What Healthcare Providers Should Know and Can Do Regarding Interpersonal Violence Against People With Disabilities During the COVID-19 Pandemic
by Dr. Emily Lund (Assistant Professor, Rehabilitation Counseling firstname.lastname@example.org)
This is a summary article.
Full article (with citations) by Dr. Emily Lund is available at https://psycnet.apa.org/fulltext/2020-59952-001.html
The increased risk of interpersonal violence experienced by people with disabilities has long been noted in the literature. The increased risk for abuse persists across disability types, although individuals with certain types of disabilities—namely, developmental and psychiatric disabilities—are at even higher risk.
The ongoing novel coronavirus (COVID-19) pandemic has led to considerable and sudden social upheaval, including the lockdown of cities, states, provinces, and other localities. Lockdowns, quarantines, and safer-at-home measures may also place vulnerable individuals in situations in which they may be at greater risk for abuse by increasing their contact with perpetrators and by increasing the difficulty and risks of engaging in help-seeking and leaving behaviors.
A unique risk factor for violence victimization among disabled people is their frequent reliance on the perpetrators of their abuse for assistance with daily life activities, such as getting out of bed, eating, getting dressed, and accessing mobility devices.
Because the activities of daily living with which people with disabilities receive assistance are often critical to maintaining health, well-being, and functioning, people with disabilities often feel like they have no choice but to tolerate the abuse for fear of being left without access to critical daily assistance and care.
Disability-related abuse is seldom recognized by professionals outside rehabilitation- and disability-related fields and may not be adequately screened for or recognized as part of standard abuse screenings. Despite this, such abuse can be immediately physically harmful or even deadly, potentially resulting in medical complications such as pressure sores, malnutrition, dehydration, and urinary tract infections. Additionally, disability-related abuse can also perpetuate other forms of abuse. For example, destroying an individual’s mobility or communication device may make it impossible for them to either physically leave the situation or to report it to others.
Factors to Remember about Interpersonal Violence Against People with Disabilities as a Result of the Pandemic
People with disabilities have historically been and currently are subject to emotional abuse as a result of their disability status. Perpetrators could use the public devaluation of disabled lives during the COVID-19 pandemic as new verbal ammunition with which to attack their victims. Additionally, the circumstances of the pandemic may encourage perpetrators to begin abuse or heighten the intensity of abuse against disabled people, knowing they are now in a more vulnerable place and may have even fewer physical and emotional resources available to counter or protect against abuse.
People with disabilities experience considerable barriers to reporting abuse, even outside the context of a pandemic. These include fear of or lived experience of not being believed because of one’s disability, fear of retaliation from the perpetrator, fear of retaliatory responses from Adult Protective Services systems as a result of mandated reporting requirements, inaccessible reporting mechanisms, stigma, and lack of provider knowledge about the intersecting issues impacting abuse and disability. These barriers may be enhanced and heightened by the pandemic.
Many providers are currently providing services via telehealth to eliminate or greatly reduce in-person contact unless absolutely medically necessary. The use of telehealth, combined with the effects of quarantine and safer-at-home, means that it may be extremely difficult for individuals with disabilities to truly be in a private location when talking to providers.
People with disabilities often need to make complex decisions regarding reporting abuse because of Adult Protective Services (APS) laws that mandate that providers report suspected abuse of adults with disabilities. Concern that APS involvement could make the situation worse rather than better—for example, by leading to forced institutionalization or other loss of independence—has often led people with disabilities to deliberately choose not to disclose abuse
Abuse has considerable physical and psychological sequalae, including posttraumatic stress symptoms, depression, anxiety, gastrointestinal symptoms, and orthopedic pain and injury. These may occur as a direct result of violence (e.g., broken bones as a result of physical abuse) or as a result of ongoing chronic physical and mental stress related to abuse.
The COVID-19 pandemic has resulted in decreased utilization of routine and acute health care for non–COVID-19 conditions because of widespread avoidance of hospitals and other health care agencies because of concerns about potential exposure to the virus while receiving care. As a result, providers report concerns that patients are not seeking care until they reach a stage of acute medical crisis or that they are potentially not seeking care at all and dying at home.
People with disabilities have been historically cast as ideal victims in the eyes of some perpetrators because of their greater barriers to leaving, reporting abuse, and accessing care. The circumstances of the COVID-19 pandemic may further exacerbate that by creating a situation in which obtaining care itself is even more fraught with risk and barriers.
Strategies for Healthcare Providers
Providers who work with individuals with disabilities must educate themselves regarding some of the core issues surrounding violence against people with disabilities, such as disability-related abuse and disability-related barriers to addressing abuse. Some seminal and introductory articles and chapters on these issues may be helpful (e.g., Lund & Thomas, 2017; Powers, Hughes, & Lund, 2009; Nosek et al., 2001; Saxton et al., 2001, 2006).
It is vital that providers familiarize themselves with the mandatory reporting laws in their states because the laws for what types of disabilities fall under mandatory reporting requirements for vulnerable adults differ considerably by state and use the guidelines as part of the informed consent process. Although it may be uncomfortable for providers to know that clients may be purposefully withholding information about abuse, it is important to recognize that clients are making complex and potentially life-altering decisions regarding their own safety.
Because not all clients who experience abuse choose to disclose it, providers may want to provide resources and information about abuse to all clients during the pandemic, especially people with disabilities and those in other high-risk groups. As part of this universal psychoeducation process, providers should consider providing information about how to access abuse-related resources safely, such as using an incognito browser, immediately clearing browser history, and using websites with an immediate exit button that automatically clears browser history and takes the user to a neutral page.
Providers should work with all clients to develop contingency plans if they become ill or lose access to support for any reason during the pandemic. These plans can serve many of the same purposes as safety plans, such as identifying social supports; developing strategies for safely leaving the home, accessing emergency health care and maintaining care of chronic conditions; and identifying resources for backup care. Framing these plans as general care plans, rather than abuse-specific safety plans, may relieve potential client concerns about mentioning abuse directly or specifically while still providing clients with access to the same information and planning. Furthermore, safety and contingency plans that have been previously developed with clients may need to be reviewed and updated in light of the pandemic. Additionally, both new and existing safety and contingency plans may need to be reviewed regularly because of frequently changing circumstances.
Providers may consider beginning a discussion of safety planning with broad prompts, such as “Would you like to work on a contingency plan in case you become ill or lose access to care?” Such prompts will allow the client to inconspicuously decline if a perpetrator is present or can otherwise overhear the conversation.
Providers who are providing telehealth care should make every effort to help the client locate a private area in which to receive services. Electronic, web- or phone-based applications or questionnaires may be used to silently screen for abuse prior to the appointment, although providers should be aware that not all clients may have secure, private phone or Internet access.
Rehabilitation psychologists and other providers who work with individuals with disabilities should play a part in advocating against the systemic ableism and devaluation of disabled lives in the health care system and in society as a whole. Although the pandemic has resulted in both new and magnified concerns for people with disabilities, the devaluation, discarding, and disrespect of disabled lives that facilitates and perpetuates individual-level interpersonal violence against people with disabilities is not new.
Providers should take steps to become aware of their own ableism, including centering work by disabled psychologists, and actively discuss ableism and anti-ableist attitudes and practices with trainees. Providers should adopt a framework in which the abuse of people with disabilities is recognized as a consequence of systemic oppression as opposed to an individual weakness or lack of capacity.
Providers must thoroughly assess and address the additional cultural, linguistic, and social barriers that disabled clients with multiple marginalized identities may face when seeking assistance with abuse-related issues. Providers should be aware of unique barriers faced by people of color with disabilities, both in general and in the specific context of the COVID-19 pandemic. They must be willing and able to help clients navigate those barriers and find truly culturally competent care.
The systemic roots of violence against people with disabilities run deep. The process of eradicating them is a long, slow one that requires a continuous self-reflection, professional growth, and an ever-present willingness to listen and respond to the concerns and needs of people with disabilities. This process starts with informed, culturally competent clinical practice and professional advocacy that addresses both immediate individual barriers and long-standing systemic issues that perpetuate the abuse of people with disabilities.