Practitioner: Elliot Wylde is an approved social worker in an assertive outreach team.
Field: Mental health.
Client: Julie*, 43, is a single woman with a history of borderline personality disorder, which has been complicated by her drug misuse. She has had numerous admissions to hospital under the Mental Health Act 1983.
Case History: In the late 1980s, Julie tried to commit suicide by setting fire to her flat, which led to a long spell in a medium secure hospital. In recent times, she has been detained by police under Section 136 of the Mental Health Act 1983 (the police’s holding powers) 45 times in five years for being “unwell in a public place”. However, her behaviour has presented complex dilemmas for the police, A&E departments, in-patient units and out-of-hours emergency staff, resulting in unco-ordinated management of her impulsive behaviours, such as climbing to the top of high buildings and threatening to jump, cutting herself or taking overdoses.
Dilemma: Unco-ordinated responses from social and health care staff and police to Julie’s impulsive behaviour was feeding her chaotic lifestyle, not changing it.
Risk Factor: Julie was in danger of being placed in secure forensic care, possibly for many years.
Outcome: Working positively with all those involved with Julie brought a co-ordinated and agreed approach that sees Julie remaining in the community, taking more responsibility for her behaviours.
Traditionally, people with a primary diagnosis of personality disorder have had difficulty receiving mental health services and especially assertive outreach teams, where the trend is to work with people with psychotic illnesses.
Research by the Sainsbury’s Centre for Mental Health could find little evidence to suggest that assertive outreach teams “have had an impact on people with a personality disorder”, and few assertive outreach resources have therefore been deployed to work with this group of people.
As a result, people such as one particular client called Julie* can miss out. Her behaviour, complicated further by substance misuse, was becoming unmanageable for police, out-of-hours emergency staff and hospital-based professionals.
Following a further section under the Mental Health Act 1983, a psychiatrist contacted Julie’s local outreach team and laid it on the line: either they work with her to gain some control over her own life or she will end up again in forensic care – possibly for many years.
“We took a co-ordinated approach in working with Julie,” says approved social worker Elliot Wylde. “We identified the people and systems she was involved with, and then looked at how the positive impact of these could be amplified.”
These “systems” included in-patient services and out-of-hours services, the police and Julie’s family. “There had been a lot of friction between Julie and services because of the difficulty of managing her behaviour,” says Wylde. “Her impulsiveness made assessment difficult.”
If Julie agreed to informal admission, the out-of-hours assessors would be relieved, as this would be a safe outcome for them. “Short-term formal admissions (under the Act) seemed to help Julie in times of crisis, but she would often be so distressed that she would be unable to ask for these appropriately,” says Wylde. “Likewise, when she wanted to leave, this would cause a panic because of the risks that it could entail.”
The assertive outreach team met health and social care teams and Julie to devise protocols to aid admission but, crucially, also placed much of the responsibility back with her. “This was obviously backed up with a robust risk assessment and management plan,” adds Wylde. “The idea was to leave Julie to use the service as she felt necessary, as well as reducing the number of days in hospital, and time being assessed in A&E and police cells.”
Wylde and his team also sat down with Julie and police. “Again, the idea was for Julie to take responsibility for her actions, and to give a certain amount of guidance to the police,” he says. “We then drafted a behaviour management plan, which was placed on the police national computer.”
This plan included agreements for dealing with Julie in certain situations, such as treating her as a drunk and disorderly if she is a problem when drunk, but to call a police doctor if she seems to be unwell or exhibiting suicidal behaviour, so they can decide whether an assessment under the Mental Health Act is needed.
Julie was also assigned a female link officer. “She would be someone to build up a rapport and as a point of contact when she was distressed,” says Wylde. “This again showed a reduction in the number of hours in police custody as well as re-building some of Julie’s confidence with the police.”
Within her family, dynamics were poor, with Julie often treated as a lesser member because of her mental health problems. “This caused her great distress,” says Wylde. “The family was mistrustful of help from outside services. The whole system was also influenced by the amount of alcohol that the family consumed.” The team managed to involve the mother in Julie’s care (with Julie’s consent).
This approach demonstrated to the assertive outreach team the critical experience of working proactively with people with a personality disorder.
“This approach also helps address the issue of stigma and the ‘nuisance factor’ associated with this disorder, and instils a level of responsibility back with the client,” Wylde says.
* The name of the service user has been changed.Arguments for risk
* Given the way Julie’s behaviours and disorder were being managed in a somewhat chaotic manner, it’s unsurprising that her life mirrored that chaos. A co-ordinated and agreed approach should have been given a chance to work.
* The team had open-minded police officers to work with. Julie has only been placed in police safety twice in 18 months compared with 45 times in five years.
* Julie is also undertaking psychological work, looking at her impulsiveness and anger management, to try to unravel the need to overdose and self harm.
* The only other possibility would have been to place Julie in long-term secure care – and this simply does not work for her.
* There has been a substantial decline in the amount of crisis work that the team has had to respond to, enabling it to take a maintenance approach and give more time for other people on the caseload.
Arguments against risk
* Julie’s history of chaotic behaviour, self-harm, aggression and overdoses shows that she cannot comfortably exist alone within the community.
* Her frequent sections have been distressful, time-consuming and expensive.
* Government guidance (Personality Disorder No Longer a Diagnosis of Exclusion) highlighted that “people with a primary diagnosis of personality disorder are often unable to access care they need from secondary mental health services”. Julie’s case seemingly proved this point.
* Her suicidal tendencies remain. However, her medication is now kept in a cash box with pictures of her niece and nephews. Wilde says: “She still has the key but, rather than just snatch her drugs off the side to overdose, she has to find the key, unlock the box, look at the photographs and then decide whether to go ahead.”
There are a couple of critical issues that are worth expanding on, writes Tom Dodd. One is the impact of a “whole-team” approach when working with people who have a diagnosis of “personality disorder”.
Clearly the stability of consistent boundaries is key. The whole-team approach may bring all assertive outreach team members in contact with Julie at some point. Is this helpful, or does it increase the risk of an inconsistency in approach?
There is room within an assertive outreach framework to restrict the number of workers who deliver a clear and well-constructed plan, which includes relapse management and crisis pathways.
Second, it can be exhausting for everyone when things become chaotic. There is a damaging stigma attached to the diagnosis, which also attracts a myth that “nothing can be done” or “they won’t change”. The guidance mentioned is a helpful way for practitioners and services to begin to undermine the myth – and is illustrated here through the efforts of Wylde and the team.
The cash box idea is a good starting point that could be negotiated to become a “recovery box” – reminders of soothing images, behaviours, relationships and directions for the future – owned and constructed by Julie. It can provide an anchor to combat the dissociation that Julie may well experience.
Tom Dodd is national programme lead for primary care, and joint lead on dual diagnosis at Care Services Improvement Partnership
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This article appeared in the 19 July issue under the headline “Reach out and we’ll be there”