Jem Mills, Alec Grant,
Ronan Mulhern and Nigel Short
Learning objectives
After reading this chapter and completing the activities at the end of it you should be able to:
1 identify the key aspects of assertive outreach
2 identify the people most likely to benefit from an assertive outreach approach
3 discuss the relationship between assertive outreach and social control 4 identify how the CB approach fits with the recovery concept
5 generate CB formulations of resistance
6 identify how the CB approach might be incorporated into assertive outreach work.
Introduction
Assertive outreach is the British version of an intensive, community-based mental health service first developed in North America in the 1970s. Although assertive outreach has varied in its development internationally, research evi-dence indicates a number of shared core components (DoH, 2001b):
• a self-contained team responsible for providing the full range of interventions
• a single responsible medical officer who is an active member of the team
• treatment provided on a long-term basis with an emphasis on continuity of care
• the majority of services delivered in the community
• emphasis on maintaining contact with service users and building relationships
• care coordination provided by the assertive outreach team
• small caseload – no more than 12 service users per member of staff.
The approach is aimed at people for whom traditional services have proved unpalatable. This could apply to many in the population, but the Department
of Health (2001b) describes a common profile. This includes people with a severe and persistent mental disorder (such as psychosis), a history of high use of inpatient or intensive home-based care, and those who have difficulty in maintaining lasting and consenting contact with services and have multiple and complicated needs.
People with this profile commonly experience a variety of practical and social difficulties (Hemming et al., 1999) such as poor general health, low income and unemployment. In addition, such people are likely to be homeless or in unstable accommodation, with few social contacts and experiencing diffi-culties with shopping, budgeting and personal hygiene.
The potential outcomes of the assertive outreach approach have been identi-fied as (DoH, 2001b):
• improved engagement with services
• reduced hospital admissions
• reduced length of stay in hospital
• increased stability in the lives of service users and their carers/family
• improved social functioning
• cost-effectiveness.
Assertive outreach as social control?
The term ‘assertive outreach’ first became prominent in British government literature with the publication of the White Paper ‘Modernising Mental Health Services’ (DoH, 1998). The central message – that services would become more ‘safe, sound and supportive’ – followed a wave of policy development concerned with public safety. This notably occurred at the same time as a small number of high-profile incidents in which carers or professionals were killed by people experiencing mental illness (Ryan, 1999). The underlying implication was that the rapid refocusing of mental health services from resi-dential to community-based care had failed to provide adequate monitoring of those people at risk of harming others and this had led to an increase in violence by people experiencing mental health problems. However, it has since been strenuously argued that the community care of people experiencing mental distress has contributed nothing to the general rise in violence in British society and over-reporting is to blame for this misconception (Hemming et al., 1999).
Despite this, Morrall (2000) argues that public fear of people with severe emotional and psychological difficulties is not just a product of overzealous media reporting, but also stems from mental health professionals’ reluctance to acknowledge the social control aspects of their roles. He argues that the increas-ingly controlling nature of mental health services is a consequence of society’s failure to address this negative public perception. Interestingly, professional resistance to the social control aspects of assertive outreach is not explicit in mainstream mental health literature.
Confusion about the function of assertive outreach
… there has been considerable debate about, and resistance to, the prescription of the model, and this has served to confuse local service developers and hamper their attempts to implement the service effectively.
(Davidson and Lowe, 2001: 2)
Ryan (1999) shows that at the outset the message ‘safe, sound and supportive’
(DoH, 1998) contains inherent contradictions that serve to confuse those seek-ing to develop assertive outreach services. Despite the clear link to a social con-trol agenda, the term ‘safe’ is applied to the public, mental health service users and their carers. As Ryan (1999: 4) rightly asks, ‘whose safety actually comes first? Where are services to place priorities?’
Right from the very beginning it seems as if assertive outreach has been influenced by the need to address a variety of organisational and public health issues, not just the needs of those most affected by mental distress. These apparently contradictory influences are arguably difficult to contain within the everyday practice of assertive outreach workers. The result can be conflict among the professionals involved in its delivery, which has its own deleterious consequences (Mills, 2003). A sad consequence of this is the tendency for pro-fessionals to blame themselves for not being able to contain these conflicting influences. Professionals can view themselves as deviant when they choose to prioritise client need over the needs of the organisation (Mills, 2003). Dealing with these conflicting influences, along with the reluctance towards acknow-ledging the social control aspects of the work, may be a factor in the rise of a more client-focused model of care within assertive outreach – namely the recovery model.
What is recovery?
Recovery is the process by which people start to live their lives more fully after experiencing catastrophic events, such as serious illness, accidents, bereave-ment, financial devastation or personal attacks. The concept is more commonly associated with managing physical disabilities and illnesses, moving beyond the idea of cure to living with suffering or reduced abilities.
Anthony (1993) describes the inclusive nature of the concept, given that all human beings will experience some catastrophic event in their lifetimes. The event will never be forgotten – it becomes part of the person as they find a way to move on. The process is an individual one, although commonalities are shared.
The concept of recovering from mental illness varies among people, particu-larly between practitioners and their clients. Meddings and Perkins (2002) found that people with mental health problems were more likely to associate recovery with having more money, a job and somewhere nice to live.
Practitioners from a range of disciplines tended to give higher priority to Working with People in Assertive Outreach 145
accessing help and daily living activities as signs of recovery. Although both groups identified symptom reduction as important, improved mental well-being is often only a first step in the process within a recovery model:
People with mental illness may have to recover from the stigma they have incorporated into their very being; from the iatrogenic effects of treatment settings; from the lack of recent opportunities for self-determination; from the negative side-effects of unemployment; and from crushed dreams.
Anthony, 1993: 15
It is difficult to describe a process of recovery, given the individual nature of people’s experiences. However, Townsend et al. (2000) identify a number of principles (described below) that can guide the application of a recovery model to mental health and, in particular, to the incorporation of the CB approach within assertive outreach work.
Recovery, compassion and CB case formulation
The principles of the recovery model arguably have much to offer the devel-opment of the CB approach. For instance, the problem-focused nature of CB work can leave people feeling as if all their worst points have suddenly been placed before them or that their current distress is related to deeply ingrained inadequacies ( James, 2001). This is not so within a strengths/assets model, which seeks to build on the helpful aspects of the person’s reactions to their difficult circumstances. One way in which to incorporate these ideas into a CB approach is to develop the notion of a ‘compassionate case formulation’. This attempts to highlight the adaptive nature of the compensatory strategies that the person has developed as a result of their life experiences. It suggests reduc-ing the use of these strategies in less helpful contexts, but buildreduc-ing them up in the helpful ones. One example is the tendency to ‘people please’ that those with low self-esteem often develop ( Fennell, 1997). This strategy is usually adopted in childhood as a way of avoiding rejection or some kind of abuse. In adult circumstances, it can have a range of more or less helpful consequences, including:
• being able to easily put one’s own needs second to those requiring care
• being extremely helpful to others
• not letting people down
• being very diplomatic
• not being able to say no
• not looking after oneself properly
• coming across as disingenuous.
The compassionate case formulation would lead the person and the practitioner to understand that the people-pleasing strategy was once very useful, if not vital. It also sees it as a potentially useful way of operating that is sometimes overused or used to the person’s own detriment. In this way, the person is left
with the less daunting prospect of modifying how they apply a natural tendency rather than righting a lifelong problem.
The 12 guiding principles of the recovery concept (Townsend et al., 2000) are listed below, alongside aspects of the CB approach that either fit well or have the potential to be developed.
Working with People in Assertive Outreach 147
Corresponding aspects of the CB approach The collaborative and educational nature of the approach seeks to enable the person to apply CB theory and strategies independently – in essence becoming their own therapist.
The approach fosters independence and encourages attention to relapse prevention by means of self-knowledge/management. There are times when limited periods of dependence on the practitioner are a useful part of the process and these are discussed explicitly (Beck et al., 1990;
Young, 1990; Leahy, 2001).
The linking of CB work to explicit goals defined with the person help to foster hope and make it directly relevant to their life circumstances.
However, the CB approach has a tendency to individualise problems and concentrate on internal psychological mechanisms. For instance, there is great scope for developing the cultural and gender sensitivity of CB work (see also Chapter 15).
An individualised, compassionate case formulation approach can incorporate these aspects, but is less apparent with more technique-focused styles of CB work (see Epilogue).
CB psychotherapy is often presented as having great potential for integrating other approaches.
For instance, the application of CB methods for people hearing voices draws heavily on vulnerabil-ity stress models (Kingdon and Turkington, 1994), which have the capacity to draw together a bio-psychosocial approach.
This principle is fundamental to any
psychotherapeutic approach (see Chapter 2).
The CB approach has a problem focus, which can have negative consequences. These can possibly be addressed by developing the notion of a compassionate case formulation (see above).
Recovery model principles The consumer directs the recovery process, so consumer input is essential throughout the process.
The mental health system must be aware of its tendency to enable and encourage consumer dependency.
Consumers are able to recover more quickly when their:
• hope is encouraged, enhanced, and/or maintained
• life roles with respect to work and meaningful activities are defined
• spirituality is considered
• culture is understood
• education needs as well as those of their family/significant others are identified
• socialisation needs are identified.
Individual differences are considered and valued across their lifespan.
Recovery from mental illness is most effective when a holistic approach is considered.
In order to reflect current best
practice, there is a need to merge all inter-vention models, including medical, psycho-logical, social and recovery.
Practitioners’ initial emphasis on hope and the ability to develop trusting
relationships influences the consumer’s recovery.
Practitioners operate from a strengths/assets model.
(Continued)
Engagement and resistance
People in all walks of life resist healthcare services for a variety of reasons. For instance, it is quite common for people to stop taking medication such as antibi-otics when they start to feel better. Fear and avoidance of dental treatment is commonplace and people often ignore physical symptoms of illness, hoping that they will right themselves. These types of resistance obviously occur with mental health problems as well, but are complicated by three major factors:
• mental health treatment can be compulsory
• there is great stigma associated with mental health problems
• mental health services can be invalidating, abusive and traumatising ( Johnstone, 2000).
People targeted by assertive outreach teams have been described as:
… a small number of people with severe mental health problems with complex needs who have difficulty engaging with services and often require repeat admission to hospital.
DoH, 2001b: 26
This description demonstrates a problematic, one-sided view of the issue of engagement. Conceiving people’s resistance to mental health services in this way plays down the possibility that previous contact with services may have:
Corresponding aspects of the CB approach The problem-solving nature of CB work, alongside attention to environmental factors impeding recovery, can work well with this principle.
Mainstream CB work is not usually associated with family involvement. There is a tradition of including significant others as co-therapists, but attention to wider family dynamics and the potential for draw-ing on family resources is often neglected.
Traditionally, like other psychological interventions, the CB approach has been applied within healthcare settings. However, there are examples of using telephone and Internet contact (Burgess and Chalder 2001; Kenardy et al., 2003). Adapting CB methods to suit the client’s own environment is something that an assertive outreach approach can bring to CB work.
The CB approach has hitherto paid very little attention to community aspects of a person’s recovery. This presents another development opportunity for the approach.
Recovery model principles Practitioners and consumers collaboratively develop a recovery management plan. This plan focuses on the interventions that will facilitate recovery and the resources that will support the recovery process.
Family involvement may enhance the recovery process. The consumer defines their family unit.
Mental health services are most effective when delivery is within the context of the consumer’s community.
Community involvement as defined by the consumer is important to the recovery process.
(Continued)
• failed to meet people’s needs
• been invalidating
• been experienced as abusive or unsafe
• constituted a traumatic incident, leading to enduring psychological and emotional consequences.
Moving beyond the view that people mainly resist mental health services because of a lack of insight into their illness can lead to more flexible and creative approaches to building collaborative relationships. The CB approach has two particularly valuable sources of flexibility and creativity applicable to the issue of engagement. These are structured assessment and models of resistance.
Structured assessment
A process of structured, comprehensive assessment can be very useful in devel-oping an in-depth understanding of issues surrounding resistance to services. In particular, the service engagement scale (Tait et al., 2002) highlights the follow-ing 14 aspects of client difficulty with engagement, grouped under 4 headfollow-ings:
• availability
1 the client seems to make it difficult to arrange appointments 2 when a visit is arranged, the client is available*
3 the client seems to avoid making appointments
• collaboration
4 if you offer advice, does the client usually resist it?
5 the client takes an active part in the setting of goals or treatment plans*
6 the client actively participates in managing their illness*
• seeking help
7 the client seeks help when assistance is needed*
8 the client finds it difficult to ask for help 9 the client seeks help to prevent a crisis*
10 the client does not actively seek help
• treatment adherence
11 the client agrees to take prescribed medication*
12 the client is clear about what medications they are taking and why*
13 the client refuses to cooperate with treatment
14 the client has difficulty in adhering to the prescribed medication.
The items are rated 0 (not at all or rarely) 1 (sometimes), 2 (often), 3 (most of the time).The items with asterisks are reverse scored.
Although the service engagement scale necessarily focuses on client behaviour as an observable measure, the authors emphasise that ‘there are often valid reasons Working with People in Assertive Outreach 149
Clinical example
‘Sally’ avoids appointments with her psychiatrist because she finds him unwilling to engage in discussion about her spiritual crises. She refuses to take medication as it interferes with her ability to hear God’s commands. The mental health services describe this journey to enlightenment as an illness.
‘Adrian’ believes that, if he talks about his difficulties, he will be overwhelmed by his emotions. He thinks that if he starts to feel emotional, he might lose control of himself and hurt someone. He avoids any depth of discussion about his distressing experiences by referring to his problems as a pain in his head.
‘Bijal’ has just about coped with her prob-lems by never throwing anything away. It feels as if this way of coping is part of who she is as a person. She feels that if she changes now she will be giving up a big part of herself.
Because ‘Dave’ believes that he is evil, he also believes he does not deserve to be helped. He tries to make sure that he is out when his practitioner calls.
‘Izzy’ believes that her difficulties stem from her relationship with her family. Her family say that Izzy is to blame for her troubles. She thinks that accepting help for her problems is giving in to this view. She becomes angry when practitioners suggest change.
‘Cyril’ believes that his voices are a punishment for a series of things he did in his childhood. Although he knows that medication helps, he also believes that he deserves this punishment and so regularly stops taking it.
‘Marie’ believes that she will always need help. When she feels unsupported, she has thoughts about suicide. She worries that if she improves, she will be discharged from the service and end up killing herself. She tries to underplay her progress and ensure that she always has a problem she needs help with.
‘Danny’ believes that he is a failure and anything he tries will go wrong. He believes that if he tries to change, he will fail and people will see how useless he is. He finds ways in which to avoid the changes to his lifestyle suggested by his practitioner.
How this dimension might
for client withdrawal from services or non-acceptance of services’ (Tait et al., 2002: 92). Once an individualised and specific profile of a person’s behaviour towards services is understood, a more in-depth understanding of the factors at play can be achieved by considering the reasons behind this resistance.
Leahy’s (2001) model of resistance to therapy formulates a range of interac-tions between the therapist or therapy process and clients’ beliefs about them-selves or their difficulties. He presents eight dimensions of resistance, related to both client and therapist beliefs and behaviour. This model – outlined in the dimensions of resistance table above – can arguably be mapped on to the
Leahy’s (2001) model of resistance to therapy formulates a range of interac-tions between the therapist or therapy process and clients’ beliefs about them-selves or their difficulties. He presents eight dimensions of resistance, related to both client and therapist beliefs and behaviour. This model – outlined in the dimensions of resistance table above – can arguably be mapped on to the