The Risk Factor examines a case in which a mental health team has to prevent a patient who is behaving in an antisocial manner from being detained
Practitioner: Elliot Wylde is an approved mental health practitioner and team leader for an assertive outreach team.
Field: Mental health.
Client: Andrew,* 45, is a single man who lives in his own home. He has a history of psychotic illness.
Case history: Andrew has been receiving mental health services for nearly 20 years. He has been detained several times under Section 2 of the Mental Health Act 1983. In recent months, Andrew has been shouting aggressively at neighbours and getting into confrontations with them.
Dilemma: Andrew’s neighbours perceive the behaviour as abusive and feel harassed, but the police feel that the case should be dealt with through mental health services. The assertive outreach team needs to balance the needs of both Andrew and his neighbours.
Risk Factor: If his behaviour continues, police may be forced to intervene.
Outcome: Working with the police, the assertive outreach team devise a co-ordinated plan to enable Andrew to remain in the community.
In recent years, advances in community care have meant that people with severe mental health problems can live in their own homes, writes Mark Drinkwater. However, some cases require the intensive services of an assertive outreach team to work with individuals who are not engaging with services.
Andrew is a 45-year-old single man with a history of psychotic illness. He had been causing concern to his neighbours by regularly shouting aggressively at them, which results in them calling the police. The police have powers under public order legislation but were reluctant to use these to arrest a man in an obvious state of mental distress.
Andrew was referred by his community mental health team (CMHT) to the local assertive outreach team led by Elliot Wylde. “He would shout and scream at neighbours when a car door was slammed or someone was using a mobile phone,” says Wylde. “He also would get up close to members of the public – invading their personal space. This would be frightening to passers-by. And some males would find the situations confrontational. It was always a risk.”
Initially the assertive outreach team made slow progress with the case. The team used the HCR-20 (Historical, Clinical, Risk Managment-20), a risk assessment tool. “This assessment procedure identified the key triggers to Andrew’s antisocial behaviour, which guided our work,” Wylde says.
However, the real breakthrough came when the team reassessed Andrew through a psychiatrist who confirmed the psychosis but also diagnosed Asperger’s syndrome. This fresh perspective changed the whole approach. “Knowing that he had Asperger’s, we could see that he was only able to consider ‘his world’ and that he had difficulty considering other people’s feelings. He just didn’t understand the impact his behaviour had on others,” says Wylde.
Like many people with Asperger’s, Andrew found it hard to follow the conventions of social interaction. Drawing on their multidisciplinary skills, the team devised a plan where it was emphasised to Andrew that his neighbours had been encouraged to contact the police if he was behaving anti-socially, while he continued to receive help.
The team reasoned that they had to get Andrew to focus on the negative consequences his behaviour would have on him. “Of course, we put it to him politely and in terms that he could understand,” Wylde says. “We made it clear that continuing the behaviour would have negative consequences for him. Because of the Asperger’s, he had not been able to empathise with the distress caused to his neighbours. But he did understand that antisocial behaviour would result in police intervention.”
For some, this might have seemed like a drastic approach. But it worked Andrew was able to understand the negative consequences and the antisocial behaviour stopped.
Since the plan was implemented five months ago, there have been no untoward incidents. Andrew continues to receive support twice a week from the assertive outreach team, which is more than he would get from a CMHT. Wylde says: “The support has prevented incidents and ensure that people feel safe and protected.”
* Not his real name.
Arguments for risk
● Nuisance to his neighbours
Andrew was causing a nuisance to his neighbours by shouting and screaming. The situations were escalating in intensity.
● Outreach team committed to support
There was a commitment from the assertive outreach team to provide intensive support.
● No medical solution
With the knowledge of Andrew’s Asperger’s syndrome, it was clear that his antisocial behaviour was unlikely to improve from either anti-psychotic medication, or from being detained in hospital.
Arguments against risk
● Relationship might fail
If the plan did not work, it might damage the good relationship that the team has built up with Andrew so far.
● Draconian approach
A plan that emphasises criminal justice sanctions might seem controversial. The approach might seem draconian to some.
● Criminal justice intervention
If the approach did not work, Andrew might be detained in the criminal justice system, just as he was previously in the mental health system.
by Mark Sloman, a social worker with a community mental health team in Somerset
The development of assertive outreach teams in the past 10 years has done much to support clients with the most severe mental health problems who have found it difficult to engage in mainstream mental health services.
I couldn’t help but feel a sadness for Andrew, tinged with a bit of professional frustration and annoyance that it has taken 20 years and numerous inpatient admissions before someone considered Asperger’s syndrome.
What seems impressive in this case is the team approach adopted in Andrew’s care – an advantage of a small team with a small caseload. It also highlights the importance of seeing assessments as a continuous process and something needing constant review and reflection rather than a one-off event.
It is essential that the team draws on specialist resources available in their area, along with research on working with adults with Asperger’s. This should ensure that their engagement with Andrew is client-centred, based on the principle of recovery.
The new approach to working with Andrew seems to be working well. It is essential that the approaches are clearly documented, so that if they pass his care back to the CMHT the lessons learned will not be lost, ensuring that Andrew experiences a seamless service.
Published in the 19 February edition of Community Care under the heading ‘Action to avoid detention’