Home grown solution

Assertive outreach teams should consist of a broad range of professionals (see panel). The reality is that in the UK, unlike in the US where assertive outreach (AO) originated, this has been unrealised, due to resource pressure and competing priorities. Teams are usually made up of nurses and social workers. If they are fortunate they will have a psychologist, occupational therapist and a full-time psychiatrist. AO services visit people with mental health problems and broker services for them but this approach has had repeated service failings, as seen in the Clunis Report(1) for example, and so the need for AO services to be creative is paramount.

Knowsley offers an example of how creativity can overcome deficiencies. The council covers 110,000 people served by the Five Boroughs Partnership NHS Trust. Data suggests that people in the area have an increased risk of mental illness. The adult mental health service, which houses Knowsley’s assertive outreach team, is served by three community mental health teams (CMHTs), one crisis resolution/home treatment/access team and two in-patient wards.

The Knowsley team has been operational since November 2003 and is achieving some positive outcomes, despite not having a full range of professionals. But one difficulty the team has faced is suitable housing for service users. Although placements were sought, they were not always suitable for promoting recovery, inclusion and stigma reduction. A more creative way forward was required but the team has no housing officer, or welfare rights worker, leading to a brokerage approach being required.

As most clients referred for AO were disabled by their condition, repeatedly admitted to hospital and had a reduction in community tenure, referrals to the adult placement scheme of the charity PSS were made in the belief that these placements could promote recovery, reduce stigma and enable service users to reclaim their lives.

PSS operates in north west England, Wales and south west Scotland. It provides five key services to enable vulnerable people to live in the community with support according to individual need. The five services are: shared living; home and community support; children and families; mental health and counselling; and adult placement.

PSS adult placement has been shown to provide a useful adjunct to AO intervention and help particularly disabled people experiencing severe mental illness to rebuild their lives.

The first referral from Knowsley assertive outreach team to PSS adult placement was for a 20-year old man called Steve.* He had a diagnosis of schizophrenia, and additional social difficulties (low motivation, abuse of illicit and non-illicit drugs). He had become highly vulnerable while in the community and was being exploited both financially and for drugs. His living conditions had deteriorated to a crisis level and he was no longer looking after himself. He refused to engage with the CMHT and was referred to the Knowsley team whose priority was to find Steve suitable housing to begin his recovery.

The Knowsley team referred Steve to the PSS adult placement scheme with the aim of providing support in promoting his independence, increasing his motivation and monitoring his progress. Unsupported housing was not an option as the risk assessment showed a significant history of relapse when living alone. Steve needed a placement where he could build up his skills, and over time, increase his confidence towards independent living. Steve now lives with Ronnie* a PSS adult placement carer and his two sons. Steve has found living in a family environment stabilising.

Steve had a long-standing history of alcohol misuse, but he has now achieved significant control of this. His use of alcohol has declined and he now only drinks on Saturday nights with Ronnie, in a normal social manner. One benefit of this is that he responds better to his depot medication and is always available for the community psychiatric nurse from the Knowsley team  to administer it.

Steve states that his medication “gets him through the day”, and now the CPN is working with Steve to educate him on the side effects of depot medication with a view to considering a transfer to the new atypical anti-psychotic medication. Steve now chooses how to conduct his life without the restrictions that the negative symptoms of schizophrenia and the effects of alcohol had previously placed on him. Adult placement has provided Steve with the means to regain his dignity, self-esteem and place in society.

Services for the severely mentally ill should find alternatives to hospital in the least restrictive environment possible. But this is not always easy, since services are either institutionalised or over-priced and achieve  little in psychosis recovery.

There is little empirical evidence to support the use of adult placement for people with mental health needs, but, as this case study demonstrates, adult placement has an effect on the well-being and future recovery of individuals with a severe and enduring psychotic condition. Adult placement isn’t for all service users. However, the right placement can restore people’s self-esteem and help rebuild lost skills in an environment that engenders the development of social skills.

Assertive outreach cannot exist in a vacuum and should utilise services in the community to help rebuild service users’ lives. Assertive outreach teams that deliver services creatively and in partnership with the service user and the community are likely to witness favorable outcomes. In Merseyside, we have found that services such as adult placement help support an important part of the care plan and promote recovery for the individual.

Research in this area would be invaluable in aiding an understanding of the outcomes of adult placements and their potential benefits in augmenting community mental health care for a discrete population. Research and single case studies may also assist AO teams to access and understand effective and creative methods of rehabilitation and community participation.

* Names have been changed.

What is assertive outreach?

Assertive outreach was introduced as a government target for services with the introduction of the National Service Framework for Mental Health. AO intervention, developed from a US model,(2) aims to engage the service user to promote recovery, reduce disability and improve community tenure. The AO team should be a distinct body made up of health and social care professionals,(3) along with welfare workers, employment officers, housing officers and others.

Caroline Williams is a registered mental health nurse and a teaching fellow at the University of Manchester. She is also an independent mental health nurse consultant for her mental health consultancy User Friendly Psychiatry. At the time of writing the article, she was a manager of the Knowsley assertive outreach team.

Margaret Rowlands is a service manager for adult placement in England and Wales with PSS. She is social work qualified and has a particular interest in young onset dementia.

Rita Lalley is the project manager for mental health adult placement at PSS.

Training and learning
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.

Abstract
Assertive outreach provides community-based mental health care to people who are severely disabled by their mental illness and fail to engage with services. AO started in the US and its adaptation in the UK is a cause of some debate in the field. Adult placement services provided by non-statutory agencies provide an alternative to a catch-all AO solution to recovery. This article discusses the experience of a brokerage partnership between AO and adult placement and provides some implications for practice and research.

References
(1) J Ritchie, D Dick, and R Lingham, The Report of the Inquiry into the Care and Treatment of Christopher Clunis, HMSO, 1994
(2) L Stein, M Test, “Alternative to mental hospital treatment. Conceptual model, treatment program and clinical evaluation,” Archives of General Psychiatry, 37, pp392-397, 1980
(3) G Teague, G Bond, R Drake, “Program fidelity in assertive community treatment: development and use of a measure,” American Journal of Orthopsychiatry 68 (2), pp216-231, 1998

Contact the author
caroline.williams@ufpmentalhealth.com