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September 10, 2012

May I Sit Down? Safety vs. Dignity Engaging Clients during ACT Home Visits

At Assertive Community Treatment (ACT), social workers provide mental health care to clients both in the office and in the community. During the hours of 9:00 AM to 11:30 AM, the ACT Ypsilanti team travels to the homes of 7-12 clients each day to provide at home care. During this visit, social worker provides Am eyes-on medication and observe the client set-up his/her medication in a med box up to the next time s/he will be visited. The social worker also conducts a mental status exam and inquires about whether the client needs any resources or assistance. The whole visit lasts approximately 10-15 minutes, and for the entirety of the visit, the social worker remains standing, while the client often sits.

Current ACT written policy states that the social worker should remain standing as a personal safety precaution (ACTA 2011). Other similar safety precautions involve keeping the client’s door open, and standing between the client and the door. These written policies are in place to protect the social worker from potential violence. Unwritten policy states that the social worker should remain standing so as not to contract bed bugs (White 2012). While this unwritten policy may not be true for all ACT teams, it is one that is viewed with great importance by Ypsilanti ACT team. The threat of bed bugs residing in seat cushions and cloth fabric, or even carpet causes much distress to the Ypsilanti team, and the team takes great precautions to remain standing with pant legs rolled up.

The issue of a standing social worker first came to my attention when conducting a home visit. The client, who often presents with labile affect, yelled “just come in. You people never sit down, so let’s go to the kitchen”. For a social worker to remain standing while having a fifteen minute conversation with a seated client is controversial because of the research that has been conducted on the importance of being on the same level as clients. Although safety concerns are valid, standing while clients sit may not be conducive to helping clients. Even though written and unwritten policy states that the social worker should remain standing during home visits, standing causes a disconnect between the client and social worker because it creates a power dynamic in which the social worker is superior to the client.

Although there is already a power dynamic in place when a social worker visits a client’s home, this power can change based on the type of interaction between the individuals. In fact ACT strives to alter the power relationship between the helpers and help-seekers through home-based treatment. Home based treatments allow clients to continue to reside on their own and give them back independence over their lives, empowering them and allowing them to maintain dignity. This is based on the mission of ACT which is “to promote, develop, and support high quality assertive community treatment services that help improve the lives of people diagnosed with serious and persistent mental illness” (ACTA 2011). With a mission statement promoting the improvement of those with mental illness, it seems clear that empowering clients to be independent would be one way to achieve this mission.

One of the best evidence-based practices for improving relationships between case workers and clients during home visits is for the social worker to act as a guest and allow the client to act as the host (Muir-Cochrane 2000). By acting as a guest, the social worker relinquishes power and gives it to the client, creating a more balanced relationship. This can be especially helpful for clients who have an alternative treatment order (ATO), and do not want treatment, and who find having a social worker at their home to be invasive. In a study of nurses who conducted home visits, Muir-Cochrane (2000) found that acting as guest in a client’s home made a profound impact on the client’s mental health because it shifted the power dynamic and empowered the client. The client felt that s/he had control over his/her home and life. However, acting as a guest also involves sitting down when invited to by the client. Similarly, clients could choose not to ask workers to sit down, and by having control over this decision, there was a more evenly balanced power dynamic between the worker and client.

Other research has also discussed the importance of being at the same eye level as a client. Lawrence-Weiss (2010) has found that regardless of the client’s age, one of the most effective ways to assist a client in building self-esteem is to speak to them at eye level. Lawrence-Weiss suggests that if a client stands, then stand; if a client sits, then sit, kneel, or bend over because this allows a client to feel validated. Furthermore, speaking to a client when not at eye level can induce frustration at not being truly heard or understood. It creates an unbalanced power relationship in which the social worker is superior to the client.

Standing while a client sits may also have important cultural implications that lead a client to feel inferior to the social worker. According to Cultural Competency Guides, it is important when working with clients of other cultures, that the social worker shows utmost respect for a client (Saldaña 2001). It further states that a client may not be as engaged in treatment if s/he perceives social distance between self and the worker. It seems that by communicating on different planes, and not maintaining the same eye-level, that the client may suffer as a result of a worker’s unwillingness to meet him/her at eye-level.

Based on the research, it seems painfully obvious that clients greatly benefit from having a social worker sit down to speak to them when they are also seated. This lends to the question, why don’t social workers just sit down if it’s so important? The answer is unfortunately, personal safety. Although Sadock and Sadock (2007) maintain that the amount of crimes committed by the mentally ill are not statistically different than those of the general population, other sources provide different statistics. Trainin Blank (2006) provides statistics that reveal that “51.3% of the sample reported feeling unsafe in their jobs. Nearly one-third have experienced some form of violence, including verbal abuse... Nearly 15% reported at least one episode [of violence] in the field”. Crime among the mentally ill is viewed as more dangerous than the general public because of the perceived randomness and lack of an understandable motive. Because of these safety concerns, practitioners are encouraged to take great caution when conducting home visits.

Although ACTA (2011) policy states that social workers should remain standing, Trainin Blank (2006) encourages social workers to remain at eye-level with clients to de-escalate clients. Other home visit procedures also state that sitting in a hard-backed chair may be beneficial (Multiple Program Worker Guide 2011). It does discourage sitting on cloth seats but states that this is due to the possibility of sharp objects being hidden beneath the cushion, rather than bed bugs. The guide also states that before sitting down or entering the home, the social worker should observe the surroundings for safety concerns and cleanliness.

Another important consideration is the National Association of Social Worker’s (2008) Code of Ethics. For example, NASW code 1.01 states that “Social workers’ primary responsibility is to promote the well¬being of clients”. If a client is not engaging in treatment because of an uncomfortable power dynamic in which the social worker is perceived as superior and imposing him/her self on the client in the home, then it seems as though the social worker would not be meeting the first standard in the code of ethics. Because a client’s wellbeing comes first and foremost, social workers need to consider the possible implications of standing while a client sits and critically analyze if this is hindering the client’s treatment. Secondly, under 4.05, it states, “social workers should not allow their own personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties to interfere with their professional judgment and performance or to jeopardize the best interests of people for whom they have a professional responsibility”. Unpacking this standard is more problematic because of it begs the question, would fear of bed bugs or fear of personal safety fall under the category of psychosocial distress? If a social worker assesses the client as they enter the home and finds that the client does not seem threatening or agitated, there are not visible weapons, and the house is not overly unclean, is it then an irrational fear and personal psychosocial distress which causes the social worker to remain standing despite the safe surroundings?

In the end, the simple decision about whether to sit or stand when working with clients is actually much more complicated and requires a great deal of thought because it significantly impacts the power dynamic between the client and social worker, which then impacts the client’s level of engagement with the social worker. Being a social worker, and following the NASW code of the ethics means making the client the primary priority, which means that social workers may be placing themselves in risky situations from time to time.

While ACT home visit policies state that the social worker should remain standing for the duration of the home visit, current evidence-based practices show that this may not be the most conducive way to work with clients. ACT needs to review current evidence-based practices and adjust written policy in order to follow the NASW code of ethics and provide the best possible services to clients. Safety for social workers still needs to be a concern, but there are ways of assessing risk that can be incorporated into new policy. For example, assessing a client’s mental status and observing the surrounding area for cleanliness and potential weapons can be the determinant for whether a social worker should sit down (if the client is sitting) or remain standing. Respect should be the utmost priority, especially since the social worker is in the client’s home, so it is also important to ask if you may sit, if the social worker typically remains standing.

Clients are most engaged and thus receive the best treatment when social workers show respect to clients and ‘get on their level’, so that the client and social worker have good eye contact, and so that there is not an unfavorable power dynamic. One way to measure client engagement is to observe the length of time spent at a client’s home. On the ACT Ypsilanti team, the length of time is closer to 7 minutes on average, rather than the full 15. Changing one simple interaction, from standing to sitting with a client, can make a huge difference in a client’s recovery and mental health maintenance. Sitting with a client will also encourage conversation and the client’s level of engagement. While social workers need to maintain personal safety, it seems that the positive aspects of sitting outweigh the risks, so long as the social worker is able to assess the condition of the client and the home.

References

ACTA (2011). Mission statement. Assertive Community Treatment Association.

Lawrence-Weiss, S. (2010). Do you meet your child at eye level? Early Childhood News and Resources.

Muir-Cochrane, E. (2000). The context of care: Issues of power and control between patients and community mental health nurses. International Journal of Nursing Practice, 6, 292-299.

Multiple program worker guide #19. Home Visit Guidelines, 63. 2011.
NASW (2008). Commitment to clients. Code of Ethics of the National Association of Social Workers.

NASW (2008). Impairment. Code of Ethics of the National Association of Social Workers.

Priebe, S., Watts, J., Chase, M., & Matano, A. (2005). Processes of disengagement and engagement in assertive outreach patients: Qualitative study. British Journal of Psychiatry, 187.

Sadock, B. J., & Sadock, V. A. (2007). Scizophrenia. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10, 484-485.

Saldaña, D. (2001). Cultural competency: A practical guide for mental health service providers. Hogg Foundation for Mental Health.

Trainin Blank, B. (2006). Safety first: Paying heed to and preventing professional risks. The New Structural Social Worker.

Posted by desolada at September 10, 2012 08:40 PM

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