Faculty of Psychosis
& Complex Mental Health
Clinical Psychologists and Assertive Outreach
Briefing Paper No. 21
November 2013 update
This document was written on behalf of the Division of Clinical Psychology Psychosis
and Complex Mental Health Faculty by:
Caroline Cupitt
Bexley Assertive Outreach Team, Oxleas NHS Foundation Trust, London.
[email protected]
Ben Frayne
West Hampshire Community Treatment Teams (Assertive Outreach
Psychology Function Specialist), Southern Health NHS Foundation Trust
[email protected]
Stuart Whomsley
Assertive Outreach Team for Cambridgeshire and Peterborough NHS
Foundation Trust
[email protected]
Morna Gillespie
North Assertive Outreach Team, Birmingham & Solihull Mental Health
NHS Foundation Trust
[email protected]
Sara Meddings
East Sussex Assertive Outreach Teams, Sussex Partnership NHS
Foundation Trust
[email protected]
Acknowledgements
In revising this briefing paper the views of those present at the meeting of the Network of
Psychologists in Assertive Outreach, in January 2012 were sought. The comments made
were extremely helpful and many have been incorporated into this document.
We would also like to thank the following people who commented on earlier drafts:
Julian Pitt, Consultant Clinical Psychologist, Cwm Taf Local Health Board, Wales.
Simon Wharne, Chair of the National Forum on Assertive Outreach and Team Leader,
Sussex Partnership NHS Foundation Trust.
Hannah Steer, Principal Clinical Psychologist, 2gether NHS Foundation Trust.
Dr Mary Corr, Consultant Clinical Psychologist, Western Health and Social Care Trust,
Northern Ireland.
Dr Frances Baty, Consultant Clinical Psychologist, NHS Fife, Scotland.
The Network of Psychologists in Assertive Outreach can be contacted via the authors.
Note
The terms ‘client’ and ‘service user’ are both commonly used by psychologists working in
assertive outreach. This paper generally opt for ‘service user’ when discussing people in
the context of services, and ‘client’ when talking about work done that requires someone’s
active engagement with us, for example in therapy or care planning.
If you have problems reading this document and would like it in a
different format, please contact us with your specific requirements.
Tel: 0116 252 9523; E-mail: [email protected].
Contents
Page
Executive summary ..............................................................................................................2
Introduction .........................................................................................................................4
Section 1: What is assertive outreach?...........................................................................4
1.1
Key features and policy context .................................................................................4
1.2
Is it effective? ...............................................................................................................6
Section 2: Service models .............................................................................................8
2.1
Designated assertive outreach teams .........................................................................8
2.2
Hybrid teams ...............................................................................................................9
2.3
Flexible assertive community treatment (FACT) ......................................................9
2.4
Integrated assertive outreach function ....................................................................10
2.5
Ceasing to provide assertive outreach......................................................................12
Section 3: Interventions..............................................................................................13
Section 4: Team composition and functioning ............................................................15
Section 5: The role of clinical psychologists................................................................17
5.1
Direct clinical work ...................................................................................................17
5.2
Indirect clinical work/Working with the whole team.............................................20
5.3
Research and evaluation...........................................................................................20
5.4
Training and supervision ..........................................................................................21
5.5
Service development .................................................................................................21
Section 6: Service user and carer involvement ............................................................23
Section 7: Specific employment considerations ..........................................................24
7.1
Gradings.....................................................................................................................24
7.2
Full- or part-time .......................................................................................................24
7.3
Working hours...........................................................................................................24
7.4
Supervision ................................................................................................................25
Section 8: Conclusions: The future for clinical psychology in assertive outreach ........28
References .................................................................................................................29
Clinical psychologists and assertive outreach
1
Executive summary
Introduction
This document is an update of a 2006 Division of Clinical Psychology Briefing Paper on the
same topic and is aimed at clinical psychologists, managers and commissioners. It focuses
primarily on practice within England and Wales but the principles would apply across all
four home nations.
It provides an overview of the service model in terms of underlying principles, available
models and the evidence base. This will assist in local decision making about the most
effective way of providing such a service.
It identifies roles and functions of clinical psychologists and makes recommendations for
psychology staffing.
What is assertive outreach?
Assertive outreach is an outreach service, based on a recovery approach, for adults with
severe and persistent mental health problems associated with a high level of disability, a
history of high use of inpatient or intensive home based care, difficulty in maintaining
lasting and consenting contact with services; and multiple and complex needs. The
assertive outreach client group generally fall into the psychosis clusters 16 (dual diagnosis)
and 17 (psychosis and affective disorder difficult to engage) (CPPP, 2012).
It is helpful to think of assertive outreach not as a team, service or a collection of specific
staff, but rather as a function. To provide this function, different models are used in the
UK and these are described in the document. Although designated teams were
recommended in the past, and are supported by the most evidence, current national
mental health policy does not favour one over another (DoH, 2011).
Function of assertive outreach
Assertive outreach aims to improve the quality of life of service users and their carers,
friends and families, prevent social exclusion, assist people in managing and coping with
their difficulties, promote informed choice about medication, manage risk and reduce
hospital admissions. It achieves this by sustained and persistent efforts, by reaching out to
people in their homes, workplaces, cafes or elsewhere, and by reaching into hospitals
where necessary.
The benefits of assertive outreach
Research has shown that people receiving assertive outreach are more likely to remain in
contact with services, less likely to be admitted to hospital, experience shorter admissions
and show improvements in accommodation status, employment and satisfaction with
services. It is thus a cost effective intervention.
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The impact of not providing assertive outreach
Ceasing to provide any form of assertive outreach carries a number of risks, not least that
of recreating the very problems that were identified by Keys to Engagement (SCMH, 1998)
and led to the inclusion of assertive outreach teams as a key element of the 1999 National
Service Framework. If the needs of this vulnerable group are not proactively met in the
community, they will simply manifest in other ways such as through acute admissions,
homelessness and the criminal justice system.
DCP recommendations
1.
2.
The DCP recommends that mental health services should include provision for
assertive outreach and the document outlines options to achieve this.
The DCP recommends a ratio of one whole time equivalent (1.0wte) Band 8A or
above clinical psychologist for a team caseload of 90 clients to meet need. Where
designated teams do not exist, it may be possible to provide the assertive outreach
function in other ways, but whatever model is used there should be a psychology
post with an assertive outreach specialism.
Clinical psychologists and assertive outreach
3
Introduction
This briefing paper is intended for use by clinical psychologists, service managers and
commissioners of services within mental health.
The aims are to:
1
2
3
4
assist in local decision making about the implementation of assertive outreach
through providing an overview of service principles and models;
identify the positive outcomes for service users from assertive outreach and also the
risks and impact of not having such a function within mental health services;
outline the roles and function of clinical psychologists in assertive outreach services;
and
provide clear guidance about how clinical psychology in assertive outreach should be
structured, taking into account, as far as possible, recent health service initiatives.
This paper updates the earlier Faculty of Psychosis and Complex Mental Health Briefing
Paper, Clinical Psychologists and Assertive Outreach (BPS, 2006). It primarily focuses on
England and Wales but the principles would apply across the four home nations.
Section 1: What is assertive outreach?
Assertive outreach aims to improve the quality of life of service users, their families and
carers, prevent social exclusion, assist people in managing and coping with their
difficulties, promote informed choice about medication, manage risk and reduce hospital
admissions (Hemming et al., 1999; O’Halloran, 1999; SCMH/CMHSD, 1999; Davidson,
1999; Burns & Firn, 2002; Ryan & Morgan, 2004). It aims to do so by sustained and
persistent efforts, working with people in situ: by reaching out to people in their homes,
workplaces, cafes or elsewhere, and by reaching into hospitals where necessary.
There has been some confusion about the term ‘assertive’, which has sometimes been
understood to mean aggressive, and to imply a coercive medical approach. In fact UK
teams have tended to emphasise the need to work with users of services in partnership,
to improve a wide range of aspects of their lives. Most of these services were designed for
people needing enhanced care and at risk of losing contact with mental health services,
but some have assumed more specialised functions.
1.1 Key features and policy context
Assertive outreach originated in the United States where it is now more often referred to as
assertive community treatment (Stein & Test, 1980; Allness & Knoedler, 2003). In the early
2000s a network of assertive outreach teams (AOTs) was set up across England in response
to the National Service Framework (NSF) for Mental Health (DoH, 1999) and subsequent
NHS plan (2000). Since political devolution in 1999, Scotland, Wales and Northern
Ireland have developed different systems of governance and different policies, and none
have seen the same level of investment in assertive outreach services. Both Scotland and
Northern Ireland previously had assertive outreach teams for adults, but there are now
none in Northern Ireland and few in Scotland. A significant number of teams were
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established in Wales as a result of Designed for Life (Welsh Assembly Government, 2005) and
Strategic and Financial Framework Target 21 in 2007/8 (National Public Health Service for
Wales, 2007), which continue. In England and Scotland current policy does not promote
assertive outreach (DoH, 2011; Scottish Government, 2012) although there remain
significant numbers of teams in England.
The Mental Health Policy Implementation Guide (DoH, 2001) sought to define the model of
assertive outreach recommended by the NSF. It identified the following:
Key features:
assessment – comprehensive, multi-disciplinary, standardised, culturally competent;
team approach – all team members involved with all clients, providing continuity by close
team working;
age, culture and gender sensitivity – gender and culture culturally competent service
provision, including access to interpreters and translation services;
regular multi-disciplinary user focused reviews – brief daily meetings, full weekly meetings
and six monthly Care Programming Approach (CPA) reviews;
small caseloads – ideally 1:10 ratio per whole time equivalent care co-ordinator;
frequent contact and extended hours – 8am to 8pm, seven days a week;
inpatient and respite care – maintaining contact through in-reach and liaison; and
discharge and transfer – indefinite care from the team whilst of benefit and until recovery
is made. All relevant parties involved in discharge planning with the potential of rapid rereferral if required.
Additionally, services should:
work in clients’ own environments as much as possible;
work with clients’ expressed as well as their assessed needs; and
involve service users as closely as possible in the processes of assessment, review and
discharge.
Assertive outreach services are for adults with:
a psychiatric diagnosis of severe and persistent mental health problems associated with a
high level of disability;
a history of high use of inpatient or intensive home based care;
difficulty in maintaining lasting and consenting contact with services; and
multiple and complex needs, e.g. a history of violence or persistent offending, significant
self-harm or neglect; poor response to previous treatment; problems related to drug and
alcohol misuse (dual diagnosis); experiences of detention under the Mental Health Act
(1983) on at least one occasion in the past two years; unstable accommodation or
homelessness.
Clinical psychologists and assertive outreach
5
In the context of the more recent Mental Health Clustering Tool (MHCT), the assertive
outreach client group generally fall into the psychosis clusters 16 (dual diagnosis) and 17
(psychosis and affective disorder difficult to engage) (CPPP, 2012).
Many assertive outreach teams were developed with recovery oriented practice and social
inclusion central to their function. This is now supported by policy (e.g. DoH, 2011) which
emphasises the importance of a recovery-orientated approach in mental health services.
Recovery oriented practice now provides an over-arching framework for assertive outreach
work.
The introduction of Community Treatment Orders (CTOs) in England in 2008 under the
revised Mental Health Act (1983) has provided the legislative framework whereby people
can be compelled to adhere to treatment while living in the community, and for many this
has meant medication delivered as a depot injection. Many teams have therefore
experienced increased tension between their overarching priority to engage people in
collaborative relationships and the need to consider use of CTOs. Such a tension between
collaboration and control is not new to the assertive outreach model, but it has been
brought into sharper focus by the introduction of CTOs. Less coercive approaches have
included incentivising service users for taking medication (often depot medication), but
these too are not free from ethical tensions (e.g. Staring et al., 2010)
The Equality Act (2010) has made a significant impact on all public services and has a
special relevance in assertive outreach since services tend to include a high proportion of
people who have experienced discrimination (Wharne & Williams, 2011). All services now
have a duty to ensure that people are not discriminated against due to age, disability,
gender reassignment, marriage and civil partnership, pregnancy and maternity, race,
religion or belief, sex, and sexual orientation. In many areas this has led to teams working
with people beyond the age of 65.
1.2 Is it effective?
Assertive outreach has been shown to be effective when the key features are adhered to
and when conducted by designated teams. It has demonstrated increased engagement of
the target population, decreased hospital admissions and length of stay, increased
appropriate accommodation and improved functioning (e.g. Hambridge & Rosen, 1994).
Compared with standard community care, the Cochrane Review found people receiving
assertive outreach were more likely to remain in contact with services, less likely to be
admitted to hospital, experienced shorter hospital admissions and showed improvements
in accommodation status, employment and satisfaction with services (Marshall &
Lockwood, 1998). More intensive support also facilitates improved social networks (Becker
et al., 1998), and greater quality of life (Taylor et al., 1998). Some service users find it a
more meaningful or acceptable approach than traditional services (Beeforth et al., 1994;
Graley-Wetherall & Morgan, 2001; Hayward et al., 2004).
Nevertheless, findings are not unequivocal, particularly in relation to reducing disability
(Thornicroft et al., 1998; Wykes et al., 1998). Some UK evaluations have shown
disappointing results (e.g. UK700 Group, 2000; Killaspy et al., 2006), which early
researchers attributed to low fidelity to the original model (e.g. Marshall & Creed, 2000).
However, some teams with high fidelity have also shown disappointing outcomes (Fiander
et al., 2003). There is now some evidence to suggest that this finding may be explained by
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improvements in the comparison services (i.e. community mental health teams together
with crisis resolution and home treatment teams) which have led to the situation where
rates of hospital admission in the UK are already so low that teams are unable to show the
dramatic improvements achieved by the early teams (Burns et al., 2007). Burns et al.’s
findings lend some support to this hypothesis, since they found that those studies which
showed high rates of hospitalisation at baseline were more likely to find a reduction in
hospital care than those where the threshold for admission was already high. In the UK it
may therefore not be appropriate to measure the effectiveness of assertive outreach by
simply relying on numbers of admissions or days in hospital. An over-reliance on
hospitalisation data as an outcome may not only be misleading, it may also neglect more
positive and meaningful outcomes for service users.
By contrast, whenever the quality of teams is evaluated by measuring user satisfaction or
engagement rate, the research findings are consistently positive for assertive outreach
teams (e.g. Killaspy et al., 2006). As a result there is now interest in focussing more
research on recovery processes and outcomes within assertive outreach services.
There is now a wide variety of assertive outreach services in the UK (Hovell, L, 2004; Ghosh
& Killaspy, 2010) and few, if any, conform to the model originally advocated by the Mental
Health Policy Implementation Guide (DoH, 2001). A survey of London teams (Wright et
al., 2003) found that there were broadly speaking two kinds of team philosophy, one based
on the principles of social inclusion and the other allied more closely to a medical model
of treatment. They are likely to reach different groups of people and have differing
effectiveness, but these factors are as yet poorly understood.
Recently researchers have tried to look more closely at the original model to identify which
features are key to effectiveness. Burns et al. (2007) have conducted a meta-analysis which
suggests that fidelity to the structure and organisation aspect of the assertive community
treatment model (community based, manager with case load, full clinical responsibility,
meeting daily, shared caseload, time unlimited service, extended hours) were related to
decreased hospital use. Interestingly there is now significant overlap in some of these key
features between AOTs and CMHTs (e.g. integrated health and social care, community
based, manager with caseload, full clinical responsibility, in vivo work). A separate study by
(Wright et al., 2004) concluded that the critical factors for reducing hospitalisation were an
integration of health and social care, together with home visiting. However, in their
observational study Brugha et al. (2012) found that they could detect no effect on
admission rates attributable to joint management, or indeed of other team characteristics.
They identified the provision of specialised psychological interventions as a key process
variable, but note that few teams are resourced to deliver them.
Clinical psychologists and assertive outreach
7
Section 2: Service models
It is helpful to think of assertive outreach not as a team, service or a collection of specific
staff, but rather as a function. Different models are used in the UK to provide this function,
and although designated teams were recommended in the past, current national mental
health policy does not favour one over another (DoH, 2011). Whilst it used to be
considered appropriate to offer assertive outreach on an indefinite basis, there is a growing
expectation that clients will move on, with the majority able to move on to services offering
a lower level of support. However, most local audits reveal the existence of a significant
group of assertive outreach clients who continue to need this service in the longer term.
Examples of current models:
■
■
■
■
■
Designated assertive outreach teams
Hybrid teams
FACT (flexible assertive community treatment)
Integrated assertive outreach function
Ceasing to provide assertive outreach.
2.1 Designated assertive outreach teams
This was the model proposed in the Mental Health Policy Implementation Guide (DoH,
2001). Designated assertive outreach teams are generally thought to be best placed to meet
the needs of the clients they serve and are able to follow the key features of the model
closely. They are most practical in inner city areas, which tend to have relatively large
numbers of people whom traditional services have not been able to engage, in a relatively
small geographical area. Whilst the Mental Health Policy Implementation Guide (DoH,
2001) recommends that they be based in statutory services, there is some evidence that
voluntary sector teams are more able to reach people who are most alienated by
mainstream services (Wright et al., 2003). However, locating such a team within an NHS
Trust has the advantage of facilitating a single point of access to many different services.
Designated assertive outreach teams are multi-professional, including psychologists as core
members. Such teams show highest fidelity to the evidence base, and have been most
successful in engaging the target client group discussed above and in delivering
psychological interventions (Brugha, 2012). They have been the predominant model in
the UK, accounting for 84 per cent of the 233 teams in existence at the time of the
National Assertive Outreach Study of Service Organisation in 2003 (Hovell, 2004), but are
also the most expensive, resulting in many recent closures. It is thought that the number of
designated teams has halved in recent years with many Trusts now looking to provide the
assertive outreach function in other ways.
One major area of challenge has been how to deliver a service in rural areas. This is not a
unique challenge for assertive outreach: the challenge of delivering health and social care
in rural areas compared to urban ones is a noted phenomenon (McCann et al., 2005). In
some areas with low population density, a number of smaller designated teams have been
used in place of one large team. These are not necessarily able to provide the full range of
key features, and this may restrict access to psychological therapies, but they have been shown
to be effective in reaching people who are often extremely isolated (e.g. Repper et al., 2003).
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2.2 Hybrid teams
In areas of moderate morbidity and population it might be advantageous to combine the
function of assertive outreach with another team. Common associations are with
psychosocial rehabilitation, early intervention, community forensic and recovery teams.
For this to work, both services need to have a focus on people with severe mental health
problems combined with experience of working with people who are difficult to engage.
Of the 233 teams in existence at the time of the National Assertive Outreach Study of
Service Organisation, 30 per cent of assertive outreach teams had previously been
community rehabilitation teams (Hovell, 2004), suggesting a successful merging of
function for these teams. More recently, several assertive outreach teams have either
merged with community forensic teams or taken over this function. There needs to be a
careful process of mapping separate service functions to preserve individual functions
effectively so that distinct functions can be preserved and shared functions combined. It is
also important to focus on preserving similar levels of access and intensity of service
provision within hybridised services.
An example of a service function mapping exercise below shows the distinct and shared
functions of the four NSF recommended community mental health teams.
CMHT
EIP
AOT
Primary function Active community Early detection & Engagement,
treatment
reducing duration reducing
Relapse prevention of untreated
admissions &
psychosis
relapse prevention
Relapse prevention
Care delivery
Coordination &
Emphasis on PSI Emphasis on
sign posting
family
meeting complex/
interventions (FI) high need,
Relapse prevention including FI and
Low dose atypical social inclusion
antipsychotics
Type of care
Low intensity
High intensity
High Intensity
Structured
Structured
Flexible
(time limited &
Time limited
Long term
long term)
Location of
Outpatient clinic Outreach
contacts
appointments
Crisis response
Refer to CRHT
Manages the majority of own crises
Team
organisation
Monitoring
CRHT
Crisis resolution &
gatekeeping
Emphasis on
resolving problems
reinforcing coping
skills, accessing
resources
High intensity
Flexible
Brief
Individual case management
Team approach
Reactive
Assertive Monitoring
Follow up
2.3 Flexible assertive community treatment (FACT)
The FACT model originates from the Netherlands and as such is a genuinely European
variant on the original ACT model. Although designated teams do exist in the
Netherlands, mostly in urban areas, about 70 per cent of teams providing services to
people with psychosis are FACT teams. These combine functions that, in the UK context,
Clinical psychologists and assertive outreach
9
would be provided by a variety of services, including assertive outreach, crisis resolution,
recovery and rehabilitation. The variety of need is met by providing two distinct levels of
service within a single team: one which is high intensity, following the classic assertive
outreach shared caseload approach, the other offering low intensity, which is more like
individual case management. Clients move easily between these levels depending on need,
but the staff group remains the same, ensuring continuity of care (Van Veldhuizen, 2007;
Van Veldhuizen & Bahler, 2013).
The FACT model, as described by its originators, requires a high level of investment and
this has been the main obstacle to its implementation in the UK. However, some services
are using elements of FACT in redesigning their services, and promising evidence is
starting to emerge from early implementers. Firn et al. (2012) report on the amalgamation
of two dedicated assertive outreach teams into six CMHT adopting the FACT principles of
judicious use of two levels of care, whole team working, and daily coordination and
allocation of AO care for patients in periods of higher need. They demonstrated significant
efficacy in reducing bed days, less use of crisis response and home treatment and improved
clinical and cost effectiveness despite fewer contacts and poorer engagement. They
concluded that FACT allows access to periods of assertive outreach equivalent care for a
wider CMHT population according to current need rather than historical team allocation.
However, their study is observational and not controlled, making it difficult to rule out
other interpretations of the results, such as a ward closure being responsible for reduced
bed days. Another service redesign evaluation study in Southern Health NHS Trust showed
that adopting FACT principles in teams did not dilute the assertive outreach function
compared to the previous dedicated assertive outreach provision and it improved care
pathways for assertive outreach service users. Qualitative data showed that the FACT model
was considered advantageous for patient care (Rathod et al., in preparation).
The early evidence for FACT suggest that it may allow the assertive outreach approach to
be retained in places where designated teams have been lost; however, the population
receiving assertive outreach changes with the FACT model and this needs further research.
Clinical psychologists are very much part of the FACT model as used in the Netherlands.
However, their role is predominantly in the lower intensity function of the service, rather
than the high intensity, ‘assertive outreach’ function. This may have implications for the
ability of psychologists in FACT teams to reach the most disabled clients.
2.4 Integrated assertive outreach function
In some areas assertive outreach workers have been integrated into other teams, often with
a view to reducing cost. They may continue to be part of a ‘hub and spoke’ model whereby
they meet with each other at ‘the assertive outreach hub’ for training and supervision, but
work day-to-day in separate locations (‘the spokes’), which might be generic CMHTs. A
strength of this way of working is that it can promote adherence to the model by bringing
assertive outreach staff together regularly; it also allows for localised service delivery and
strong links with local community resources.
However, this model compromises on a number of key features of the evidence based
model. Workers can become easily overwhelmed, particularly at times of high service
demand, when the host culture and organisation may not support enough team working.
A team approach has been found not only to be a very important feature of effective
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service provision, but also a source of job satisfaction for staff undertaking challenging et
al., 1999; Billings et al., 2003) and in some circumstances facilitating higher levels of
therapeutic risk taking. Services providing an assertive outreach function using this
approach rarely employ a specialist clinical psychologist and consequently there may not
be adequate access to appropriately skilled psychological interventions. Individual assertive
outreach workers could find themselves expected to provide a broad range of specialist
functions, without quality training or supervision. Access to psychology would probably
depend upon the skills and availability of a CMHT psychologist who may well have more
stringent referral and attendance criteria and lack the time to travel or participate in
engagement interventions.
In some areas former assertive outreach team psychologists have managed to maintain the
assertive outreach specialism even after integration into CMHTs. It can be quite a
challenge for the psychologist to understand how to relate to a function rather than a team
or service. Part of this process involves clarifying distinct assertive outreach psychology
functions above and beyond colleagues in more generic roles, especially in:
–
–
–
–
–
–
Conducting psychological approaches in the client’s own environment.
A greater emphasis on understanding (formulating) and resolving engagement
issues, building client centred therapeutic alliances and resolving ambivalence about
change.
A more flexible approach to the delivery of evidence-based psychological
interventions, including formulation based treatment planning; placing a greater
emphasis on psychological principles rather than protocols; coordinating delivery via
a team approach.
More flexible criteria for psychological interventions for service users with complex
needs, challenging service led criteria for service provision and discharge.
Prioritising functioning and quality of life over symptom remission; a greater
emphasis on living with symptoms and working with strengths.
Supporting an effective team approach to delivering psychologically informed care
plans.
In situations where there is no shared interest in delivering the assertive outreach function,
individual assertive outreach workers are likely to experience conflicts in service models,
typically pressures to discharge those service users who do not attend appointments
regularly, inter-colleague envy relating to smaller caseloads, and criticism for making
routine appointments when there is currently no clear treatment plan. At times of staff
shortage within the CMHT (particularly at times of sickness, annual leave and staff
turnover), individual assertive outreach staff may struggle to avoid becoming involved in
more generic team functions such as assessments and duty, thus detracting from their ability
to deliver their more specialist function. There is evidence that teams are more effective and
have more satisfied staff when they have a clearer, less broad remit (BPS, 2007).
There are clear dangers with this approach. If a distinctive culture of assertive outreach is
not maintained within the service, staff are unlikely to have enough time to do the
proactive engagement work that some people need. This has been a complaint in
Northern Ireland where designated assertive outreach teams have been closed.
Clinical psychologists and assertive outreach
11
2.5 Ceasing to provide assertive outreach
In some areas assertive outreach teams have closed and the assertive outreach function has
not been provided in another form. Ceasing to provide any form of assertive outreach in
this way carries a number of risks, not least that of re-creating the very problems that were
identified by Keys to Engagement (SCMH, 1998) and led to the inclusion of assertive
outreach teams as a key element of the NSF (DoH, 1999). Although to the authors’
knowledge there has been no recent research in the UK about the effects of ceasing to
provide assertive outreach, anecdotally it appears that outcomes for service users vary.
People who have received substantial assertive outreach already may be willing and able to
move on to use other services. However, their experiences with other services may not be as
satisfactory and there is evidence that it is likely to be more coercive (Killaspy et al., 2006;
Davidson & Campbell, 2007). Those whose engagement remains difficult are more likely to
be lost to mental health services. This latter group are likely to be extremely vulnerable
people and if their needs are not proactively met in the community they will simply
manifest in other ways, such as through acute admissions, homelessness and the criminal
justice system. Keys to engagement argued that the costs of Assertive Outreach Teams are very
reasonable in comparison with these alternatives.
Any area which does cease to provide assertive outreach should be encouraged to
commission research which follows up the outcomes for people who used to receive
assertive outreach or could have received assertive outreach.
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Section 3: Interventions
The Mental Health Policy Implementation Guide (DoH, 2001) suggests that the following
multi-disciplinary interventions should be available from within assertive outreach teams:
■
■
■
■
■
■
■
■
■
■
■
Assertive engagement – persistent and creative, focusing on strengths and interests
Daily living skills – practical and hands on help from within the team as well as skills
training to increase independence and access local community resources.
Social systems – social inclusion, maintaining and expanding social networks
Education and employment – helping people to find and maintain employment,
accessing local courses and relevant services
Family/carers – carers assessments, psycho-education and family therapy
Cognitive behavioural therapy – range of techniques available from within the team.
Treatment of co-morbidities – substance misuse, anxiety, depression, suicide and
self-harm.
Relapse prevention – individualised early warning signs, shared relapse plans,
ecological work to improve the environment.
Crisis intervention – intensive support, access to least restrictive option in crisis.
Medication – home delivery, side effect monitoring.
Physical health – GP liaison, healthy lifestyle advice and health screening.
Evidently such interventions require the different skills of a whole range of professional
and other groups, but psychologists are particularly well placed to ensure many of these
interventions are carried out effectively. When clients disengage from mainstream services
it is often because they have not experienced those services as useful. Users and staff may
have different understandings about what getting better and recovery mean (Meddings &
Perkins, 2002). It is obviously crucial that services provide what service users have been
asking for, such as information, choice of treatments, decent housing, work, and help with
finances (Shepherd et al., 1995; Read, 1996). Services also have to focus on peoples’
strengths as well as their difficulties (Ryan & Morgan, 2004). It is important to plan and
deliver this effectively, with attention to rebuilding the relationships which underpin all
interventions. As well as helping to achieve some of these outcomes, when psychologists
participate in such generic work it offers a means for them to gain access to a client group
who have rarely received specialist psychological help in the past. Psychologists have found
that they can then introduce clients to psychological approaches, for example through
using problem solving techniques, which engages them in a style of work that may lead to
a more specific psychological intervention in the future. In this way, providing sufficient
psychology time within assertive outreach to allow for some generic working offers a means
to increase access to psychological therapies.
Psychologists can make a unique contribution to formulating engagement difficulties,
which enables the team as a whole to work more effectively (Whomsley, 2010). For
example, attachment theory and recovery style may help to explain why people may have
experienced general difficulties with relationships in their lives and how this has extended
to services (Tait et al., 2003; Cupitt, 2004a, 2010a). Psychologists are often able to form
collaborative relationships with service users who have rejected mental health services
because of past experiences of exclusively pharmacological interventions for their mental
Clinical psychologists and assertive outreach
13
health problems, often whilst subject to compulsion. Many have disengaged because they
do not share the belief they have a mental illness and wish to avoid any treatment,
particularly compulsory treatment. Interestingly, people who do not believe they have
mental health problems tend to construe getting better in similar ways to those who do
believe they have mental health problems, including seeing improved mental state as
important (Meddings & Perkins 2002). People in this situation have rarely received any
psychological help and are often happy to meet with a psychologist (Cupitt, 2001). If this
approach constructively validates a person’s own account of their experience, it can lead to
a new relationship with services, in which they feel more involved and in control of
decisions about their care (Gillespie & Meaden, 2010). It may further lead to involvement
in critiquing and changing the wider mental health service. In this way psychologists can
make a significant contribution to assertive outreach services, helping to develop a culture
of recovery-orientated practice.
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Section 4: Team composition and functioning
Team members bring three sets of attributes to their work: the core functions of their
profession, specialised training in specific interventions, and different life experiences and
social backgrounds (Watts & Bennett, 1983). A multidisciplinary mix of staff with
appropriate expertise is essential to ensure the possibility of a well-resourced and
representative service. The Mental Health Policy Implementation Guide (DoH, 2001)
recommends that an average team covering a population of 250,000 has eight whole-time
equivalent care co-ordinators, made up of community psychiatric nurses, approved social
workers, occupational therapists and a psychologist. The team also requires support
workers, a dedicated psychiatrist and administrative support. Ideally there should be an
appropriate mix of gender, sexuality and ethnicity, and staff would need to be low in
‘expressed emotion’ (Leff & Vaughn, 1981). In addition, some teams employ other
specialist staff such as dual registered nurses, dual diagnosis workers and vocational
specialists. Vocational rehabilitation is a key feature of the Assertive Community Treatment
Association model in the US (ACTA, 2004) and has also been used in the Early Treatment
and Home-Based Outreach Service (ETHOS) at South West London St George’s NHS
Trust with good results (Rinaldi et al., 2004). Some teams, notably TULIP, have successfully
used generic outreach workers to help clients gain access to other services. Staff with lived
experience of mental health problems can make a particularly useful contribution,
increasing engagement with the team, vocational and community services; being valued as
role models; advocating for service users; and challenging other staff to examine their
attitudes (Craig et al; 2004; Doherty et al., 2004; see also South West London and St
George’s NHS Trust). Ideally, new teams should be supported by whole team training in
assertive outreach, which can be provided by a number of national organisations or
organised locally and tailored to local needs. Most teams also find it helpful to spend time
learning about one another’s life experiences and interests, because of the impact this can
have on engagement with clients.
Care co-ordinators should have low caseloads, ideally about 10–12 clients; specialised staff,
including psychologists, normally provide a service across the whole team’s caseload as
needs are identified. To be able to provide specialist psychological interventions, a
psychologist should carry no more than half a caseload of clients for care co-ordination. In
practice most psychologists do not engage in care coordination, either because they work
part-time with the team or out of a need to focus on specialist psychological interventions;
however, they do make a contribution to care coordination through care planning and
formulation. Increasingly teams are seeing the value of preserving psychology time to
provide psychological therapies so that they can meet NICE guidelines (e.g. NICE, 2009)
and this view is supported by research (Brugha et al., 2012). However, all such
arrangements need to be flexible over time, to allow the team as a whole to respond to
crises and periods when the work becomes more demanding. Whilst many psychologists
welcome the opportunity to be care co-ordinators when they judge that their knowledge
and skills as a psychologist brings a specific benefit to the task, for those working part-time
it may just not be feasible. Many psychologists have described difficulty participating in the
generic work of care co-ordination whilst at the same time trying to conduct individual
psychological therapy (Pipon-Young et al., 2010). When care coordination is appropriate,
Clinical psychologists and assertive outreach
15
allocation of cases should be done in consultation with the psychologist concerned, with
specific attention to the ways in which it may affect their therapy work.
Some teams have made extensive use of staff other than psychologists who are trained in
psychosocial interventions such as family interventions, behavioural activation, relapse
prevention and coping strategy enhancement. Some services have developed competency
frameworks which identify different levels of psychological intervention, specifying what
training and supervision is needed to offer each (e.g. SLAM, Sussex Partnership Trust).
This may increase access to psychological therapies such that all clients can be offered
some form of intervention according to their need. Psychologists tend to work at the
higher competency levels on the basis of their doctorate level training which crosses many
client groups and different models of intervention. They may supervise those offering
psycho-social interventions at lower levels who, whilst valuable members of a multidisciplinary team, should therefore be seen as complementing rather than replacing the
psychologist’s role in the team.
Different models of team working exist within assertive outreach teams. The literature
suggests there should be a team approach, but does not define this (e.g. The Mental Health
Policy Implementation Guide, DoH, 2001). The original US model advocated that every client
of the team knows and works with every staff member (Stein & Test, 1980). This was a
feature of the early UK assertive outreach teams in the independent sector such as TULIP
(Navarro, 1998) and IMPACT (Cupitt, 1999). When used appropriately, it can have
significant advantages, particularly in providing emotional containment for staff and
service users (Cupitt, 2010b). Some statutory teams continue to use this whole team
approach, others use less integrated, more traditional care co-ordination; whilst others
have adopted a mixed model, in which care co-ordinators are the primary point of contact,
taking responsibility for the overall care plan and paperwork, supported by the
involvement of a cluster of three or four other staff (Steer & Onyett, 2011). In deciding
which approach to use, consideration should be made of the overall team caseload size, as
the more integrated team approaches tend to only function well in smaller teams. The
delivery of specialist psychological work is possible within both approaches but they can
lead to different roles for a psychologist and this needs careful consideration. Where a
more integrated model of team working is used, psychologists can struggle to maintain
their professional identify and so this may need to be supported by regular contact with
other psychologists outside the team.
To be effective assertive outreach teams need to develop good relationships with other
teams, the wider organisation and relevant community resources. When difficult local
inter-team relationships become an issue, psychologists have often taken the lead in
developing a systemic understanding of these tensions. The psychologist may then be able
to help teams to develop active mechanisms to improve the situation, such as ‘warm
networking’ (Steer & Onyett, 2011).
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Section 5: The role of clinical psychologists
There are five identified aspects of the clinical psychology role: direct clinical work,
indirect clinical work/work with the whole team, research and evaluation, training and
supervision, and service development.
5.1 Direct clinical work
Many people who are referred to assertive outreach teams have long histories of mental
health problems that have been poorly understood. Consequently, psychologists can play
an important role by conducting in-depth assessments to determine the nature and extent
of the person’s difficulties. The timing of such an assessment needs to pay respect to issues
of engagement and be carried out in an imaginative and flexibly way, to maximise its value
(Meaden, 2010). There may also at times be a need for more specific assessment, for
example of mental capacity or risk.
Psychological interventions have been shown to be effective with people with a variety of
severe mental health problems. Interventions can help people cope with psychotic
experiences such as voices and distressing beliefs; help people understand their difficulties
in their life context and learn to cope more effectively; enable people to give up selfdefeating behaviours such as drug and alcohol use, self-harm and attempted suicide;
enable informed choice about treatment and other aspects of their lives; facilitate relatives’
understanding and improve relationships through family interventions; develop strategies
to identify early warning signs and prevent crises, and help with the social disability caused
by severe mental health problems (Cupitt, 2010a). These are most likely to be offered
individually, or to families but some teams are able to engage clients in group work.
For people with a diagnosis of schizophrenia, who generally make up the majority of
assertive outreach clients, there is particularly good evidence for the efficacy of cognitive
behaviour therapy (e.g. Kuipers et. al., 1997), family therapy (Burbach, 1996; Pilling et al.,
2002) and employment (Rinaldi et al., 2004; Warner, 2000; Social Exclusion Unit, 2004),
each reducing relapse rates by about 30 per cent (equivalent to the effect size attributed to
Clozapine in Kane et al., 1988). The National Institute for Health and Clinical Excellence
schizophrenia guideline suggests that all people with schizophrenia should be offered
cognitive behavioural therapy (CBT) if they continue to experience psychotic symptoms,
family work if they live with, or are in close contact with family members, and art therapies
for negative symptoms (NICE, 2009). However, many people with this diagnosis do yet have
access to such therapies (Schizophrenia Commission, 2012).
Considerable flexibility of approach is required to work successfully with people who have
rejected conventional mental health services and most psychologists working in assertive
outreach find that they need to adapt the recommended interventions to make them
accessible to their clients, such as by doing therapeutic work in more informal settings
(Cupitt, 2010b; Griffiths et al., 2011). These kinds of adaptations have not yet been
rigorously evaluated, but in practice are often essential to engage clients. In addition
psychologists may draw on a variety of therapeutic approaches including CBT (e.g.
Morrison, 2001; Garety et al., 2001; Chadwick, 2006), acceptance and commitment therapy
(Bach & Hayes, 2002), cognitive remediation therapy (Cupitt, 2004b), motivational
Clinical psychologists and assertive outreach
17
interviewing (Miller & Rollnick, 2002) ‘hearing voices’ (Romme & Eschir, 2000), cognitive
analytic therapy (Ryle & Kerr, 2002), dialectical behaviour therapy (Linehan, 1993),
humanistic (Doubt, 1996), narrative (White & Epston, 1990), systemic (Burbach &
Stanbridge, 1998; Seikkula & Arnkil, 2006; Meddings, Gordon & Owen, 2010), recovery
(Anthony, 1993; Turner-Crowson & Wallcraft, 2002), rehabilitation (Perkins & Repper,
1996; Watts & Bennett, 1991), existential (Hulme, 1999; Spinelli, 2001), spiritual (Clarke,
2010) and psychodynamic (Navarro, 1998; Gillham & Meaden, 2010) models. They may
also facilitate group interventions, such as Hearing Voices Groups, recovery groups and use
other alternative approaches (Meddings, Shaw & Diamond, 2010).
As Lambert (1992) points out, the therapeutic relationship and factors outside therapy are
likely to be more significant factors in therapeutic change than the specific model of
therapy used. The ability to offer a range of therapeutic approaches is also important in
engaging clients who may feel that their treatment options have been restricted in the past.
The National Study of Assertive Outreach found that although 80 per cent of teams said
they could offer some psychological interventions, only 20 per cent could offer a wide
range of psychological therapies (Wright, 2005). Brugha et al. (2012) found that the
number of clients actually receiving interventions remains small, often as a result of limited
psychology resources. Clearly there is still a long way to go before clients of assertive
outreach teams have the access to psychological therapies that they need.
One important feature of assertive outreach teams is that they allow for very close
multidisciplinary working. Psychologists often find themselves jointly planning
psychological interventions with other staff with training in psychosocial interventions.
These interventions may then be carried out jointly by a number of staff, either working as
co-therapists or by following a structured care plan. To ensure such plans work well, teams
usually use an integrated electronic clinical record system, which ideally is accessible
remotely. Such close multidisciplinary working, which values each discipline’s contribution,
can enable an assertive outreach team to provide the kind of consistent and reliable
support necessary for people to overcome very long standing difficulties (Cupitt, 1999;
Cupitt, 2010b).
In the early stages of development of a newly formed team or service, most psychologists
find that there is limited scope for specific psychological interventions because of the poor
engagement of service users. During this phase, a psychologist’s direct work is likely to be
focussed on understanding and resolving engagement difficulties. As engagement
increases and the team matures, the psychologist is likely to want to preserve more of their
time for specific therapeutic work. The support of line managers and supervisors in
negotiating this change of emphasis is vital.
Assertive outreach work requires psychologists to make creative adaptations to
psychological work in order to engage with their clients. As a consequence, assertive
outreach psychologists need to be flexible and creative with professional boundaries in
their clinical work (Gray & Johanson, 2010). For example, the process of engagement and
assessment often takes much longer than suggested by treatment manuals, and may take
place in a wide range of settings. Although a clinic setting generally offers an environment
which feels separate, safe and free from distractions, and is consequently the preferred
setting for psychological therapy, most psychologists in assertive outreach teams see clients
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in other settings such as a pub, cafe or out walking. It would be usual to begin by seeing
someone in their own home or a place of their choosing, and when clients prefer so, it may
be necessary to conduct the whole of therapy in the client’s own home or other place of
their choice (Whomsley, 2012).
It may also be necessary to consider and formulate the engagement of relatives. Many
assertive outreach clients describe experiences of surviving alone, disconnected from family
as well as services (Lukeman, 2003). Families may have felt blamed for their relative's
difficulties, they may have felt traumatised by previous experiences with their relative or
mental health services, or they may have ongoing concerns about risk. The process of
exploring and rebuilding these relationships takes time, and some relatives do not want to
engage with services at all. For some, family work may simply involve the provision of
information and practical support; for others psycho-education and further support from
the team is welcome; and for a minority, formal systemic family therapy is appropriate. It is
generally appropriate to provide such support in peoples’ homes, but the approach needs
to be flexible and centred around the particular family’s needs (Meddings, Shaw &
Diamond, 2010).
In common with psychologists working in rehabilitation and other longer-term settings,
assertive outreach psychologists tend to offer more self-disclosure. Perkins and Dilks
(1992) provide an excellent discussion of this issue in the context of working with people
with severe social disabilities, suggesting that ‘some self-disclosure, real two-way interaction
and sharing, is essential in forming an effective relationship with someone who has few, if
any, other close relationships’. Nevertheless, professional boundaries protect both the
client and the therapist so on-going discussion of such issues is important, both within the
team and in supervision with other psychologists (Gray & Johanson, 2010). Such reflection
should involve consideration of the client’s psychological formulation, the intended
therapeutic benefit and the risks involved. These discussions should be documented.
Since November 2008, when the Mental Health Act amendments came into force,
psychologists have faced an added dimension to their work in that their clients may be
subject to a community treatment order (CTO). Local audits suggest that about 10 per
cent of assertive outreach clients at any one time may be on such an order (Cupitt &
Ingliss, 2010), which requires the individual to adhere to specific conditions. The effects of
CTOs are as yet unknown, but the numbers of people subject to them continues to rise
(NHS Information Centre, 2012). In the absence of evidence, current advice is that
psychologists should assume that interventions will have greater efficacy if offered as a
choice, and should psychological interventions be included in the conditions of a CTO
without consultation, psychologists should decline to provide them (BPS, 2009). Current
MHA legislation allows psychologists to take on the role of Approved Mental Health
Professional or Approved Clinician, but to the authors’ knowledge no psychologist working
within assertive outreach services have yet taken on this role.
It is possible that access to psychological therapies will expand in England under the
Increasing Access to Psychological Therapies for Severe Mental Illness (IAPT for SMI)
initiative (IAPT, 2012). At the time of writing it is unclear how psychological therapies
within secondary care will be affected by this initiative, but clearly psychologists who are
embedded in assertive outreach services are better placed to ensure access to psychological
Clinical psychologists and assertive outreach
19
therapies than when a referral to specialist services is required (Mankiewicz & Turner,
2012). To demonstrate this, it is important that records of offers and actual psychological
therapies are kept and regularly audited. Care will be needed when implementing IAPT
for SMI in assertive outreach services to ensure that people who do not find it easy to
engage with traditional services are not disadvantaged by requirements to complete
packages of outcome measures.
5.2 Indirect clinical work/Working with the whole team
The majority of psychology posts in assertive outreach are part-time, limiting the amount of
direct clinical work that they can contribute. In addition, the team approach offers great
potential for psychologists to do indirect work, for example in facilitating team
formulations of clients’ difficulties (Whomsley, 2010). This is especially important for a
client group which has long-standing and complex needs, which conventional mental
health services may have not been able to understand to the client’s satisfaction.
Psychologists are a crucial part of the CPA process involving comprehensive systematic care
planning, which involves service users as fully as possible. For psychologists to offer full
input to these processes with all team clients, they need to be fully integrated into the team
structure and have sufficient time with the team to have some face-to-face contact with
each client (e.g. Cupitt, 1999). Psychologists also have a role in consultancy with individual
team members and the team as a whole, for example in psychological understanding and
management of challenging behaviour; being proactive in reducing violence or risk;
developing team policies, and helping the team reflect on their work. They may also be
able to support the team to reduce staff stress and burn out (Gray & Mulligan, 2010).
5.3 Research and evaluation
In the context of assertive outreach, where clients are generally receiving multiple
interventions in parallel, it can be very difficult to isolate and measure the impact of any
one intervention. For this reason most psychologists working in assertive outreach have
focussed on team-based outcome measurement. Most of the research has used symptomsbased measures, which are problematic for various reasons, including their insensitivity to
the kinds of changes that are most likely to occur, and their failure to capture the service
user perspective. There is a growing consensus that outcomes measures which focus on
engagement (see Gilliespie & Meaden, 2010) and social recovery (e.g. Neil et al., 2009) are
the most relevant.
Whilst assertive outreach has been widely evaluated in the US, the UK model is still
developing and research is ongoing. It is a feature of assertive outreach that services need
to be tailored to the local situation and these adaptations need evaluating. Psychologists
might be involved in researching broad models of assertive outreach as well as specific
aspects of assertive outreach, such as the engagement process (Hall et al., 2001) and the
adaptations required of existing therapies for this client group (e.g. Tait et al., 2003).
Evidence-based practice, audit and evaluation are essential to service development and
psychologists are one of the few professions whose basic training includes research
methods to doctorate level. It has been suggested that following the NSF recommendation,
too many teams just got on with their work assuming that it was effective without collecting
data to prove its effectiveness, thus failing to establish the ongoing need for their existence.
Clinical psychologists should take a lead in rectifying the urgent need for more research
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and evaluation.
5.4 Training and supervision
Many services providing assertive outreach have a high demand for training and
supervision. Clinical psychologists can make a major contribution to team induction and
ongoing training needs. Psychologists may also take a role organising team supervision and
reflective practice, including provision of specialist psychological supervision to other team
members such as those trained in psycho-social interventions. Good team supervision is
important to enable clinicians to keep working effectively and safely with such a
challenging client group and clinical psychologists are well placed to deliver this. The close
team working that is part of the assertive outreach function offers great opportunities for
training by co-working and shadowing, which can contribute to all staff gaining basic
therapy skills.
5.5 Service development
Psychologists have an important role in service development, in line with New Ways of
Working (BPS, 2007). This overlaps with their role in supporting teams with clinical
governance: striving to improve quality and clinical outcomes. This includes some of the
areas already mentioned such as research and evaluation, training and supervision, which
are key to ensuring high quality care. Service development includes policy development
and implementation of national guidelines, such as NICE guidelines for schizophrenia
(NICE, 2009) and bipolar disorder (NICE, 2006). It can also involve the auditing of team
practice against Trust standards (e.g. quality of relapse plans) and national standards
(e.g. NICE guidelines). At a service level, psychologists can be involved in ensuring that
teams maintain fidelity to the assertive outreach model and thinking about how teams
move forward. Psychologists have a particularly important role in developing appropriate
and enduring systems of working which are more psychosocial than conventional services.
In the pan-London assertive outreach study a significant proportion of teams identified
themselves as following a social inclusion rather than medical treatment model (Wright et
al., 2003). Clearly teams wishing to use psychosocial models of assertive outreach benefit
from the presence of a psychologist to develop effective working practices.
Given the recent national trend towards the integration of assertive outreach into more
generic services, psychologists can play an important part in helping to consider how best
to provide an appropriate service to this client group in the future. The initial challenge
for clinical psychologists is to ‘find a seat at the table’ of service reconfigurations so that
they can help inform decision making, with a particular eye to various forms of evidence,
be they scientific, historical or stakeholder contributions. Secondly, clinical psychologists
have a potential role in evaluating the impact of any new service model. Thirdly, there is a
role in developing new approaches/ways of working, gathering evidence for their
effectiveness and disseminating this evidence through publication. Fourthly, psychologists
are well placed to help determine which component variables of any new model have the
largest effects on a range of valued outcomes.
Large, rapid and radical service reconfigurations contain the potential for cracks to appear
in provision. If these demands are not promptly resolved they can potentially swamp and
even temporarily paralyse a service or get lost as an unmet need, which may surface later as
a much more challenging problem. Consequently service reconfiguration needs to be
Clinical psychologists and assertive outreach
21
approached with a great deal of care and planning, and involve service users, carers and
the local community. Research into local needs and demands, in the light of existing
models and service provision, is essential. Efforts should be made to reduce any disruption
to the care received, particularly for clients of assertive outreach services, whose
engagement with services is likely to remain fragile. Some service users will require a great
deal of support through what they perceive as a loss or abandonment by services, others
may be ambivalent about such changes, and some may even be pleased. A good knowledge
and understanding of each individual client, without prejudging their likely reaction, in
the context of a strong working alliance are important to support them through a process
of change.
At times of radical change it is equally important to support and protect the staff working
in the service. Staff are a critical resource in any service, particularly one where the primary
objective is in relationship building. While clinical psychologists are not themselves
immune from such stresses, there may be a need to shift the balance of their work at such
times towards supporting colleagues, listening to their concerns, validating their reactions
and counselling them through the process of change. Clinical psychologists going through
such changes also need support themselves, and to consider how they can maintain
specialist knowledge and skills in a new environment.
Whenever services are reconfigured there is always the risk that evidence-based practice is
replaced by new and untried service models that look good on paper, but which lack
supporting evidence. When this happens there is still an opportunity to develop services
based on the idea of practice based evidence (Ryan & Morgan, 2004). This requires a
culture of reflexivity whereby novel approaches are implemented, evaluated and
reconfigured, through a continual evolving and learning process. When services are
redesigned without any reference to evidence, there is a risk of encountering the same
problems that led to the development of the NSF in the first place, including leaving the
assertive outreach population without adequate support.
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Section 6: Service user and carer involvement
To be effective at engaging their clients, assertive outreach services need to be especially
good at understanding the perspective of those who use their services (Wharne et al.,
2011). Clients and carers should be encouraged to participate actively in identifying their
own needs and wishes from the earliest point of contact with the team. Many psychologists
have played an important role in involving service users, their caring families and friends
in the development of assertive outreach teams, for example by devising methods to elicit
user feedback on the service and supporting individuals to become user and carer
representatives at a strategic level in their organisations.
When working with a client group which is generally very alienated by mental health
services, the initial stages of user involvement can be a challenge. One of the most
successful models has been to organise a user forum with a social focus (e.g. Birmingham
AO User Forums). Other teams have employed user consultants within their team, used
focus groups, service user and carer advisory groups, questionnaires to elicit feedback
(e.g. Birmingham AOTs), tools such as CUES (Lelliott et al., 2001), or encouraged
individuals to become user reps (e.g. Peterborough AOT), with varying degrees of success.
In addition, many teams have sought ways to involve their clients in both the running of
the assertive outreach team and the wider health service. Increasingly peer workers are
employed within assertive outreach services to give voice to the service user experience and
provide peer support. The assertive outreach team in Portland, Oregon USA (the
Community Survival Program) was entirely user staffed and user run (Perkins, 1993; Nikkel
et al., 1992). This work extends the notion of engagement to mean full and active
engagement with the whole system of mental health service delivery. The ultimate aim
should be to work towards involving users and their carers in all aspects of assertive
outreach: in their own lives and care plans, in selecting and training staff, setting up selfhelp groups, writing information leaflets, working as paid staff and volunteers, research
and audit, managing services, setting priorities and developing the service (Meddings,
Collins & Simmonds, 2002).
Clinical psychologists and assertive outreach
23
Section 7: Specific employment considerations
The work of a clinical psychologist in assertive outreach is influenced by the model of
service delivery, team composition and grading of the post. Clinical psychologists are best
placed to perform the above roles within a designated team.
7.1 Gradings
A grading of Highly Specialised Clinical Psychologist (Band 8a) or above is needed
under the Agenda for Change framework (DoH, 2004) to provide the complex
clinical assessments and interventions, work with high risk in a community setting and
carry out the consultative and service development work described above. At this
level, it is also possible to have trainee clinical psychologists on placement with the
team. However, many teams have recruited newly qualified Specialist Clinical
Psychologists (band 7), who have completed a training placement in assertive
outreach. Appointing such a junior psychologist is only appropriate where there is
already a more senior assertive outreach psychologist employed nearby in the same
Trust and when the team is well established. Some teams have appointed assistant
psychologists, who have contributed a great deal to the work of the team and gained
good clinical experience. However, the Division of Clinical Psychologists (DCP)
strongly advises against the appointment of assistant psychologists in services without
a clinical psychologist (DCP, 2003).
7.2 Full- or part-time
The Mental Health Policy Implementation Guide (DoH, 2001) states that all assertive
outreach teams should have a psychologist whose main responsibilities lie within the
team. Ideally teams would employ a whole-time psychologist since this provides the
greatest opportunity for the psychologist to become a full member of the team. The
recommendation is for a ratio of 1 WTE psychologist for a team caseload of 90 clients
to meet need. In practice, however, the majority of psychology posts are part-time
within a team, as part of a split post (Yates, 2004). This can work well provided the
psychologist has sufficient time to become involved in all aspects of the team’s work, or
there is more than one psychologist attached to the team. In practice this means a
minimum of three days a week for a team caseload of 90 clients. Many teams have
never had sufficient psychology resources to meet the needs of their clients and this
has been identified as reducing the effectiveness of the team as a whole (Brugha,
2012). The reasons for this are likely to be varied, including lack of resources,
difficulties in recruiting and a lack of awareness of the contribution psychologists can
make to the work of the team. There is an urgent need to develop and recruit to these
posts, especially in Wales where few posts exist.
7.3 Working hours
Whilst some assertive outreach services operate extended hours, usually 8am to 8pm, seven
days a week, the vast majority of clinical psychologists work broadly traditional hours (Yates,
2004). The team is likely to gain most from their psychologist if there is flexibility for the
psychologist to work the hours required to perform their function. This may mean working
occasional evenings, for example, to meet families or run groups, but is unlikely to involve
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shift working which can make it difficult to conduct regular therapy sessions. It should be
borne in mind that there is evidence that out-of-hours working reduces a team’s capacity to
provide specialised interventions (Brugha et al., 2010).
7.4 Supervision
It is essential that psychologists of all grades have access to appropriate supervision (DCP,
2003), strong links to their local psychology colleagues and access to the support of a
consultant psychologist who has expertise and understanding of the speciality area. Many
psychologists have had difficulty accessing support and supervision locally from other
psychologists with experience of assertive outreach. In a speciality that can present many
challenges, this can lead to a feeling of professional isolation and dissatisfaction, leading to
difficulties with retention. In such situations the Network of Psychologists in Assertive
Outreach may be able to facilitate access to support and supervision.
Clinical psychologists and assertive outreach
25
Section 8: Conclusions: the future for clinical psychology
in assertive outreach
Since the previous briefing paper in 2006 there has been a significant shift in context, both
broadly with the implementation of New Ways of Working, and more specifically in the
delivery of assertive outreach after the end of the NSF. Recent financial pressures on NHS
resources have also led to a wish for limited resources to be used more innovatively rather
than more intensively (so called ‘smarter ways of working’). This appears to be leading to a
greater diversity of service models, increasing integration of the assertive outreach function
into more generic services and a shift towards prioritising specialist aspects of psychology
roles. Given the wealth of evidence supporting the model of designated assertive outreach
teams and the recognised need to provide dedicated psychology time for this population,
such trends are concerning.
Whatever the form in which assertive outreach services continue, it is vital that they
demonstrate their effectiveness, both clinically and as a part of the wider network of care.
This is likely to mean adopting routine outcome measurement, regular caseload reviews
and auditing referral and discharge rates. An effective assertive outreach service continues
to offer a valuable contribution to a health system which will have to prioritise those with
highest need as resources reduce (Cogan et al., 2012). Services with a designated clinical
psychology post are more likely to be clinically effective and be able to demonstrate their
effectiveness, giving them more chance of survival in an increasingly outcomes-driven
system. There therefore remains an urgent need to develop and recruit to psychology posts
in assertive outreach nationally.
Where service redesign is occurring, clinical psychologists are well placed to help, given
their professional training in problem formulation, evidence-based decision making,
problem solving and innovation. This is underlined in a recent BPS response to the NHS
Chief Executive Innovation Review:
‘The training of practitioner psychologists equips them as innovators … the challenge is assessed,
data collected, a hypothesis or formulation arrived at which points to possible solutions, and
data collected on the effects of applying the solution. The results are then used to inform service
development and innovation. This rigorous approach encourages both creative thinking and
methodical testing of new ideas...
‘Where service changes are made to accommodate cost pressure, psychologists are often well placed
to lead the innovation essential to continue to provide effective and acceptable services in the new
conditions…’
(BPS, 2011)
Finally, it is essential to emphasise that assertive outreach is neither a team, nor a service
nor a collection of specific staff, but a function. Assertive outreach is an opportunity to
provide intensive support in situ for people disabled by serious mental health problems
and has been shown to be an effective means to rebuild relationships following
engagement difficulties. Clinical psychologists should play a major role in assertive
outreach and its development. Through identifying the effective elements of assertive
outreach, and by developing, delivering, and evaluating innovative approaches, clinical
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Division of Clinical Psychology
psychology can be a driving force in assertive outreach’s future development. Given the
resources challenge that the NHS faces, clinical psychologists are arguably in a strong
position to assess this challenge, collect meaningful data, derive a hypothesis or
formulation which points to possible solutions and then evaluate the effectiveness of these
solutions. These principles and skills are no less useful when faced with a challenge to a
service than they are when faced with a challenge to a service user.
Clinical psychologists and assertive outreach
27
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