NFAO Assertive Outreach book published in March 2011

The National Forum for Assertive Outreach has published a textbook entitled ‘Assertive Outreach in Mental Healthcare: Current Perspectives’. I was engaged to contribute a chapter in collaboration with Sue Jugon, the Team Manager of the AO North based in Kettering, Northamptonshire. This presented me with a wonderful dual opportunity… to write a creative piece with enormous respect to the work Sue has done with her team over the last 11 years, but also to respond to the review in 2004 of my previous publication with Peter Ryan which referred to the work as ‘the funky business of mental health care’. I have long since wanted to expand on the theme of funky mental health, so here it is.

FUNKY MENTAL HEALTH

Steve Morgan & Sue Jugon

Warning: the following chapter should only be read by those with an open mind, and a challenging disposition!

Introduction

If you spend so many of your waking hours, and some anxious restless nights, devoted to working in mental health, are you right to expect at least some joy, fun, excitement, productive challenge, and even intrinsic reward from your complex interactions with service users and colleagues? Our managed, regulated, monitored and audited system is intended to ensure consistent good practice, but it is arguable whether it contributes anything towards producing a motivated workforce through its relentless pursuit of numbers and targets. A sea of fidelity scales, outcome measures, policy initiatives, service protocols and templates, research based models, and increasing mountains of paperwork may be a satisfying representation of service delivery for the academics and managers, but largely feels unconnected to the pursuit of genuine creative person-centred practice for practitioners, or service users for that matter.

The strengths approach to assertive outreach was fully articulated by Ryan and Morgan (2004), and in a review of their book (replicated in Practice Based Evidence, 2009) the approach was likened to ‘the Funky Business of mental health care’; providing practitioners with a different perspective from the mire of mechanistic, risk averse, box-ticking required by most organisations. The book places a strong emphasis on creative collaboration, true team-working and the need to be anchored by the well-being of the people we serve.

Continuing the theme of this book review, funky mental health should be seen primarily as working with and around the rules. It is about how different people may look at the same thing but see something different. A small proportion of all practitioners are exceptional in their ability to reflect on situations, think creatively about complex interactions, and manage the demands placed on them organisationally without losing their vision of person-centred practice as the most important goal. A small proportion of all practitioners are exceptionally poor, shouldn’t by rights be inflicted upon service users, but organisational systems and teams can be cursed by an inability to offload them. The large majority of practitioners are good people wanting to do good work, but become easily paralysed by their narrow interpretation of policies and outcome measures within the wider perceived context of a blame culture. They unintentionally prioritise a focus on what might go wrong before considering the challenges and often risk-taking demands of a genuine person-centred approach. The ultimate losers will always be the service users, though you wouldn’t necessarily believe this from the incredible spin the management machine can often place on its own contradictory demands of services.

Funky mental health is not about ignoring the rules or breaking the rules in any illegal way. Buckingham and Coffman (2005) talk about ‘First, break all the rules’, but only as a challenge to see and do things differently in order to gain the most positive and successful outcomes from identifying and working with anyone’s individual talents. Rules are generally guidelines, not usually immovable impositions or rigid barriers. Assertive outreach has been established specifically to find ways of working with people for whom the traditional rules of community mental health have proved less workable. So, by definition these rules, or norms, have failed to bring about anyone’s desired outcomes (neither service user nor service provider). In this instance do we give practitioners more time to do more of the same thing, in the hope of re-shaping the service user to better fit the pattern of service delivery? This undeniably represents a ‘service-centred’ approach to practice, and often includes punitive responses towards the service users and their needs. Or, do we give practitioners the permission to create new ways of engaging and working alongside the service users in creative and flexible ways (i.e. a more person-centred approach)?

Funky working needs a vision

In some instances funky mental health should produce the ‘I can’t believe you do that’ response from the majority of the good practitioners. It starts with a clear underpinning vision that can be returned to and checked against at any stage of a team’s development or experience of significant challenges. The vision should be about how we develop and sustain a ‘team’ that can incorporate the maximum range of qualities in a small group of practitioners so they may be made available to the diverse range of people who naturally make up the client group. It is about a clear underpinning philosophy, and an eagerness to reflect, individually and collectively, on the personal values that influence our every decision; including the big questions of why we do this type of work, what we feel about the people who need services, and how we intend to best work with them. It is about people who have a healthy respect for how work and personal lives inter-relate, not about rigid 9-5 demarcations. It is about genuine flexible responses to needs, rather than the rigidity of extended shift patterns. It is about being challenged to think, and being aware of the rewards of the intrinsic value of thinking through a challenge. In the world of funky mental health there is a more healthy developed appreciation of how much we become a part of service users lives; but also going one step further, seeing how service users become an important part of our lives if we have a belief in the value of the work we are doing.

Remaining contents:

 What do the exceptional few do?

 It is also about the environment

 Underpinned by a ‘team’

 Can local effectiveness be centrally legislated?

 A Day in the Life

 8.56a.m. … Morning Handover…

 White Lightening…

 9.49a.m. … Doing the work…

 1.14p.m. … Team Reflection & Practice Development…

 4.01p.m. … Administration Hour…

 6.29p.m. … Real flexibility and response to needs…

 7.00p.m. … A daily phone conversation…

 7.11 p.m. … A call to the ‘buddy’

 Conclusions

 The practice of a funky mental health approach is not without its challenges and difficulties; not the least of which will be some staff members within any team who just don’t get it. There is no accounting for the lack of reflection and fixed mindsets that will regularly be encountered, and even denied or defended by those practicing them. For some, the opportunity to reflect on, think about, and creatively develop their practice is nothing more than a hindrance to just getting on with all the pressures they experience in a busy and demanding job. There is also no substitute for a good consistent moan to some people. This is not to say they do not do good work; but the amount of energy expended on negative feeling and expressions of emotion takes away from time that could be devoted to more constructive management of the challenges, but also serves to demotivate others subject to the whining and claims to have done it all before. 

The individuals who practice funky mental health are a lucky few… predominantly reflective and ethical people, they understand how to achieve a level of enjoyment out of their work, it being an intrinsic part of their life interwoven with other elements of who they are. They encounter a majority of people who are eternally trying to find reasons to separate what they do at work from who they are as people outside of demarcated work hours. They understand that the less you integrate the more you fragment, and a fragmented life is the basis for further dissonance. However, these practitioners or team managers are not naïve enough to allow themselves to be exploited by the considerable demands of a system more equipped to grind down excellence for the sake of uniform bureaucratic mediocrity. They understand the system better than most, because they reflect on and analyse what is going on around them, and think about the sometimes hidden motives and connections in the games people play.

In the real world of person-centred practice funky mental health is about ‘permission’ to think and do things differently, rather than a ‘prescription’ of how things are expected to be done. Traditional expected ways can be fine, in some circumstances, but don’t have to be the usual way in all circumstances. Can funky mental health apply outside of AO? Yes, in the funky world of trying to recapture all that is interesting, motivating and exciting about working in mental health… assertive outreach could be seen as providing a guiding light for other areas of practice to adapt into their functions and responsibilities. Whether that will be understood from a higher level policy and management perspective is another question altogether.

To order the book click here.

Creating Capable Assertive Outreach Teams - slide presentation

The following Powerpoint presentation, 'Creating Capable Teams: AO (North) Northamptonshire A Case Study', was written by Steve Morgan (Practice Based Evidence) and Sue Jugon (AO North Team Leader)

Powerpoint: Creating Capable Teams: AO (North) Northamptonshire A Case Study (119kb)

'Strengths' Assertive Outreach: A Review of Seven Practice Development Programmes

The following article was first published in the Mental Health Review Journal (June 2008) and is reproduced with their kind permission.

Abstract

Assertive outreach is based on extensive international research and has been promoted in the UK in 1999 as a key area of the National Service Framework for Mental Health. Its primary aim is to provide a specialist service for people disengaged from traditional approaches of mental health services, but very little attention has been paid to how such services can be developed. Practice Based Evidence, a practice development consultancy, has engaged seven assertive outreach teams to focus on development first, and follow-up evaluation of the impact of reflective practice on team functioning. This has prompted a number of strengths-based recommendations for changing the way we think about developing services before we engage in research and evaluation.

PDF: 'Strengths' Assertive Outreach: A Review of Seven Practice Development Programmes

Excerpt from Part 3: Evaluating a Strengths Approach to Practice Development

Developing a tool to guide and capture the strengths messages

The rationale underpinning a strengths approach led to the development of a 13- item tool to help capture some measurement of how practice development and team functioning can influence positive changes in team practice. The tool should also act as a prompt to areas of good practice, so the items are designed to be a sufficiently comprehensive reflection of ethical issues, care process, team functioning, and an underpinning knowledge base. Yet, this also needs to be a manageable tool (i.e. fitting one side of paper) if it is to engage practitioners interests and be used.

Ethical practice
1. Service users are fully involved in determining the ‘priorities’ for the working relationship.
2. As a team, we regularly examine and review the impact of ‘values and principles’ on our practice.
Care process
3. Time for creative approaches to ‘engagement’ is a priority.
4. Our assessment of needs includes the identification of service user ‘strengths’.
5. We identify and manage the appropriate opportunities for ‘positive risk-taking’ in practice.
6. Our working practice draws on a broad range of ‘practical and research based’ approaches.
Team working
7. We are clear about our ‘purpose’ as an assertive outreach team.
8. We have a clearly agreed model of ‘team-working’ (within team).
9. We have effective systems of ‘support and supervision’.
10. We have clear processes of ‘decision-making’ in the team.
11. We ‘link’ effectively with other parts of the mental health system (including primary care).
Knowledge in practice
12. We make full use of the ‘diverse’ knowledge, skill and experience within the team.
13. We access appropriate expertise from outside of the team.

Developing the method of evaluation

The method focuses on evaluation of changes in practice that gives useful feedback to the teams about their global functioning, as well as indicators to priorities they may choose to focus specific attention on. This is not the same as the approach established in many of the well known research projects examining the effectiveness of assertive outreach. The research approach has been one of top-down influences, whereby external sources examine questions relating to their desire to compare outcomes to other known and established research. The evaluation approach is a bottom-up influence, whereby the practitioners are engaged in reflecting on how their team is performing in relation to practice-based outcomes.

Risk-making or Risk-taking?

The following article was first published in Openmind (101, Jan/Feb 2000) and is reproduced with their kind permission.

Steve Morgan argues that assertive outreach is a positive service model that must resist being set up to be the new face of the 'risk business'

Assertive outreach (AO) is a term used to describe a range of services for 'people with severe mental illness who are hard to engage with services'. In 1998 the publication of Keys to Engagement by the Sainsbury Centre for Mental Health synthesized much of the existing knowledge and research on developing assertive outreach services in the UK, and there have since been a number of important developments in both theory and practice.

New service models have to establish themselves in the context of the prevailing political climate, and, undoubtedly, the current climate for UK mental health services is strongly influenced by the media portrayal of 'risk', despite what the evidence may say. Just as 'cost effectiveness' is inextricably linked to reduced hospital bed use, so new service models will be measured by their ability to achieve unrealistic expectations of 'risk elimination'.

Assertive outreach faces the danger of becoming closely associated with enforced restriction and compliance to medication regimes. Short sighted expectations imply that if hard to engage people are closely policed and made to take their medication, risks to the public will be reduced. Assertive outreach is potentially being set up to become the new face of the 'risk business', entrusted with the role of tracking resistant individuals, and equipped with the mechanisms of coercion and enforcement. Vote winner this may be, but a basis for effective services it is not.

In short, no consideration will be given to the reasons why people disengage, and service users' worst fears of 'aggressive' outreach will be fulfilled. The potential benefits of collaborative assertive outreach will be shattered, as more people feel driven to greater extremes of service avoidance. A good idea will be misappropriated, and turned into risk promoting failure.

Such 'policing' expectations of AO sit comfortably with traditional responses to potential risk, i.e. negative and restrictive practices. It also conveniently lets policymakers and some service providers off the hook, by avoiding the need to scrutinize their own gaps and failings. Far from offering incentives to engage, it confirms users' suspicions, and creates more distance between users and providers. In this scenario, 'risks' become more likely to happen!

I would like to propose the following definition of assertive outreach: 'A flexible and creative client centred approach to engaging service users in a practical delivery of a wide range of services to meet complex health and social needs and wants. A strategy that requires the service providers to take an active role, working with service users, to secure resources and choices in treatment, rehabilitation, psychosocial support, functional and practical help, and advocacy ....in equal priorities.'

An extremely small proportion of service users will resist mental health services at all costs, and some degree of restrictive power will need to be carefully considered on rare occasions. The majority of people labelled 'hard to engage' have been repeatedly demonstrated to engage when services are offered in a more flexible and client centred way. This has been equally true in UK statutory and voluntary sector agency AO teams. Most people will engage, at some level, with services they perceive to be in tune with their own needs and wishes.

The challenge to service providers is to be more flexible and creative in their active attempts to engage trusting relationships. AO approaches need to recognize the complexity of service users' lives, and the need to work with reasonable and practical priorities within the whole picture. It is not about reducing complicated social, cultural and environmental factors down to a narrow identification of symptoms, risk factors and strategies for restrictive management. The quashing of aspirations contributes to the potential for risk.

The established examples of good practice in AO recognize that risks are an integral component of comprehensive mental health services. They do not deny that people both pose risks, and are at risk, on a frequent basis.

The AO definition given opposite offers a more holistic view of personal needs, wishes and aspirations. It encourages service users to express their own views of their world, to be listened to and worked with. This takes service providers into relatively uncharted territory, beyond the safety of 'professional judgement' and the more usual need to offer restriction as a solution to identified problems.

AO approaches therefore open up the prospect of 'positive risk taking'. The majority of the population enjoy the benefits of exercising choices and taking chances learning equally from the outcomes of success and failure. However, there is an implicit assumption that mental health problems should exclude people from such benefits.

'Positive risk taking' is not negligent ignorance of the potential risks. Nobody, especially service users, benefits from allowing risks to play their course through to disaster. Positive risk taking is about collaborative working, based on the establishment of trusting working relationships, whereby service users can learn from their experiences, based on taking chances just like anyone else. It is about understanding the consequences of different courses of action; making decisions based on a range of choices, and supported by adequate and accurate information. It is about knowing that support is instantly available if things begin to go wrong, as they occasionally do for us all. Positive risk taking is also about explicit setting of boundaries, to contain situations that are developing into potentially catastrophic circumstances for all involved.

The realistic emphasis is on 'risk minimization', not risk elimination. AO services expect to take responsibility and be accountable for their work. However, they need a more cohesive framework that clearly links responsibilities at individual, multidisciplinary team, and service organization levels. Responsibilities need to be strongly aligned to principles of good practice, clearly defensible in the face of the more usual damaging hunt for scapegoats. The culture that needs to blame dedicated individuals working in very challenging situations, is a culture that destroys the seeds of confidence and success before they have a chance to flourish.

Service providers and policymakers sometimes hear only the messages they want to hear, or read into the evidence that which they want to see. The result is that as a society we often get the services we deserve which are not necessarily the services that users deserve

Assertive outreach has a positive record of effectively linking the function of engagement to practical tasks and evidence based clinical interventions. Flexible and creative services hold benefits for both service users and providers who engage within them. They also offer a constructive approach to managing risks. Alternatively, we can hijack a good idea, to fulfil short sighted ideals.

Engagement by degrees
Assertive outreach workers recognize that engagement is not automatic; it has to be earned, and always worked at. It can frequently be tenuous, and in need of negotiation, but will always be the foundation of all other work.

• Someone reluctant to discuss mental health orientated issues may stil engage with discussions of their own priorities e.g. housing or money. Contact enables some trust to develop, and may form the basis for subsequent negotiations on more delicate issues.
• An individual feeling suicidal may feel their intense distress is being listened to and understood, if intensive support is offered at home through active listening. Hospital admission doesn't always guarantee safety, and may hasten an attempt for those people who feel they are simply having responsibility stripped away.
• Verbal aggression and agitation may occasionally be better supervised through non-judgemental support from respectful workers. Medicalizing the situation increases the volatility for some. Pranoid suspicions may be a response to reality, not psychotic symptoms. AO offers opportunities to observe and discuss social reality rather than psychiatric interpretations of individual behaviour.
• Someone who is chronically institutionalized and neglectful may be supported to remain in their own independent accommodation, through regular planned respite to enable cleaning of the home environment. Conversely, expectations of skill development and raised standards of hygiene may not always be realistic, and could lead to loss of tenure.
• A volatile and angry person, intent on the benefits of hard drugs, with no concern for the consequences of their aggression on others, will probably require prompt and restrictive interventions. But, only on the basis that efforts will be made to offer a wider range of supportive options when the situation settles

References

1. 1. Sainsbury Centre for Mental Health (1998). Keys to Engagement: Review of Care for People with Severe Mental Illness who are Hard to Engage with Services (SCMH).
2. 2. PRiSM (1998) 'Psychosis study, papers 1-10' British Journal of Psychiatry 173, pp. 359-427.
3. 3. Hemming, M., Morgan, S. and O'Halloran, P. (1999) 'Assertive outreach: implications for the development of the model in the United Kingdom' Journal for Mental Health 8(2), pp. 141-7.
4. 4. Taylor, P. J. & Gunn, J. (1999) 'Homicides by people with mental illness: myth and reality' British Journal of Psychiatry 174, pp. 9-14.
5. 5. Morgan, S. and Hemming, M. (1999) 'Risk management and Community Treatment Orders' Mental Health Care 31, p. 20.

Illustration: Jules Feiffer/1975 from Man Bites Man: Two Decades of Satiric Art (edited by Steven Holler, Hutchinson 1981).