1.1 Purpose of the Resource

Guidance on Disability Inclusion for GBV Partners in Lebanon: Case Management for Survivors & At-risk Women, Children and Youth with Disabilities is designed to support GBV Case Workers and GBV Supervisors to strengthen case management services for survivors and at-risk women, children and youth with disabilities, and to uphold GBV guiding principles while working with these individuals. It includes guidance, key actions and tools to improve accessibility and inclusiveness of existing case management processes and activities.

1.2 How to use this Resource

This resource complements, and should not be used in isolation to, existing GBV prevention and response procedures, guidance and training in Lebanon, including:

• Inter-Agency Standard Operating Procedures (SOPs) for SGBV Prevention & Response in Lebanon (2014)
• Standard Operating Procedures (SOPs) for the Protection of Juveniles in Lebanon – Operational toolkit (2015)
• SGBV Case Management – Minimum standards and tools for Lebanon (2014/2015)
• Interagency Gender-Based Violence Case Management Guidelines: Providing Care and Case Management Services to Gender-Based Violence Survivors in Humanitarian Settings (2017)
• ABAAD Gender-Based Violence Case Management in Emergency Settings: Online Learning Course
• IRC Case Management Training, Peer-to-Peer Coaching Program for GBV Caseworkers and Supervisors
• IRC Caring for Child Survivors of Sexual Abuse: Guidelines for Health and Psychosocial Service Providers in Humanitarian Settings (2012)

The material presented in this guidance should be adapted and integrated into existing guidance, tools and trainings. It features boxes to inform case managers and supervisors of key actions they should take, as well as to direct them to sample tools and suggested training materials.

2.1 Concept of Disability

The definition of disability continues to evolve over time. It is important to remember that persons with disabilities are not a homogenous group; they have different capacities and needs and contribute in different ways to their communities. 11

The national Lebanese Law 220/2000 defines a person with a disability as “a person whose capacity to perform one or more vital functions, independently secure his personal existential needs, participate in social activities on an equal basis with others, and live a personal life that is normal by existing social standards, is reduced or non-existent because of partial or complete, permanent or temporary, bodily, sensory or intellectual functional loss or incapacity, that is the outcome of a congenital or acquired illness or from a pathological condition that has been prolonged beyond normal medical expectations.” 12

Article 1 of the UN Convention on the Rights of Persons with Disabilities (CRPD) states:

“Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.” 13

An impairment is a problem in the body's structure or function. 14 Impairments may be physical, intellectual, psychosocial and sensory.

• Physical Impairments: This includes individuals who are difficulty moving. Some individuals with physical disabilities will use assistive devices, such as a wheelchair or crutches, to conduct daily living activities.
• Sensory Impairments: This includes individuals who are deaf or have difficulty hearing, as well as individuals who are blind or have low vision (finding it hard to see even when wearing glasses).
• Intellectual Impairments: This includes individuals who have difficulty understanding, learning and remembering new things. For example, people with cognitive or developmental disabilities.
• Psychosocial Disabilities: This includes individuals who experience mental health difficulties which, in interaction with discrimination and other societal barriers, prevent their participation in community on an equal basis with others. 15

Disability, however, is not just a health problem or impairment. Societal attitudes and a person's environment have a huge impact on their experience of disability and their access to our activities.

• Attitudinal Barriers: Negative stereotyping, social stigma, and discrimination by staff, families and community members all affect a person with disabilities access and inclusion in society.
• Communication Barriers: Information may be presented in formats that are not accessible for persons with disabilities, including those with visual, hearing and intellectual/ psychosocial disabilities.
• Environmental or Physical Barriers: Buildings, roads and transport may not be accessible for persons with disabilities.
• Policy & Administrative Barriers: Rules, polices, systems and other norms may disadvantage persons with disabilities, particularly women and girls.

Improving access and inclusion for people with disabilities requires interventions to remove these different types of barriers in our GBV activities.

2.2 Models of Disability

There are different ways in which society may view or interact with persons with disabilities that can result in their exclusion or inclusion in our society. There are four different approaches or “models” that describe how members of society view or interact with persons with disabilities:

• Charitable Model: People may look at persons with disabilities as not having any capacity to help themselves and so must be “cared for” or “protected”.
• Medical Model: People may think that persons with disabilities need to be cured through medical interventions before they can actively participate in the community.
• Social Model: In this model, people instead look at the barriers in the community and remove these so that persons with disabilities can participate like others.
• Rights-based Model: In this model, persons with disabilities have the right to equal opportunities and participation in society. It also emphasizes that we all have a responsibility to promote, protect and ensure this right, and that persons with disabilities should have capacity to claim these rights.

Both the charitable and medical models result in other people making decisions for persons with disabilities and keeping them separate from society. The social and rights-based models, however, are aligned with the guiding principles for GBV prevention and response and should therefore guide the work of development and humanitarian actors, as well as governmental entities, with persons with disabilities, their families and communities.

Previous needs assessments in Lebanon have highlighted that family members, communities and service providers often view persons with disabilities through medical or charitable models, failing to recognize social factors, such as age and gender, that may increase their vulnerability to gender-based violence, requiring inclusion in prevention and empowerment efforts, and / or referral to case management agencies for appropriate follow-up. 16

2.3 Rights of Persons with Disabilities

The move towards a rights-based approach for working with persons with disabilities has gained significant international momentum over the past decade with adoption of the United Nations Convention of the Rights of Persons with Disabilities (CRPD). Persons with disabilities have a right to protection in situations of risk or in humanitarian crisis and should be able to both access services and participate in GBV programs and activities on an equal basis with others. 17 Persons with disabilities have a long history of discrimination and disempowerment by family members, caregivers, partners, and even service providers. GBV actors can play a central role in supporting women, children and youth with disabilities to make their own decisions and addressing the barriers they experience in their relationships, households and communities. GBV actors must use a rights-based approach when working with persons with disabilities, ensuring women, children and youth, with or without disabilities, have the same access to their programs, services and support.

PRINCIPLE 1. Ensure Safety

Case workers should start by getting to know the individual with disabilities – the things they like and dislike, and the ways they behave and communicate when comfortable, happy or distressed. This will help the case worker to better understand when a survivor does and does not feel safe talking to the case worker. Watch for signs of agitation, anger or distress that may indicate the individual is not happy to proceed at this time, and respect this, especially if you are talking with the caregiver.

Some persons with disabilities may require assistance to communicate effectively with case workers. The decision about who to involve and when should be made in partnership with the survivor and include an analysis of risks to the survivor's safety if they choose to involve another person. Case workers should be aware that caregivers of persons with disabilities may also be perpetrators of violence. Case workers should discuss with the survivor their relationships with family members and both primary and secondary caregivers – this will help to identify appropriate risk mitigation strategies 13 where a caregiver is a perpetrator, as well as protective relationships that may support the survivor's recovery.

Case workers must also ensure that the space in which they speak to the survivor feels safe and should follow existing guidance on selecting counseling and meeting spaces. Given the environmental context in Lebanon, it will not always be possible for GBV service providers to have fully accessible counseling spaces. Hence it is recommended that GBV program staff conduct a small mapping in each region to identify at least one accessible counseling space or mobile safe space per district with safe and confidential transportation arrangements for those survivors who will require it. Ideally an accessible counseling space should be a location where GBV counselling already takes place and meets the following guidance:

• Safe ramp access (recommended ramp gradient is 1:20 / 5% and ramp should have handrails)
• Counseling room is located ground floor and/or in building with fully functioning elevator
• Doors should be at least 90 cm wide, in order for wheelchair to pass through
• Space in counseling room is wide enough for wheelchair used to complete a full turn

Case workers and supervisors should work together to develop options to ensure that all survivors can receive case management. This may require developing new strategies for reaching those who may be unable to attend a service facility, such as adults with more profound disabilities who are unable to leave their homes or those who face severe risk of harassment or abuse when in the community. Home visits should be considered as a last resort, when there is no other option for the survivor to receive appropriate support. Case workers and supervisors should decide together if a home visit is the only option to provide case management services, and develop a thorough risk assessment with appropriate mitigations strategies. Some options to mitigate risks associated with home visits to survivors with disabilities include:

• Developing a mobile strategy for visiting multiple households at a time in a small geographic area to provide information or some other type of service not related to GBV. The case worker can then visit a survivor's household in that area during this time, which should not draw attention. 22
• Identifying if the survivor is receiving any other services in their home already – e.g. medical or rehabilitation visits – if so, a GBV case worker could consider conducting a joint visit with another allied health professional – in order to minimize speculation that the individual is receiving GBV responses services.
• Making a plan with the survivor and / or a protective caregiver to have a code or signal that they can use to let you know that it is no longer safe for you to come to their house. This could be a message sent through a mobile phone, or another system developed between the case worker and the survivor which will let you will know that it is not safe to speak with the person. 23

PRINCIPLE 2. Respect Confidentiality

Any support persons engaged in the case management process, family members, caregivers and/or sign language interpreters, should be briefed on the principles of confidentiality. The case worker should also provide appropriate caregivers and family members with information about how to be supportive of the 14 healing process (e.g., by maintaining confidentiality; by not judging or blaming the survivor; and by not pushing them to take a particular action or service). Participatory activities may also be useful to assist persons with intellectual disabilities to better understand the principles of confidentiality; decide who they may and may not want to share information with; and to explore different strategies or ways to respond to questions from others.

Describing confidentiality to persons with intellectual disabilities

Confidentiality means that when we tell someone something private or personal about ourselves, they can’t tell anyone else unless they have our permission. If someone respects you, they won’t share your personal information. (Expand or simplify as necessary.) The professionals we go to when we have concerns about our bodies (like doctors or nurses) or our feelings (counselors or social workers) must keep things confidential … I want you to feel safe talking about your feelings, so we have a rule that all of us (point to self and support people) will keep what we discuss CONFIDENTIAL. If family members, friends, parents or others ask what we talked about, we say “That's confidential.”

Adapted from Arc of Maryland (n.d.) Personal SPACE – A Violence Prevention Program for Women http://www.ncdsv.org/images/Arc_PersonalSpace-AViolencePreventionProgramForWomen.pdf

PRINCIPLE 3. Respect their Wishes, Rights and Dignity

Persons with disabilities have the right to make their own decisions and it is the job of the case worker to assist in upholding this right. In situations where a protective caregiver is involved, the case worker can still empower the survivor by: directing the conversation to the survivor first; asking permission from the survivor to consult with the caregiver from the very beginning and throughout the conversation; and checking back in with the survivor throughout the process.

In the past, the survivor with disabilities may have been dismissed by others when trying to communicate their feelings and experiences. As such, the case worker should reassure them that they are believed, validating any experiences and emotions that they share. The case worker can validate a survivor's feelings and convey empowering messages through both verbal and non-verbal techniques, i.e. using drawing, pictures or body language, particularly facial expressions. It may take some time to establish ways of communicating with the survivor that allows the case worker to convey these important messages –throughout this process case workers should remain thoughtful and creative.

PRINCIPLE 4. Non-discrimination

The guiding principle of non-discrimination means that case workers provide the same quality and range of service options to every survivor. It is important to present all available options to survivors with disabilities, even if it is not yet clear are how they will participate in these activities. Present all the options in a way that the survivor will understand. Be prepared to try several different ways of communicating these options (e.g., if there is an English class in your women's center, support the survivor to visit the class to show them what it involves). Give the survivor time to think about these 15 options and to ask questions. If the survivor expresses interest in a particular service or activity, then discuss together the potential barriers and strategies to address these.

5.1 Informed consent process 26

The informed consent process has three key components:

• 1. providing all possible information and options to a survivor in a way they can understand;
• 2. determining if they can understand this information and/or their decisions; and
• 3. ensuring that the decisions of the survivor are voluntary and not coerced by others (e.g., family members, caregivers or even service providers).

When conducting the informed consent process, it is important for case workers to remember the following:

• Assume capacity – All adults have capacity to make their own decisions unless demonstrated otherwise. This applies to people with all types of impairments, including those with intellectual impairments. GBV case workers should assume that all adult survivors with a disability have the capacity to provide informed consent independently.
• Understanding can vary according to the way we communicate information. For example, Maria has an intellectual disability. She may initially decline or accept referral to an economic empowerment activity. But have we conveyed the information in a way that she can understand it and use it in making her decision? If we discuss her goals, describe the activities to her, explore what she likes and doesn’t like about these activities, and support her to visit the class without having to make any commitment to participating, then Maria will understand better the activity, and the possible positive and negative outcomes for her, enabling her to make a more informed decision.
• Understanding may vary over time. In some circumstances, it can be more helpful to seek consent for smaller steps in a longer process, so that survivors are in control of every part of a process and can stop it at any time. It is also important to revisit options that survivors may have declined at later stages in their case management process. For example, Maria may not understand the purpose of psychosocial support activities when she was first meeting the case worker, but later she notices that talking to others makes her feel less frustrated and angry.
• Understanding may vary according to the complexity of the decision. Understanding can change over time, but also according to the nature and complexity of a decision. Maria may have the capacity to understand and consent to HIV post-exposure prophylaxis, because she understands the concept of taking medicine as a treatment and has taken medicines before to prevent other illnesses. She may, however, find it more difficult to understand what legal assistance means and therefore would not be able to consent to a referral to legal assistance.

Consent is an ongoing process and not a one-time event. It is important that we never assume that a survivor's consent to one service means that they consent to everything.

A Note About Children with Disabilities: In accordance with the Inter-Agency Standard Operating Procedures (SOPs) for SGBV Prevention and Response in Lebanon, children with disabilities above 15 years of age are able to participate in the informed consent process as individuals. However, their parent or a trusted adult should be included with the child's permission, unless they are involved in the abuse. Children under 15 years of age can participate in an informed assent process, but require the permission of a non-perpetrating parent or caregiver as well. 27 For additional information, please see the Standard Operating Procedures for the Protection of Juveniles in Lebanon (and the annexed guidance on working with children with disabilities).

5.2 Informed Consent Flow Chart 28

Image Description

This image shows a flowchart illustrating informed consent procedure which to be adopted for disable children and adults. The chart contains 14 stages or steps of lessons to be followed by case workers.

Step 1 depicts for assuming capacity. Steps 2-4 show the following options: provide information as to be understood by survivor; give enough time to think and be able to ask questions; if for speaking disability, to adopt any other gesture for agreement or disagreement or provide a sign interpreter. These steps may be repeated for several times. Steps 5-10 follow several questions and some examples of such questions, to be quite sure about the mental ability of the disable persons to properly understand these options. Some of these questions are like such: “Do they remember the information?”; “Do they understand that there are options”; “Is the person being coerced?”; “Can the survivors explain the reason for their decision?” etc. Each of them provide both ‘Yes’ and ‘No’ choices. At the end of step 10, survivor's decision is to be followed. Then comes step 11, that asks—“What are the wishes and preferences of the survivor”, which also to be followed after repeating steps 2-4 several times. It also needs documentation regarding communication strategies implemented and the steps which the survivor didn't understand. No. 12 asks—“Is this the least harmful course of action?” and need documentation of the negative and positive outcome of action on survivor's physical, emotional and social well-being. For positive outcome of action it is advised to “Respect the wishes and preferences of the survivor”. For negative outcome, steps 13 and 14 are to be followed. No. 13 advises to “Identify someone to support the survivor in decision-making” which includes: ‘allow them to choose who they trust’ or ‘discuss any risk for engaging this support person’. Lastly, step 14 monitors the quality of interaction between the support person and the survivor and looks for any signs of fear, threat, deception or anything like such.

5.3 Involving a trusted support person in the informed consent process

After trying multiple communication approaches, if the case worker is still unsure that a survivor understands the information, they should involve a supervisor to help determine whether there is a need to provide additional support for informed consent. The survivor may wish to involve a trusted support person.

Family members, caregivers and peers of persons with disabilities can be a valuable resource in facilitating understanding and communication with the survivor. If you determine that it is safe to do so, ask the survivor's permission to include someone they trust in your discussion as a way of supporting communication and enhancing the survivor's ability to provide informed consent. Let the survivor identify who they would like to involve and watch for any signs that they agree or disagree with the suggestions being made by the support person. The decision to engage a caregiver must always be reached by analyzing the survivor's situation with respect to safety.

If caregivers or others are involved, it is important to ensure that the survivor's wishes and needs remain the focus, and that the survivor feels safe. Be sure to observe the survivor's interactions with the caregiver. If the case worker feels the power dynamic and relationship between the caregiver and the survivor is affecting the right of the survivor to participate in decision-making and/or if decisions are not aligned with their wishes and preferences, they should consult with a supervisor on how to proceed.

5.4 Ensuring the rights, wishes and preferences of survivors with disabilities

When involving others in the informed consent and decision-making process, remember:

• Always talk directly to the individual, even when a caregiver is present.If a case worker is still establishing communication methods with the survivor and needs to ask for advice from the caregiver, make sure to have these conversations in front of the individual, so they can hear what is being said and participate in any way possible. Remember that people who cannot speak or move may still understand what is happening around them and what people are saying about them. 29 Please see more detailed information on communicating with persons with disabilities in Section 8.
• Even survivors who lack capacity to consent have a right to information and should play a role in decision-making .30 Case workers should continue to share information, listen to their ideas and opinions, and explain how and why decisions have been made. This interaction will also assist in the monitoring of changes in capacity to consent over time and with different types of decisions.
• Always seek informed assent from the survivor.We must always seek to obtain informed assent, which is the survivor's expressed willingness to participate in the services or activities proposed, from all survivors of any age. Use pictures, hand gestures or symbols to ask if someone is willing to participate in an activity or to access a service. Also watch for signs of agitation, anger or distress that may indicate that the individual is not happy with something that is being discussed or an activity that is being undertaken. 19
• Take measures to ensure that decisions reflect the rights, will and preferencesof the individual, are tailored and appropriate to the person's circumstances and are reviewed on a regular basis to ensure that all opportunities to exercise capacity are optimized. 31

6.1 Maintaining a survivor-centered approach

It is paramount that case workers always focus on the survivor.The survivor is the individual seeking services and all actions should be guided by their will and preferences. The interests of family members and caregivers may or may not be linked to the will and preferences of the survivor. For example, caregivers may want to pursue justice options. If the survivor does not understand the legal processes involved, then it is unlikely to promote healing and recovery, and may even expose them to further emotional harm, as they will have to recount their experiences to others. If the referral is not in the interest of the survivor, the case worker should not proceed, even if requested by caregivers. It is essential that the case worker explain to caregivers the importance of respecting the survivor's wishes, and any possible harm that could be caused to the survivor by certain actions. Exploring the reasons why caregivers think certain actions are in the best interest of the survivor can help to come to decisions that respect the needs and interests of the individual, and identify support that caregivers may require for themselves. 32

It is also important to maintain confidentialitywhen working with survivors with disabilities. If the survivor discloses information that they do not wish to be shared with their caregiver, the case worker 20 must respect and maintain the survivor's confidentiality and not share information with the caregiver. When sharing information, always think about why the caregiver needs that information and only share what is necessary to facilitate support for the survivor. For example, you may do a joint session with a survivor and their caregiver to review a case action plan, because it requires the caregiver or family member's action. In that case, they only need to know what is relevant for facilitating that part of the survivor's care. 33

6.2 Fostering positive power dynamics 34

It is important to pay attention to the dynamic between the survivor and their caregiver. The following questions can assist case workers to better understand the power dynamics at play in the relationship between the survivor and caregiver:

• What are the strengths of this relationship?
• What do both people have confidence in and what is this relationship built on?
• What are the mutual expectations and assumptions? How do these interact?
• What tensions can you see? What do you think is contributing to these tensions?

Thinking through the perspectives and needs of both the survivor and the caregiver, and the intersections and relationships between each individual and the case worker, can help to shape the process of case management in a way that ensures that the needs of both individuals are met, and that their relationship is strengthened. Providing caregivers with accurate information about the risks and impacts GBV can help them understand what the survivor may be experiencing and how to best support them. Caregivers may be inclined to blame the survivor, so be sure to communicate that what happened was not the survivor's fault. Caregivers may also blame themselves for not being able to protect the survivor from violence. Providing messages to caregivers that are supportive, non-blaming and non-judgmental may be important for them to hear. By supporting them, the case worker is also enhancing their ability to support the survivor.

6.3 Identifying and responding to caregiver needs 35

Caregivers are people first and foremost with their own perspective, needs and feelings. Care-giving is a complex role, and caregivers may have conflicting feelings — they may feel guilty, resentful, angry, afraid, concerned, and as though they have failed. They may prioritize the person they are caring for above everything else, including themselves, which can be difficult for others in the household. They may also have unmet needs of their own, particularly if they carry the full responsibility for care with no one to support them. For female caregivers, caring for a person with disabilities comes in addition to the many other responsibilities and duties expected of them at home.

Caregivers are also exposed to the threat and reality of GBV, and case workers have to pay attention to their safety concerns and their opportunities to have more control over their lives. Caregivers are most often women and adolescent girls, meaning they already experience disadvantage within the household and community, and are likely over-burdened with domestic responsibilities, including the care of children and the elderly, and household chores. Caregiving can be a very isolating experience, and more so for women who are already less likely to have access to opportunities outside the home. This is also 21 an opportunity to talk about female caregivers’ own exposure to and risk of violence, including violence from the people they care for or domestic violence, and work with them to plan for safety and access to services.

Providing good support for caregivers is one of the most effective ways to improve the safety and well-being of those they care for. It may be useful to work separately with caregivers (in addition to working with survivors and caregivers together). This can serve a psychosocial intervention in and of itself by creating a safe space for caregivers to talk about the issues that affect them, their own emotions – positive and negative – without feeling that they are being demanding or selfish, or that they are not properly heard. It is also important to recognize that feelings about being a caregiver are complex, and it is normal to feel frustration, resentment and anger, along with love and concern. Helping caregivers to understand and manage these feelings can be very helpful in strengthening the core relationship between the caregiver and the person being cared for.

7.1 Assessing needs of survivors and at-risk women, children, and youth with disabilities

The causes of GBV against persons with disabilities are rooted in the inequalities and power imbalances between women and men, the inequalities associated with disability, and in many cases in Lebanon – the displacement of the individual or family from their country of origin. GBV case workers should consider the following factors when undertaking assessment and intake processes, as they may increase the vulnerability of persons with disabilities to GBV, and provide valuable information for case action planning:

• Lack of information about sex, healthy relationships and GBV. Persons with intellectual disabilities are often assumed to be incapable of learning the same concepts or participating in the same activities as other people and are thus excluded from opportunities to learn about violence, sex and healthy relationships, and to develop new skills and strengthen peer networks.
• Loss of familial and community support mechanisms. During displacement, families and communities may become separated and traditional community support structures weakened, which disproportionately affects children with disabilities, and adults with disabilities who require assistance with daily care. They may rely on assistance from less familiar family or community members, which oftentimes adds to their risk of violence. They may also have fewer people they trust and can turn to for support if they experience violence.
• Social isolation.Depending on the level of stigma associated with disability in the community, families of persons with disabilities may hide or isolate the individual, which increases their risk and vulnerability to violence, particularly inside the home, and limits their options to report or seek outside assistance. 36

• ■ Exaggerated issues of power and control. Issues of power and control may be more complex in relationships in which one person has a disability, particularly if the caregiver is also the intimate partner. Some of the dynamics and tactics of power and control that may be used against persons with disabilities (though not limited to intimate partners) are:

  • Abusers may threaten to not take care of the person, withhold basic care and support from them (food, money, hygiene) or leave the person unattended.
  • Abusers may threaten to or withhold, misuse, or delay specific support that helps the person to function independently (e.g. medication, equipment).
  • Abusers may use the person's money for themselves and/or make financial decisions for them without their consent.
  • Abusers may isolate the person from social networks.
  • Abusers may ridicule and embarrass the person because of their disability.
  • Abusers may blame the person with disabilities for their own stress (i.e. as a result of having to care for them). 37

As described earlier, women, children, and youth with disabilities may face added attitudinal, physical / environmental, communication and policy or administrative barriers when accessing services and assistance.

• Attitudinal Barriers: Service providers may exclude persons with disabilities based on beliefs that GBV prevention and response services are not relevant to or appropriate for them. For example, there is a common myth is that people with disabilities are asexual, and thus they may not receive adequate education about sexuality, healthy relationships and personal safety.
• Communication Barriers:Important information about GBV prevention and response may be presented in formats that are not accessible for persons with disabilities, including those with visual, hearing and intellectual disabilities. Furthermore, they may be isolated in the community and excluded from informal information networks, such as peer networks. As a result, persons with disabilities may not recognize abuse when it occurs or may not know where to access support. 23
• Environmental or Physical Barriers: For example, a GBV prevention and response service may be physically inaccessible due to long distances, a lack of accessible transportation or the costs associated with reaching facilities. Furthermore, health clinics and women's centers may not be accessible for wheelchair users or those with other mobility challenges, which can also convey a message that services are not welcoming to persons with disabilities.
• Policy & Administrative Barriers:For example, survivors with disabilities may face greater difficulties returning to the facility to go through lengthy administrative processes, due to more limited resources, less independence and obstacles in accessing transportation. 38

It is important to discuss these barriers with the survivor, and identify appropriate strategies to address these, so that they will be able to access programs and services on an equal basis with others.

7.2 Identifying skills, capacities and strengths/assets

A core component of GBV case management is collaborating with survivors to identify strengths and assets, then building off these specific strengths in action planning – this same approach should also be applied to working with survivors with disabilities. The following general principles are important to remember when working to assess the skills, capacities and assets of a survivor:

• Focus on the person first, not their disability or health condition.
• Assume capacity. Look at what they can do, not just what they cannot do. This gives the case worker many more options for communication and participation.
• Treat adults with disabilities as you would other adults, paying particular attention to gender issues.
• Take time, watch and listen. Identifying skills and capacities is a process, not a one-time event. During each meeting the case worker can learn something new that will help to better understand how the person communicates and what they can contribute to action planning.
• Pay attention to any way in which the individual wishes to communicate. This could be through gestures and sometimes their emotions. It is okay, however, to say “I don’t understand.”
• Some persons with intellectual and psychosocial disabilities can exhibit a wide range of behaviors. This is sometimes the way they communicate with others.
• Watch for signs of agitation, anger or distress that may indicate that the individual is not happy to proceed at this time, and respect this, even when talking with the caregiver. Try to plan another session to see if they are more comfortable and want to continue.
• Be sensitive to any negative language being used by family members towards the persons with a disability and rephrasing in positive language as appropriate.
• GBV case workers who are working with survivors with profound functional limitations in both communication and movement may need to consider using adapted communication styles and adding additional questions during the intake phase. 39

7.3 Identifying safety concerns and developing a safety plan

As emphasized in other sections of this guidance, case workers should follow all standard operating procedures for case management when working with survivors with disabilities, including when identifying safety concerns and developing safety plans. Survivors with disabilities may have specific 25 safety concerns to take into consideration when developing safety plans with them. Safety plans for survivors with disabilities must be highly individualized and should take into account the following:

• The individual's living situation and ways in which a perpetrator may try to exploit the survivor's disability to isolate them, prevent them from leaving, or further harm them.
• How the survivor's impairment may impact on the execution of their safety plan, and adjust the plan as necessary.
• What disability-specific items the person may need to implement their safety plan, such as medication, assistive devices or equipment, or relevant documentation for health or legal support. 40

7.4 Referral pathways for survivors with disabilities – Roles of different actors

In the case of survivors with disabilities, it is imperative, regardless of the type of disability of the survivor, that they have case management services provided by service providers who specialize in GBV. GBV case workers have a central role to play in identifying needs, discussing options with survivors, and then coordinating appropriate referral processes. GBV case workers should avoid deferring to disability-related needs first, as this engages a wider range of actors who are not necessarily able to respond to the survivor's needs relating to violence and may threaten confidentiality.

7.5 Advocating for survivors with disabilities

When working with survivors with disabilities, advocacy – speaking in support of survivors to access the care and services they need and want – often becomes an essential component in the case management process. GBV case workers will frequently need to play a role in educating service providers to ensure that survivors with disabilities are not turned away from services, and/or harmed by the interactions that they have with service providers. Based on the action plan developed, case workers may need to contact the relevant service providers to refer the survivor, explaining the adaptations required to address any barriers.

8.1 Use respectful language

Different language is used in different contexts to describe disability and to refer to persons with disabilities. Some words and terms may carry negative, disrespectful or discriminatory connotations and should be avoided in our communications. The Convention on the Rights of Persons with Disabilitiesis translated into many languages, including Arabic, and can be a useful guide to correct interpretation of different disability terms. 43

Organizations of persons with disabilities (DPOs) can also provide guidance on the terminology preferred by persons with disabilities in a given country. Additionally, the national Lebanese Law 220/2000 can provide additional helpful guidance proper terminology.

DPO leaders in Lebanon have suggested the following terms to be the most respectful and most commonly accepted terms in Arabic:

The table below also has some suggestions on tips for ensuring respectful language:

8.2 Use a strengths-based approach

Do not make assumptions about the skills and capacities of persons with disabilities – this can negatively affect the way we communicate and interact. Remember that persons with disabilities are people first and foremost. Just like all people, they have different opinions, skills and capacities. Look at what the person with a disability can do. This can often give us insight into how they can communicate and participate in your activities.

8.3 General guidance

Remember that you have many skills that you can use with persons with disabilities. Every day you are listening to, communicating with and supporting women, girls, boys and men who are all different in their own ways. All of us use speech, writing, pictures and posters, and activities, as well as emotions and gestures, to both convey and understand information. Different approaches may work better with each individual. Ask persons with disabilities and their caregivers for advice about their preferred communication method, and then try different things.

• Greet persons with disabilities in the same way you would with other people – For example, if culturally appropriate offer to shake hands, even if they have an arm impairment.
• Speak directly to the individual with disabilities, not to their interpreter or assistant/caregiver.
• When speaking for a length of time, try to place yourself at eye level with that person if they are not already at the same height (e.g., by sitting in a chair or on a mat).
• Treat adults with disabilities like you treat other adults – Discussions and activities should be age appropriate and then adapted for communication needs of the individual.
• Ask for advice. If you have questions about what to do, how to do it, what language to use or the assistance you should offer – ask them. The person you are working with is always your best resource.

9.1 Caseload and Assignment System

Agencies are also strongly encouraged to consider disability when determining the complexity of cases and case assignments. Considering disability in case assignments is important to ensuring case workers who are working with survivors with disabilities have the time and capacity to provide quality care. The average time for each session could potentially double – particularly when working with a survivor with communication difficulties or those who are using sign language. Initial counseling sessions may also take longer with these survivors, as the processes of establishing effective communication, building trust, ensuring informed consent processes, and fostering their participation in decision making may move more slowly than in the case of survivors without disabilities.

9.2 Individual & Peer Supervision

In cases that involve persons with complex disabilities, it may be necessary for supervisors to provide ad hoc support to the case workers during the initial phases of the case management process – in addition to regular weekly supervision meetings. During both individual and peer supervision sessions, supervisors should provide ongoing opportunities for staff to reflect on their personal values, beliefs and behaviors and how these impact on their work with survivors with disabilities. Ensure standard group supervision sizes – no more than 6-7 case workers per group – so that there is ample time for peer 32 exchanges and learning. Encouraging case presentations relating to survivors with disabilities in peer supervision will provide opportunity for case workers to share ideas and strategies with each other.

Below are sample guiding questions that could be used in supervision with case workers:

• Share some example of how have you built trust with the survivor with disabilities – How do you know that they trust you? How do they express this to you?
• How you supported the survivor in decision-making processes? What strategies worked and why?
• Has there been any interaction with a caregiver or trusted support person? How have you supported positive power dynamics between the caregiver or support person and the survivor?
• Has this survivor discussed any specific barriers they are facing to accessing services? If yes, what strategies have you tried to address these barriers? If not, can you think though what some of the potential barriers maybe and how you would navigate them?

9.3 Supervision Tools

In addition to the supervision strategies mentioned above, case management supervisors can also create or adapt existing tools to assess staff attitudes, knowledge and skills that are important for providing survivor-centered care and case management services to persons with disabilities.

Supervisors should assess attitudes of case workers on working with persons with disabilities. Supervisors can consider adding questions related to disability to the existing Survivor-Centered Attitude Scales, currently being used by many agencies to evaluate attitudes among staff providing direct support to survivors. Specific questions about survivors with disabilities and their caregivers can help the supervisor to assess a staff member's personal values and beliefs and to measure an individual's attitudinal readiness for working directly with survivors with disabilities, while also highlighting specific areas in which the staff member may require further education and training. See Tool 2: Case Worker Attitudes Relating to Disability and GBV for a list of questions that could be integrated into standard attitudinal questionnaires and tools.

Supervisors should also support case workers by providing experiential learning opportunities – creating space for them to practice using certain tools adapted to working with persons with disabilities – particularly tools related to seeking informed consent and establishing communication. Group discussions and participatory activities can also assist in reflective practices supporting case worker teams to identify and share positive changes in their knowledge, attitudes and practices relating to disability inclusion.