Risk Beyond Reason: On the Job Safety for Washington s Community Mental Health Workers. Mental Health Workers Speak Out

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1 First Class Mail U.S. Postage P A I D Seattle, WA Permit No Risk Beyond Reason: On the Job Safety for Washington s Community Mental Health Workers Inside: Mental Health Workers Speak Out Service Employees International Union 15 S. Grady Way, Suite 200 Renton, WA Available on-line at Campaign for Quality Mental Health Care SEIU 1199NW Second Edition

2 Campaign for Quality Mental Health Care The Campaign for Quality Mental Health Care is led by mental health care workers united for a better mental health system in Washington state. The Campaign is a project of SEIU 1199NW, Washington s largest union of health care workers. Service Employees International Union District 1199NW includes more than 20,000 Washington health care employees working in acute care hospitals, clinics, mental health facilities, and agencies around the state. Diane Sosne, RN President Chris Barton, RN Secretary-Treasurer Emily Van Bronkhorst Executive Vice-President Marcy Johnsen, RN Vice-President, Public Sector Grace Land Vice-President, Private Sector We are 1,000 mental health employees working to provide care and services for clients at clinics around Washington, including: Compass Health Community Psychiatric Clinic King County West Seattle Psychiatric Hospital Kitsap Mental Health Services Behavioral Health Resources Thurston/Mason Counties Whatcom Counseling and Psychiatric Clinic Our Mission As community mental health workers in Washington state, we are committed to build a quality mental health system that provides affordable, accessible services for all who need them. We stand for adequate public funding, access to mental health services and treatment for all those in need; services that promote recovery and resilience; reasonable caseloads; and fair pay, benefits and respect for all workers. We will work with consumers, advocates, and all allies who share our vision. Our goal is to unite all mental health workers in Washington state in our union so we can build a powerful movement to accomplish our mission. This report is available on-line at

3 Executive Summary On the evening of Friday, November 4, 2005, Marty Smith a County Designated Mental Health Professional (CDMHP) from Kitsap Mental Health Services got a call from a Poulsbo resident. She reported that her son, who lived with her and was a mental health client, was in crisis and needed help. Marty, an experienced mental health worker, responded to the client s residence to evaluate him for possible commitment under the state s Involuntary Treatment Act. As is common practice in most areas of Washington, Marty went alone. Tragically, he was assaulted and stabbed to death by the client. Marty s death is, unfortunately, an extreme example of a more pervasive problem: workplace violence against community mental health workers. People grappling with mental illness are not inherently more dangerous than the public overall. But social workers, clinicians, CDMHPs, and other community mental health workers interact with clients when they are in crisis when they are most likely to harm themselves or others. A very small minority of mental health clients actually become violent. When a client has a violent episode, the community mental health worker is often the first to interact with that client. As a result, violence on the job has become a daily concern for community mental health workers. Overall, mental health workers are assaulted four times more frequently than other types of health care providers, and five and one-half times more frequently than all workers. 1 The mental health caregivers of Service Employees International Union District 1199NW Washington s largest organization of community mental health workers believe that Marty s death was preventable. Following Marty s death, SEIU 1199NW conducted a survey of 315 community mental health workers around Washington state. We found that: In the last two years, caseloads and the complexity of individual client conditions have increased. 75% of community mental health workers report feeling unsafe on the job. 78% of community mental health workers have been assaulted either verbally, physically or both; fully 22% report being physically assaulted in the last two years. 42% of community mental health workers feel they don t have adequate backup when safety is threatened. 44% of community mental health workers feel they don t have sufficient training to deal with safety issues. ENDNOTES 1 N Duhart, D.T. (2001). Violence in the workplace, (No. December 2001, NCJ ). Washington, DC: U.S. Department of Justice, Office of Justice Programs. 2 N Duhart, D.T. (2001). Violence in the workplace, (No. December 2001, NCJ ). Washington, DC: U.S. Department of Justice, Office of Justice Programs. 3 Compass Health OSHA Form 300 Log of Work-Related Injuries and Illness, Kitsap Mental Health Services OSHA Form 300 Log of Work-Related Injuries and Illness, Lisa s Law, HB 4099, Public Act 14, Session, Michigan State Legislature, (2001). 6 Bill A02570, Session, New York State Legislature. The bill passed the Assembly in the Session but failed in the Senate. The bill has been proposed every session and is currently under review in the Session. Washington state s mental health system has failed to provide a safe working environment, sufficient training, or enough support to its workers. SEIU 1199NW union members, through the Campaign for Quality Mental Health Care, are committed to work with elected officials, the Department of Social and Health Services, providers, consumers, family members and other mental health advocates toward solutions. In the 2006 Legislative session, SEIU 1199NW is supporting three measures for safer workplaces: 1) The Marty Smith Law. Increase staffing so that no crisis outreach worker will have to go alone to do a home visit to evaluate a client. Increase training in violence prevention for all community mental health workers, and ensure that crisis outreach workers have adequate information and resources to respond in emergencies. 2) Take a closer look at the caseload crisis. Through the Legislature s joint task force on mental health issues, hold hearings statewide on the rise in caseloads and their impact on clients and communities, so that we can develop long-term, comprehensive solutions to the problems in mental health care. 3) Expand alternative case management approaches, such as Program for Assertive Community Treatment (PACT) teams. PACT teams have a proven national record of improving services for those most acutely in need and reducing jail, court and hospitalization costs. 7 Bob Crittenden, MD and Amity Neumeister, No Place to Turn: Mental Health in Washington State, Working for Health Coalition, Seattle, WA. Nov

4 Survey Results From December 2005 to January 2006, 315 community mental health workers from 12 community mental health agencies in Washington state participated in a survey on workplace violence issues. The average survey participant had 11 years of community mental health experience, with individual experience ranging from 0 to 30 years. The workers represented every aspect of the community mental health system including inpatient, outpatient, residential, crisis services, evaluation and treatment, and outreach services. The survey results underscore growing problems related to job safety for community mental health workers. Three steps that the state Legislature can take 1. Adopt HB 2912, the Marty Smith Law Require that mental health crisis outreach workers pair up when sent to visit a client in the client's private home, and provide funding for the additional positions needed. Provide for annual safety and violence prevention training for all community mental health workers who work directly with clients. In the last year, we ve had staff reductions at our agency. As we lose staff, caseloads are transferred and given to other staff, who already have high caseloads. We re losing the human-to-human contact that case managers provide to our clients. Our clients have to wait longer before we can see them, and we hope to see them before their symptoms get worse. Maureen Masterson Adult Support Compass Health Worker caseloads are increasing while time with clients and resources are diminishing. In the past two years, what has happened to your caseload/workload? Remained the same, 30% Decreased, 6% Increased, 65% Ensure that crisis outreach workers have prompt access to existing case files before they go to visit clients. Provide emergency communication devices to crisis outreach workers. 2. Adopt HB 2913, which directs the Joint Legislative and Executive Task Force on Mental Health Services Delivery and Financing to study the impact of high caseloads on mental health services. The task force would make recommendations to address caseload problems and client access to services. 3. Adopt HB 2911, which provides for expansion of PACT teams We need the Legislature to act. Together, we need to stand up for quality services and manageable caseloads that will lead to increased safety for staff, clients and the community. Heather Freese Benefits Specialist Community Psychiatric Clinic Expand the state s use of PACT teams from the current pilot project in Clark County. Nationally, PACT teams are a proven and effective mental health service delivery model. PACT teams will reduce costs in the long run, by reducing hospitalization, homelessness and incarceration. 2 11

5 4. Broaden the state s understanding of the impact that high caseloads have on clients and communities, so that the Legislature can take up comprehensive system reform. It is estimated that one million Washingtonians are affected by a diagnosable and usually treatable mental disorder. Yet in 2003, only about 126,000 residents received some sort of mental health support from the network of publicly-funded community mental health clinics, programs, residences, and inpatient facilities. 7 Many or these 126,000 people likely found case managers, social workers and clinicians with huge caseloads, unable to spend sufficient time on their needs. Today, according to our survey, the situation is even worse. Too many mental health clients end up dropping out of the system, not because they no longer need services, but because they have difficulty accessing quality, timely help. The Legislature should examine the growing caseload crisis, with a goal of developing comprehensive reform of our state s mental health system. Through hearings conducted by the legislative leaders, the state should solicit the views, ideas and solutions of mental health workers, clients, families, and other mental health advocates. Legislators should conduct these hearings in time to prepare bills for the 2007 legislative session. 5. Explore alternative service delivery models to improve worker safety and client recovery and resilience. Many clients who stop seeing their case manager and drop out of the system end up in our community s court system, jails and emergency rooms. Not only does the traditional case management system lack efficacy for some clients, it ends up costing taxpayers more in the long run. In recent years, a number of alternative service delivery models have been tested in various states. One of those approaches, the Program for Assertive Community Treatment (PACT) teams, has been particularly effective with frequent users of the mental health system, such as people with co-occurring disorders who may have great difficulty navigating the traditional case management system. The PACT team model uses a multi-disciplinary team of professionals and peer supports to provide comprehensive care and services to people with severe mental illnesses. By having clinical professionals available to the client 24 hours a day, 7 days a week, PACT teams have been shown to reduce hospitalization, homelessness, and incarceration, thus improving the lives of clients while reducing government costs. Since 1999, a PACT team pilot project has operated in Clark County with positive results. This program should be expanded in our state. Increasing caseloads hurt clients and compromise quality services. If your caseload/workload has increased, what has been the effect on your clients? Nearly two-thirds of community mental health workers reported an increase in their caseloads over the past two years. Some 86% of community mental health workers reported that caseload increases have had a negative impact on their clients. Many community mental health workers have said that increasing paperwork demands have reduced the time they can devote to direct client services. Complexity of client conditions has increased, putting community mental health workers at greater risk. In the past two years, what has happened to client acuity (complexity of condition)? Remained the same, 31% Positive, 2% None, 12% Decreased, 6% Negative, 86% Increased, 63% Nearly two-thirds of three community mental health workers reported an increase in client acuity in the last two years. Community mental health workers reported seeing more clients with dual diagnoses, more clients with criminal records, substance abuse issues, and severe mental illnesses. Many community mental health workers believe this increase in acuity is a symptom of the continuing unraveling of the social safety net. I can only manage the most acute crises at any given time. I can not give clients the attention they need to prevent a crisis from developing. Often, there are clients who repeatedly miss or cancel sessions and they start quietly slipping away. We need to be able to follow up, find them and re-engage them in services so they don t go off their medications, become homeless or become dangerous to themselves or society. Instead we re always dealing with the most urgent needs because caseloads are so high we can t do both. Diane Broderick Clinician Compass Health 10 3

6 Increasing numbers of community mental health workers reported feeling unsafe on the job. In the past two years, have you ever been in a work situation where you felt unsafe? No, 25% 2. Provide additional training in violence prevention for all community mental health workers. It is unacceptable that so many community mental health workers have not received sufficient training to deal with safety issues at work. Safety affects not just community outreach workers, but also mental health workers in inpatient, residential and outpatient workplaces. The state should institute annual training for all community mental health workers. The safety training curriculum should be developed in partnership with community mental health workers, who best know the situations they face and the deficiencies in current training curricula. Yes, 75% Overall, 75% of community mental health workers reported working in unsafe work situations. It s even higher for inpatient community mental health workers, many of whom work with involuntarilydetained clients: 95% of those workers reported feeling unsafe. No, 5% Yes, 95% Both the Michigan law and the New York bill contain provisions for mandatory safety training. 3. Provide workers with the tools they need to perform effectively and safely. CDMHPs and other crisis outreach workers report that often they do not have a full understanding of the client s mental health history before they go out to do an evaluation visit. Occasionally, community mental health workers feel pressure to go out to the visit without enough time to allow them to find and review the client s case file. In addition to placing the worker at risk, this practice also compromises quality services. The state should ensure that response time regulations adopted by Regional Support Networks or providers allow sufficient opportunity for community mental health workers doing crisis outreach visits to have access to all the information they need in a timely manner. Additionally, there is no current state requirement that crisis outreach workers be provided with cell phones in case of emergencies. Providing information and cell phones to crisis outreach workers are simple steps that Washington state can take to ensure greater safety in community mental health. Many of us feel that we just have to deal with the unsafe climate of being a CDMHP, that it s a part of the job, especially new people who don t have the experience or training to know better. I always tell the new people not to go out alone, and I try not to. Having a second person there can really help you, the client, and the feeling of safety for the whole team. Hannah Antokol CDMHP Behavioral Health Resources 4 9

7 Washington state s mental health system must do more to improve safety and services Assaults in the workplace are a key concern for Washington s community mental health workers. In the past two years, have you been verbally or physically assaulted by a client? No, 22% Yes, verbally, 56% 1. Pair up mental health professionals doing home visits. Yes, physically, 22% Two people, together, make a better decision about safety than one person by themselves. Lisa Warner Lead CDMHP Behavioral Health Resources Assigning mental health professionals to conduct evaluations in pairs makes these visits safer. Had Marty Smith been paired with a colleague, it is very possible he would be alive today. This pairing practice is already established policy in King County, Washington s largest county. It should be extended statewide, to improve safety and services and prevent future tragedies. Having a second mental health professional on home visits also improves judgment: Two people, together, make a better decision about safety than one person by themselves, notes Lisa Warner, a Lead CDMHP at Behavioral Health Resources. Other states also are looking to improve safety for workers who do home visits. Four years ago, in the wake of the murder of a child protective services worker, the state of Michigan enacted a law that called for pairing up child protective service workers who do home visits. 5 And seven years ago again, tragically in the wake of the murder of a mental health worker the New York State Assembly passed a bill that would require doubling up outreach workers. 6 Pairing up crisis outreach workers will not double costs. CDMHPs report that about 20% of their visits are conducted in private homes or other non-public places. These are visits that should be conducted in pairs. The bulk of outreaches, about 80%, are conducted in places where backup help is more readily accessible, such as emergency rooms. A National Crime Victimization Survey found that mental health workers are assaulted four times more frequently than other types of health care providers. 2 In our survey, 78% of community mental health workers reported having been assaulted on the job either verbally or physically in the last two years. One out of five community mental health workers reported being physically assaulted by a client. These assaults include being punched, kicked, bitten, shoved, strangled or stabbed by a client. One community mental health agency, Compass Health, reported 24 client-related injuries in the last three years. 3 Eighteen of those reported injuries were client-assault related, resulting in 259 lost work days. Another community mental health agency, Kitsap Mental Health Services, reported 43 client-related injuries in a two year period. 4 Sixteen of the reported injuries were client assaults and thirteen were injuries that resulted from de-escalating a violent client. Twelve injuries that resulted from client assaults or de-escalation processes required medical attention. These reports are not unusual for community mental health providers. After the murder of a Pierce County Designated Mental Health Professional some years ago, King County Crisis and Commitment Services adopted the policy of going out in pairs when asked to evaluate individuals in the community. In the course of my work as a DMHP I have been assaulted several times and found it invaluable to have a partner there to help stabilize the situation. I am convinced there would have been more assaults on my person had I been required to outreach alone. It concerns me that many of my colleagues go into these inherently dangerous situations without a partner. How would you feel knowing a loved one of yours, while trying to provide services in the community for the seriously mentally ill, was required, day in and day out, to be doing so without the added security and assistance a partner provides? Miles Wetsman Designated Mental Health Professional King County 8 5

8 Assaults on community mental health workers in inpatient settings are more prevalent. In the past two years, have you been verbally or physically assaulted by a client? Community mental health workers are concerned about inadequate backup and training. In your daily work, do you feel you have adequate back-up when your safety feels threatened? No, 0% Yes, verbally, 24% No, 42% Yes, 58% Yes, physically, 76% At a previous job a client I was working with became very angry, and began flipping over furniture, punching walls and making threats to the staff. Being alone in the room with her, I knew I needed to remove myself from the situation, to give her some time to de-escalate. As I was leaving she slammed the door on me and caught my finger in the door. When I tried to pull it free she slammed it shut and tore off part of my finger. Vincent Wilson, Mental Health Professional Behavioral Health Resources In inpatient facilities, every community mental health worker who was surveyed reported being assaulted in the last two years: 76% reported being assaulted physically, and 24% reported being assaulted verbally. Do you feel you have received sufficient training in order to deal with safety issues at work? No, 44% Yes, 56% We had a client who was in a highly agitated state, and made several threats to me and the staff. When he left the building he went past staff who weren t trained in dealing with an agitated and violent client. My co-workers safety, the client s safety, and the safety of the clients waiting in the lobby were all threatened, and there was no one available in that area to deal with the situation. Barbara Wallace, BA, RN Kitsap Mental Health Services More than 40% of community mental health workers said they did not feel they had adequate backup when their safety felt threatened, and a slightly higher number said they felt current safety training was insufficient. Community mental health workers work in a variety of settings: offices, clinics, the community, private homes, hospitals and residential housing. Outside of inpatient facilities, many function without the full safety infrastructure of a fixed workplace such as a hospital. Enhanced safety programs for community mental health workers will have to account for the different factors involved in each of these varied workplaces. 6 7