Running out of choices

Providing supported housing for clients with mental health
problems can be challenging. Outreach support worker Rita McIntyre
talks to Mike George about the difficulties she faced when working
with a client whose chaotic lifestyle made it difficult to maintain
him in his assured tenancy.

The government’s Supporting People programme, aimed at providing
more effective housing support services for a wide range of
vulnerable people, is in the process of being implemented, with a
complete package of guidance for local authorities and other
agencies due to be published later this year.

This focus on the need to have integrated support services has
been widely welcomed, though it comes too late for Arthur Williams
(not his real name). He has now lost his assured tenancy with the
Richmond Fellowship, despite the considerable efforts made by his
outreach support worker, Rita McIntyre.

Williams is in his forties and lost his job, home and his family
some years ago, and was subsequently diagnosed as having severe
depression; he was also known to abuse drugs. Consequenctly an NHS
Community Trust referred him to McIntyre’s service, which provides
supported housing for people with mental health problems. Following
a review of his social history he was offered a flat in a house
which contained three other flats for vulnerable people.

McIntyre was responsible for all four tenants, and attempted to
ensure that Williams was able to keep his tenancy. She tried to
engage him but describes him as quite taciturn and generally
unwilling to “open up” to her, although when he was unwell he
tended to be more open.

From early on she began to notice that he received a large
number of visitors, and she felt that these might be drug-using
acquaintances. However the evidence was not clear, and she also had
a duty of confidentiality towards him, so was unable to take any
effective action; nor could she get Williams to disclose any
information about these “friends” or drug-taking.

She also became aware that his increasingly chaotic lifestyle
was leading him into petty offending behaviour, and she
subsequently found out that he was already subject to a probation
order for prior offences.

Her concerns grew when a girlfriend moved in. She explains that
this was not a problem as such for his tenancy, but this person
started to act as Williams’s “mouthpiece”, and effectively blocked
McIntyre’s access to him, which worried her. This added to her
concerns about his lifestyle, especially as yet more acquaintances
started to visit at all times of the day and night.

She was also concerned for the well-being of the other tenants,
one of whome had entered hospital for an extended period. She was
later unable to return to her flat because of the problems caused
by Williams.

The tenant who remained then began to complain that the visitors
to Williams’s flat had become abusive.

On more than one occasion Williams asked McIntyre for help in
getting into a methadone replacement programme, and, she says, when
he was in hospital for periods in order to become drug-free became
quite approachable.

However, once back at the flat he withdrew from her again. Also,
his drug-based lifestyle now meant he had numerous court
appearances for his offending. His behaviour in court began to
worry McIntyre and her colleagues, because, she says, it became
clear that he was able and willing to use his mental health problem
to persuade the courts not to impose custodial sentences: “While we
all accepted that he had a problem, it was worrying to see
this.”

By this time the police had made her aware that the girlfriend
had a record of drugs and other offences, and this made McIntyre
redouble her efforts to try to talk directly to Williams, but
without success. She also had “grave concerns” for the other
tenant, who was by now very distressed by the situation, and after
discussions with her manager it was agreed that he would be offered
another tenancy.

McIntyre then received a call from cleaners who were finishing
off the empty flat opposite Williams’ flat, informing her that it
had been broken into. Attempts had also been made to break into the
other two flats.

The police were called. McIntyre and two male colleagues also
attended. Williams informed the police and Richmond Fellowship
staff that he had seen and heard nothing. While McIntyre and her
colleagues were waiting for fingerprint experts to arrive she
noticed that Williams had left the windows to his flat open: “As
this appeared to be how the burglars had gained access I asked my
manager’s permission for us to enter the flat and secure the
windows, and when we went in we found the stolen property
there.”

Williams had received several warnings that he was putting his
tenancy in jeopardy, and this obvious evidence of offences against
the property led to a decision to seek possession of the flat.
Meanwhile, McIntyre had to arrange for repairs and install security
guards around the clock.

Williams then returned to hospital again, and the police began
to receive reports from neighbours that the girlfriend appeared to
be using the flat for the purposes of prostitution. Shortly
afterwards the court obtained possession of the flat from him.

“He really left us no alternative. I had tried as hard as I
could to support his tenancy, but he seemed willing to be swept
along into a lifestyle which eventually left him homeless again.
Nor was I able to obtain any help from the probation service or
social services, and although I cannot know whether this would have
made a difference to what happened, their absence certainly didn’t
help,” she concludes.

 Arguments for risk

– Williams was homeless, he had a diagnosed mental health
problem, and met the criteria used by the supported accommodation
service for issuing assured tenancies.

– He had shown that he was aware of the need to stop abusing
drugs, and trusted McIntyre enough to ask her for help in making
arrangements to do so.

– His mental health problem was controlled by a regime of
anti-depressants.

– Under the terms of the tenancy he was entitled to live his
life very much as he wished.

– He appeared to be unable to stand up for himself, and was to a
degree led by others.

– McIntyre’s duty was to support Williams with regard to his
mental health problem, to help him to integrate into the community,
and to support the assured tenancy.

Arguments against risk

– McIntyre made numerous efforts to engage him, but he
effectively refused her help on all but a few occasions.

– Despite his occasional efforts to stop taking drugs, he was
aware of the consequences of his lifestyle and to the extent that
he could choose, wanted a chaotic, petty-offending lifestyle.

– His relationship with the girlfriend and other acquaintances
was an integral part of this lifestyle, and he clearly did not want
to change these relationships.

– McIntyre was not able to return one tenant to her flat – she
had been in hospital – because of the problems caused by Williams
and his friends. The other tenant was complaining about abuse from
Williams’s friends.

– Obviously, Williams’s tenancy could not continue after it was
clear that he or his friends were involved in burglary at the
property, or after the girlfriend started to use the flat for
prostitution.

Independent comment

The chaotic lifestyle and complex needs of many clients are a
central challenge for mental health services, writes Lorraine
Reeves. The government has promised extra funding to tackle
hard-to-engage clients, creating new outreach initiatives and
targeted support for those who do not have established links with
mental health services, and who may be homeless, have a history of
offending and misusing substance.

Was Arthur happy with what he was offered? Clear agreement
around a client’s willingness to receive support while in supported
accommodation is essential. Regular tenant meetings give the
opportunity for discussion on issues such as disruption, tenants’
responsibilities and rules about drugs. Although Arthur’s
relationship with his girlfriend appears unhelpful, this must be
balanced with his right to a private life in which he lives as
independently as possible. Sadly, his desire to live a turbulent
lifestyle counterbalances others’ rights to living safely and
productively.

When support becomes difficult, inter-agency working to prevent
tenancy breakdown must be a priority. Clear review procedures
before and during a crisis and de-escalation and contingency
planning by all remain the best tool for managing tenancy breakdown
and stopping vulnerable clients from slipping through the net.

In Arthur’s case, this could have involved housing and social
services officers, probation officers, drug teams, GPs, police
liaison officers and assertive outreach teams. Assessments of any
client’s capability, wishes and needs have to be backed by joint
investment by relevant agencies.

It is worrying that McIntyre feels she received no help from
some partner services. Move-on referral systems that have joint
ownership are the most successful. Partner agency support and
de-briefing opportunities for lone working staff are crucial.

Lorraine Reeves is an area manager for MACA. She
line-manages four registered care homes, a reachout service, and a
supported accommodation scheme and is setting up a project for
clients with complex needs.