Mental Health Review, The: Progress of Assertive Outreach Services: Reflections and Examples, The

In December 1999 I wrote in the Mental Health Review that the challenge for assertive outreach services was:

To replace the institution with community services as strong and predictable as the bricks and mortar of the hospital in order to reduce the dreadful upheaval and turbulence (for many women and men who are not engaged with services and have profound long-term mental health problems) of episodic mental ill-health with its knock-ons of hospitalisation, poverty and homelessness' (Lowe, 1999).

This is still my view.

The 1999 article drew on two experiences: one of seeing American assertive outreach services first hand while working at Thresholds, Chicago; and the other as a director of Tulip Mental Health Group where I led the development of Tulip's assertive outreach services over almost 10 years.

Since then, assertive outreach services have developed across England and there is a government commitment in the NHS Plan to have 220 teams in place by 2003. This article draws on my experience as a service and practice development consultant with eight statutory sector and two voluntary sector services. Over the last four years I have been consulted by services often overwhelmed by constant change and uncertainty, and my task has often been to enable services and teams to realise the potential of the assertive outreach model and the hope it can bring for users.

The service user and the team

I offer one example of good teamwork and practice from my work with the Northumberland assertive outreach service.

'W was a very unhappy isolated man, struggling with psychosis and living in squalor with his dog in his flat in Morpeth. The assertive outreach team's psychiatrist knew about betting on horses - W's favourite pastime - and she engaged his interest in the assertive outreach service through joining him in the betting shop and discussing the form.

The leader of the Northumberland team, a nurse by training, together with the OT assistant, continued the engagement process with W through cleaning his flat and replacing stinking carpets and broken furniture (the OT assistant facilitated a small group of users who renovated and recycled furniture). The team leader fostered good practice by example - the process of practical and immediate giving leading to engagement and therapeutic work.

Over a period of months, W began to trust and know the whole team. he eventually agreed to medication prescribed by the 'gambling' psychiatrist and to sessions with his mother to heal the hurt between them. Through many clinical discussions, the team worked creatively to meet Ws many needs. The team developed and flourished alongside W; they worked collectively on using the team approach, developing a 'can do' culture, learning how to use differences and manage conflict and mapping a process for engaging hard-to-reach users. They also worked on shared governance by adopting the approach of Len Stein and Alberto Santos as described on page 73 of their excellent book Assertive Community Treatment of Persons with Severe Mental Illness (Stein & Santos, 1998). As suggested by Stein and Santos, the team thrashed out core values and planted collective decision making in value-based discussions.

For any service to work effectively, senior managers need to be right behind it. The team leader and the psychiatrist, backed up by the chief executive and others, led cultural change by working creatively, 'getting their hands dirty' and working across the hierarchy.

As Stein and Santos say:

'Influence on the team is not obtained by the letters after one's name; it is earned through demonstrated competence' (Stein & Santos, 1998).

The chief executive of the Northumberland trust was determined that this new service would be successful. I suggested to the team that the service needed a new budget, so that each worker could go out every day with £20 in cash to meet the immediate life-sustaining needs of users, such as dinner and electricity keys. The system that welcomed the assertive outreach service enabled the team leader to negotiate confidently for this budget.

The old, the new and the NSF

Assertive outreach is the first proof that the National Service Framework for Mental Health (Department of Health, 1999) is real and will be implemented, according to the clear policy implementation guidance (Department of Health, 2001). Assertive outreach is the new; a radical model, and in my experience has been greeted with a range of powerful emotions including excitement, curiosity, envy and suspicion. However, assertive outreach is often thought not to respect the old and to want to sweep it away.

By the old I refer to many workers, including psychiatrists, in CMHTs and other parts of the service who wish to maintain the status quo, who resist change and who co-operate reluctantly with implementation of the NSF. They also feel charged with the responsibility for sustaining high clinical and professional standards for the whole system. This is often accompanied by a deep suspicion of the value of assertive outreach.

This is a familiar dynamic - a rerun of the struggle in the 1990s between the hospitals - the old - and the introduction of the CMHTs - the new. The situation now is made worse by vague policy implementation guidance for CMHTs which leaves many anxious, uncertain about the future, and feeling discarded and under-valued.

Too often tension is felt between these two groups - the new and the old- both of whom, in my view, act it out on behalf of the whole system. Inevitably there is tension and conflict in the process of change; both have essential contributions, both have a place in future services and need to find ways of working together.

The team approach

Using the team approach is crucial in meeting the challenge and in my experience it is an often forgotten essential of assertive outreach, the missing piece. The team approach requires 'the subordination of western cultural values of individualism and competition and the active assumption of equality' (Opie, 1997). But for many reasons the desire to hold on to individualism remains strong and this is reinforced by the pervasive ideology in mental health services that a two-person relationship is the only basis for effective therapeutic practice.

Assertive outreach services must face the fact that individual workers have limitations when meeting the complex health and social care needs of their users. Good teams embrace the rich diversity and potential of the whole team and only by doing this will users thrive on the range of team skills and interventions. A team approach - including regular group clinical supervision - sustains and supports workers and provides opportunities for teaching and learning.

'Tulip workers (using the team approach) come out more favourably than those from the other teams (Ie CMHT and community support teams), reporting the highest levels of role clarity and team identification, the highest intrinsic and extrinsic job satisfaction and the lowest levels of burnout on nearly all dimensions' (Gauntlett etal, 1996).

The team approach also requires members of assertive outreach teams to unite in their aim towards a common purpose - to achieve practice aims in a consensual way and to create a new corporate structure. Most assertive outreach services are within the NHS, which is not viewed as a consensual organisation - the team approach is a square peg in a round hole. To sustain this position the support of senior management is essential. Also, team leaders must work at the boundary between their team and the whole system, leading and protecting from a position of knowledge of, and confidence in, the assertive outreach model.

I have explored with assertive outreach teams the one-to-one relationship with clients, which I liken to a lonely worker endlessly staggering, her arms embracing her restless client, and have compared this image with the team approach - the whole team, holding hands and surrounding the client, providing a strong and safe container. This metaphor resonates with many teams and is appealing. It is also what makes assertive outreach services 'as strong and predictable as the bricks and mortar of the hospital used to be' (Lowe, 1999).

Keeping to purpose

Keeping to the purpose, keeping to the task, is very hard to do, and below I outline some of the struggles and the ways in which assertive outreach services lose, and keep, direction.

My Tulip colleague, Trinidad Navarro, describes 'the pervasive and systemic denial of the enduring nature and the severity of the disturbance in these (assertive outreach) clients and the impact of the loss of the psychiatric institutions' (Foster & Roberts, 1998).

The purpose of assertive outreach services is to face the severity and disturbance of their clients and to tolerate, digest, manage and treat their clients' disturbance for as long as necessary. They can only do this well and sustain themselves in the long-term through the whole team regularly thinking together and sharing the impact of the work. Sadly, this space is often regarded as a luxury by assertive outreach teams themselves and, when in place, often incurs the envy and fury of other parts of the system. The purpose is also to find, engage, keep hold of and work therapeutically with some hostile, distressed and desperate women and men and 'to become familiar with a variety of locations that most professions would prefer to avoid' (Witheridge, 1985). This requires very careful recruitment and selection processes to find and engage workers who are brave, creative, relish the challenge and have energy and curiosity. These qualities are as important as the qualifications and experience, yet are rarely considered.

One way in which the enduring severe mental ill health of assertive outreach users is denied, and the purpose avoided, is to put in place a false time boundary. After two years cases are often closed or handed back to CMHTs, despite the evidence that relapse rates are very high when assertive outreach users are let go of, and that support without time limit is an essential ingredient of the assertive outreach service (Stein & Test, 1980). There is a reluctance to consider alternatives such as a step-down model. This would give some elements of the full service and would hold users, partly by assuring immediate entry back into the assertive outreach service if crisis is looming.

Assertive outreach teams also seek to establish and maintain their proper place in service systems as a service complementary to other services; this requires constant vigilance. Some assertive outreach services are eager to appease and placate other parts of the system and to stop the tension between the new and the old described earlier. One placatory measure is to take as clients people who are already well engaged with mental health services. This should raise the question, who is struggling, isolated, needs the service and is not being engaged? Assertive outreach services have a responsibility actively to seek out their potential users within vulnerable groups such as homeless women and men, those from minority ethnic communities or those with drug/alcohol dependency. In other words, services must look beyond diagnosis to the individual and their way of living. In most services the majority of clients are men and there is a need to engage with the women who are hidden from view.

Teams must discover users and discover what users need. The Manchester assertive outreach service is part of HARP, a voluntary sector organisation. N'gage commissioned an evaluation of their service entitled A Bit of Humanity: Service Users' Views of Assertive Outreach in Manchester in order to discover whether they were doing the right thing to help the people who use the service. This was a very successful way of keeping the teams focused on the purpose of the service; it also helped to shape the service and gave users an influential voice. Two-thirds of users described very practical and helpful team interventions, such as workers buying food with them; becoming appointees to prevent money going on drugs; getting a DLA or sorting out housing problems. At their review day, N'gage users and workers shared together the results of the evaluation with interest and pride (Marris, 2003).

Conclusions

Assertive outreach services are still new, but their users' illnesses and struggles are old and can last a lifetime, so there is a long way to go in refining and shaping the model in England. In the last four years I have been consulted by many very conscientious, hard-working teams who are determined to meet the challenge and improve the lives of their service users. The importance of team working in the health and social care fields has been emphasised in numerous reports and policy documents. For assertive outreach services, the team is the essential feature and I have learnt much about teams from my work with them. In this respect and others, the new services of early intervention, crisis resolution/home treatment and the new form of CMHT have much to learn from their experience.

References

Department of Health (1999) National Service Framework for Mental Health. Modern standards and service models. London: Department of Health.

Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform. Cm 4818-1. London: The Stationery Office.

Department of Health (2001) The Mental Health Policy Implementation Guide. London: Department of Health.

Gauntlett N, Ford R & Muijen M (1996) Teamwork Models of Outreach in an Urban, Multi-cultural Setting. London: Sainsbury Centre for Mental Health.

Lowe J (1999) A new model for a new challenge - Tulip assertive outreach services. Mental Health Review 4(4).

Marris V (2003) A Bit of Humanity: service users' views of assertive outreach in Manchester. Manchester: Community Audit and Evaluation Centre, Manchester Metropolitan University.

Navarro T (1998) Beyond keyworking. In: A Foster & VZ Roberts (Eds) Managing Mental Health in the Community. London: Routledge.

Opie A (1997) Effective team work in health care: a review of issues discussed in recent research literature. Health Care Analysis 5 62-73.

Stein LI & Santos AB (1998) Assertive Community Treatment of Persons with Severe Mental Illness. New York: Norton.

Stein LI & Test MA (1980) Alternatives to mental hospital treatment. Archives of General Psychiatry 37 392-397.

Witheridge T (1985) The Role of the Outreach Worker. Excerpt from a paper presented at the Johnson Centre, Racine, Wisconsin May 24-25.

Janice Lowe

Mental Health Services Consultant