Clinical: Lecture 5 Part 1
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Interviewing in possible abuse situations, what are the stages of the 3 stage process?
- intervention, if allowed
Intervention: Actions of the therapist--
- obtain history
- perform exam
- ask any accompanying SO to leave room unless authorized as guardian
- re-question to clarify mechanism of injury--probe w/out attactking
Consider your approach (as a therapist) for the intervention:
- frame w/ rationale
- direct questioning
- indirect questioning
Framing statements before asking the question:
- say: "It's customary at this point in the process to ask all pts if anyone in their life is hurting them or making them feel afraid. We ask this b/c there are resources we can offer"
- Make eye contact; wait 30 for response
- -never bring up what you are thinking; just reflect on what you know and see
- "The bruise on your neck looks more recent than the injury that brought you here. Did someone grab at you?
- Make eye contact; wait 30 sec for response
- ask: "How does your partner feel about your physical therapy sessions? are they supportive?
- "Have you been under stress at home? Have you ever gotten physically hurt as a result of this stressful situation?"
What are 4 typical responses to suspected abuse, regardless of approach?
- no response
- no, that doesn't happen to me (may seem uncomfortable that asked)
- how dare you imply that...
- yes, that happens to me.
Why would someone give no response when a therapist suggests abuse?
- pt may be waiting to see what else you'll say
- pt may not know how to tell you
- pt might not understand your question
- pt might be embarrassed
- pt may feel there is no way out, and so there is no reason to discuss it
How might a therapist follow-up after pt gives no response after the topic of abuse is brought up?
- continue exam
- rephrase question into statement: "I asked because I am concerned that your symptoms may be caused by someone that is hurting you. If that was the case, I could give you a list of places to go where you could feel safe"
- Make eye contact; wait 30 seconds
Why would a pt respond to suspected abuse w/ "No, that doesn't happen to me"?
- may be automatic denial; fear of trusting
- may fear SO can overhear conversation
- may be ashamed
- may not be ready to take action
- may consider it private business
- may be a true statement
How should a therapist follow-up to a pt responding to suspected abuse w/ "No, that doesn't happen to me"?
- therapist continues exam
- State: "Some of the physical things I am seeing do not match the history you have given me. Sometimes a pt doesn't feel they can say how they really got hurt. That's why I ask all my pts if they are being hurt by anyone"
- make eye contact; wait 30 seconds
Why would a pt respond to suspected abuse w/ "How dare you imply..."?
- pt might have social position to protect
- pt might have children to protect
- pt might fear what/how we will document
- pt might consider this a private matter
- no abuse, but pt believes myth about abuse only happening to certain types
How would a therapist follow-up to a pt responding to suspected abuse w/ "How dare you imply..."?
- stop exam...neutral body language
- explain: "Many women involved in domestic violence situations end up in medical facilities. It's my responsibility to ask everyone, so that anyone that wants help or a resource list knows that I am willing to provide it. I ask everyone, just to avoid ruling someone out on a stereotype"
- may have to stope here, to preserve rapport
Why would a pt respond to suspected abuse w/ "Yes, someone is hurting me"?
- pt might want help to take action
- pt might only want info on options
- pt might fear for own life
- pt might think therapist is trustworthy
- first time anyone asked question (but still may not want therapist to take actions)
How would a therapist follow-up to a pt who responds to suspected abuse w/ "Yes, someone is hurting me"? For an adult...
- Photography: consent; use ruler next to bruises to doc size; against plain background and print paper copy; date and sign right away; don't photgraph ant chest wall w/o standby
- Documentation: describe size of injury; color; visible marks; statements of pt; observed behavior in objective terms; illustrated body chart added to record
- manage situation: store photos in locked cabinet w/ chart; bill under regular codes...no abuse codes; don't pass off pt to aide/assistnat until bruises fade; make sure skilled care is required if treatment is ongoing
What are things a therapist can't do to help someone who is being abused?
- become part of any escape plan (we post info in facilities and refer them to shelters/organizations)
- lie about pts attendance in record (due to HIPPA, can't release pt info to family members but times and dates...)
- encourage pt to break the law (run away w/ shared-custody child or illegally obtain a weapon)
How does elder abuse differ from adult violence?
- heightened bulnerability of population (physical, mental, financial)
- more stringent reporting requirements
- occurs across spectrum--but often a typical pic of abuse victim
- 3 primary types: physical (includes sexual/emotional); negligence; financial
any physical pain or injury which is willfully inflicted on an elder by a person who has care of custody of, or who stands in a position of trust w/ that elder, constitutes physical abuse (usually most common type of abuse)
What types of actions are included in physical elder abuse?
- direct contact beatings
- sexual assault
- unreasonable physical restraint
- prolonged deprivation of food or water
- emotionally charged interactions that exceed normal civil behavior
What should therapists look for w/ physical elder abuse?
layered bruises, ligature marks, unexplained injuries; pain when touched in areas that should not be involved; missing hair clumps; scratches
Elders w/ highest risk for physical abuse:
- financially dependent
- limited social contacts
- dependent, especially w/ toileting--almost 1/2 of the victims were not physically able to care for themselves
- cognitively impaired
- adult children living in same house
- 2 out of 3 abuse victims were women
- 2 out of 5 victims were >80 years old
- 77.1% were Caucasian
- failure of any person having care/custody of an elder to provide that degree of care which a reasonable person in a like position would provide constitutes neglect. This includes but isn't limited to, failure to:
- -assist in personal hygiene or provision of clothes
- -provide medical care for physical/mental health
- -protect from health and safety hazards
What should a therapist look for with elder negligence?
- inadequate or spoiled foods
- offensive smells in home
- clothing not in synch w/ season/weather
- hoarding behavior
- consistently poor state of cleanliness
- signs of dehydration
- any theft or misuse of an elder's money or property by a person in a position of trust w/ an elder
- targets typically females and/or oldest old who are <80 years old
- % of financial abuse cases increasing as economy worsens
What should a therapist look for w/ financial elder abuse?
expensive gifts to caregivers; collection agency calls about unpaid bills; caregiver's refusal to spend money for items needed by vender
Why is elder abuse still a problem?
- difficult to identify b/c involves caregivers we depend on for info
Profile of elder abusers:
- in 89.3 cases, abuse happened in the home
- 52.7% abusers were female
- 3 out of 4 abusers were <60 years old
- most had a family connection (32.6% were abult children; 20.5% were other relatives)
- drug or alcohol issues on part of caregiver are common in situations involving abuse
- fear that reporting may result in removal from present living situation
- social impact-"this does not happen to good people/nice families" leads to denial by elder
- fear of reprisals after practitioner is gone
Does Child abuse differ from adult and elder abuse?
DEF: Abuse/negligence (neglect):
- any act of failure to act:
- resulting in imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse or exploitation
- of a child (usually under 18)
- by parents or caretaker responsible for child's welfare
Who are child abusers?
- 80% were parents
- mom acted alone for 47% of neglect cases
- mom acted alone for 32% of physical abuse cases
Child abuse: clinical observations
Problem: "childhood impetuousness"
- same as w/ adult/elder violence plus:
- bald spots on head in mobile child
- injury attributed to 3rd party
- injury inconsistnet w/ dev. level
- unusal delay in seeking care
Child abuse: clinical observations
Observed caregiver behaviors:
- overly concerned about trivial injury
- lack of concern detachment about injury
- unrealistic expectations of child
- lack of response to child's pain
- lack of trust in health professional
State reporting criteria: adult (non-elder) violence:
- requires state to offer non-mandatory multidisiplinary and discipline-specific training on child abuse and domestic violence to medical and mental health providers
- requires health care professionals to report injuries resulting from criminally injurious conduct
- since there is no duty for health professionals to report, we can't violate HIPPA and share pt's medical info w/ 3rd party w/o permission
- we CAN report violation of a restraining order that occurs at our clinic
State reporting criteria: Eldre violence
- all 50 states and DC have enacted legislation authorizing provision of adult protective serves in cases of elder abuse
- APS laws establish system for reporting and investigation of elder abuse and for provision of social services to help victim and ameliorate the abuse
State reporting criteria: Child abuse
- since 1996, all 50 states requires reporting by:
- Health care providers
- health facilities of all kinds
- mental health providers of all types
- teachers and school principals
- social workers
- day care providers
- law enforcement personnel
Issues about reporting:
- failure to report possible child/elder abuse: criminal charges are rare; civil charges: misdemeanor punishable by a fine
- false report: little chance of punishment b/c they don't want you to be scared to report when it is an actual case
Protection for reporter of suspected elder/child abuse:
What if you are wrong?
- all 50 states have immunity standard
- "Good faith standard": immunity
- once reported, provider free from charge of "failure to take action"
- may still face civil suit
In summary: Interview involves collection of verbal, non-verbal, written, and observational information from pt, confidential med records, and other providers that will help the therapist create roadmap for the course of case management.
unexpected info may require change in therapist's plan for case management
confidentiality is essential as we non-judgmentally protect our vulnerable clientele w/o exceeding boundaries of law, their consent, and/or our professional boundaries
electronic communication is both beneficial and detrimental to establishing rapport and communication
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