A lifeline in the community: the vital role of assertive outreach and rehabilitation
Dr Nuwan Dissanayaka is Consultant Psychiatrist for the Assertive Outreach Team at Leeds and York Partnership NHS Foundation Trust, and an Executive Committee Member at the Faculty of Rehabilitation Psychiatry, Royal College of Psychiatrists. Here, he explains the challenges faced in supporting people with complex mental health needs to maintain independence.
We're standing in front of Jamie's door for the second time today. It's been ten minutes but at least it's stopped raining. This could be any one of the hundreds of crumbling red brick terraced houses in Leeds. In most places back-to-backs like these were knocked down years ago. But not here.
It's not a surprise that there's no sign of Jamie, instead just the sounds of his dogs barking and the bass reverberating inside. Discarded broken furniture blocks our path next to the rubber scorched tarmac. Jamie's door still hasn't been fixed since it was forced by the police prior to his last admission three months ago, despite our pleas to the housing office. I'm drawn to next door's muffled argument until finally, just as we're about to leave, Jamie opens the door.
It's never certain what reception we will get. Sometimes Jamie thinks that we are amongst the government agencies trying to harm him, sometimes he threatens us because of this and oftentimes he just doesn't answer the door. But today he is eager to see us. And it's obvious why. His face is a mess. A fresh black eye, dried blood around his nose and painful looking scratches to his arms and knuckles. He is shirtless and painfully thin.
He explains to us that his newfound "friends" took his money, his food and even his trainers. He wanted to call us but couldn't as he sold his phone after just a week to buy food for the dogs. They always come first. He hasn't dared take them out since the assault.
"Sorry, you can't come in. I've not tidied up yet".
His newfound "friends" took his money, his food and even his trainers. He wanted to call us but couldn't as he sold his phone after just a week to buy food for the dogs.
Through the crack in the door I can see that it's worse than last time I visited. The floor is littered with old food, empty cider bottles, threatening brown envelopes about bills and benefits and unopened medication boxes; the dogs have had no choice but to relieve themselves inside amongst the detritus.
Jamie struggles to manage at home but he refused the offer of a spell in a rehabilitation unit after his last admission. He desperately wanted to be back with his dogs, the only family who want him around. He was rejected for funding for self-directed support. The council are refusing to go inside to make badly needed repairs, as are the cleaners we enlisted. Sadly the massing summer flies show no such aversion to Jamie’s property.
Jamie is frightened.
"I know I said no before but I want to talk to the police this time".
Without hesitation we agree to take him and we start to help him secure his broken door. But before we can leave Jamie's "friends" appear around the corner. They nod to him and without a word he shrugs his submission, opens the door and gestures them inside.
"See you later", he says to us as he closes it behind them.
I work as a consultant psychiatrist in an Assertive Outreach Team: once the next big thing but now in many areas discarded simply due to its failure in some research to reduce hospital admissions. Its focus on continuity and therapeutic relationships was usurped by a preoccupation with a short term approach to long term mental illnesses. Jamie is one of many people I see who have complex issues. A psychotic illness compounded by substance use, a rejection of psychiatric services both statutory and otherwise and serious risks, perhaps most significantly those he faces from others. It’s a combination which has led to numerous detained admissions. Other than his "friends" we are the only people Jamie regularly sees. We’ve hung in there over the years and Jamie has come to trust us, at least some of the time.
He has been accused of "failing to engage" by much-changed health and social care systems which in reality have failed to engage with him. Apart from the times that Jamie inconveniently becomes more disturbed in public due to his intense psychotic experiences, he remains invisible to society, and the human costs to him and people like him remain largely hidden. Or do they?
Its focus on continuity and therapeutic relationships was usurped by a preoccupation with a short term approach to long term mental illnesses.
We work hard to support Jamie’s wish to remain in the community but there are many barriers. Without access to the right health and social support, yet another admission, most likely detained under the Mental Health Act, feels sadly inevitable. And as this vicious circle continues to turn, as the stigmatising perception of him as a danger to society grows, he becomes increasingly likely to join the thousands of people who are currently in expensive, locked, often out-of-area psychiatric units. Even the lifeline support from Assertive Outreach Teams like ours is something that has been myopically stolen from many people like Jamie across the country.
The Care Quality Commission’s report “The State of Mental Health Services” has shown a worrying expansion of institutional care with increasing numbers of people spending long periods in such locked rehabilitation units. Maybe it is time to consider whether we may have made the wrong decisions along the way about how we provide health and social support for Jamie and those like him. Maybe it is time we started instead to meaningfully re-invest in better and more accessible community care. Surely we have a duty to assist this group in staying well, out of hospital and most importantly protected from the iatrogenic harm of long term institutional care, often far away from their homes, which costs us all so dearly.
‘Jamie’ is a pseudonym for an amalgam of people Nuwan sees.
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