therapist may be the best course,” she says. Any discussion of the dangers of home visiting should be tempered with a close look at the real threats during the visit. Most of the workers polled for this story made a special point of mentioning that they were often more intimidated by the environments in which their clients lived than by encounters with clients themselves. A Saskatchewan study of violence toward social workers published in Social Work in 2003 found that nurses working in urban areas reported twice the number of assaults and five times the number of risky situations as those working in rural areas. Drug deals in broad daylight, vicious dogs kept for the sole purpose of intimidation and heavy violent crime rates: these are all features of the types of neighbourhoods that many mental health clients are forced, usually through poverty, to inhabit. Greg Samuelson, community mental health services co-ordinator at the Centre for Addiction and Mental Health in Toronto, has advised colleagues to learn basic self-defence to protect them from potential threats in the client’s environment, namely, individuals unknown to the worker.

Another danger is simple complacency. Nancy Panagabko, a registered nurse in Victoria, British Columbia, says that, ironically, the powerful stigma attached to mental illness often results in less-trained workers looking for all the wrong signs. “Their fear is misplaced,” she says. “There’s not a good understanding of when it’s safe and when it’s not, which leads to going into situations where I wouldn’t go and refusing to go into situations where I would go.” Panagabko says that perhaps the most dangerous situation for any homecare worker is when the worker has known the client for everal months and feels a strong bond with him or her. The client may be off medication, and may be deteriorating; yet the worker thinks, “I know Joe. Things are fine.” The problem, according to Panagabko, is that it is usually those the client cares about and who care for the client who become hurt in this situation. During psychotic episodes, the ill client may misunderstand who the worker is or think that he or she is protecting the worker through aggressive acts such as locking them into a space.

Vancouver-based occupational therapist Jenny Hamilton-Harding visits clients in their homes. Half of her clients live in the city’s most visibly troubled area, mostly in low-rent hotels. Many have concurrent drug and mental health issues. She provides an interesting counterpoint to the often-worrying statistics about home care and client violence: “I haven’t felt at risk from clients. On the streets, I have been accosted, but even there, I haven’t felt in danger.” Last Christmas, Hamilton’s family came from Montreal to visit her. They were interested in seeing Vancouver’s infamous Downtown East Side for themselves, so she took them on a tour of the area. She says that far from reinforcing any ugly stereotype, the tour helped to alleviate her parents’ fears and showed them the human side of the area’s problems: “I took my parents to Carnegie Hall, a grand building with marble floors that is now a community centre. There were mental health clients just quietly hanging out, drinking coffee and reading.”

Clearly, while worker safety is a very real concern, it is a complex phenomenon, one that is easily misunderstood as the direct result of the inherent violence of people with mental illness. All the workers interviewed for this story were, without exception, proactive in pointing out that risks can be reduced through careful planning and simple precautions, and that they very often stemmed from more general problems of urban decay.

“There is a general impression in society that working with mental health clients is more risky as a rule than working with clients whose issues are not mental health,” Anita McNeil says. “Even those who are quite ill and psychotic do not, by any means, routinely become violent and dangerous.” 


Not only is fear a major occupational stressor and a cause of burnout and “compassion fatigue” – both topics well-publicized in the case of mental health workers – fear compromises client care, as well.


The powerful stigma attached to mental illness often results in less-trained workers looking for all the wrong signs.


“I always have the cell phone on me, and turned on, and am aware of its location. I check out with the secretary at the end of the day. There is a protocol in place if we haven’t checked out.”

            (Shannon Welsh, registered nurse, Sudbury, Ontario)


“Do not touch an aggressive client or sit on his or her bed. Give wide personal space. Do not lose your temper. Wear sensible clothes and running shoes, and nothing around your neck.”

            (Linda Todd, registered nurse, Sudbury, Ontario)


“My personal strategy for increasing my safety is to trust my gut. If I think something is wrong and my safety is compromised, I get out of the situation and re-evaluate.”

            (Patricia Spencer, social worker, Somerville, New Jersey)


“If we feel uncomfortable with the idea of going into the home after doing a drive-by, we have the option of canceling the visit and rescheduling it with more than one worker if needed. We sometimes set up appointments in a public space, such as a meeting room at a hospital or clinic. If going into a situation that raises any flags, we may arrange to get one of the other staff to give us a call at a certain time.”

            (Anita McNeil, occupational therapist, Winnipeg, Manitoba)


“Tell others where you are. Say ‘I’m going into this house. Call the police if I’m not out in 20 minutes.’ Don’t do calls alone. Don’t get so caught up in the interview that you are not aware of the environment. Ask the client to step outside or meet you in a coffee shop. Make sure you and the client have equal access to the door so that nobody is boxed in.”

            (Nancy Panagabko, mental health nurse, Victoria, British Columbia)


“Know the risky environments. Know, for example, that they deal crack on the seventh floor. Go around corners wide, and stand back from doorways. If somebody says, ‘All of a sudden he was right in front of me,’ then it’s about lack of awareness of the environment.”

            (Greg Samuelson, mental health nurse, Toronto, Ontario)