Mental Health Topics

Assertive Outreach

The Sainsbury Centre for Mental Health 2001

Recipients are free to copy or use the material from this document as they wish, provided that the source is appropriately acknowledged.

Index
Part One: Model
1. 2. 3. 4. 5. 6. 7. 8. Introduction Aims Core characteristics Origins Clients Statutory and voluntary settings Background research Future development

Page Number

2
2 3 3 4 5 5 5 6

Part Two: Setting up a Service

1. 2. 3. 4. 5. Setting up a service Needs assessment Team approach Leadership Staffing

7
7 7 8 8 9

Part Three: Running a Service

1. Liaison 2. Staff training 3. Client engagement 4. Referral criteria 5. Records 6. Access to other services 7. Risk issues 8. Medication 9. Reviews and quality assurance 10. Discharge

10
10 10 11 11 12 12 12 13 13 13

Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

Part One: Model

1. Introduction
Assertive outreach is a way of working with an identified client group of severely mentally ill adults who do not effectively engage with mental health services. The approach is characterised by work with clients in their own environment, wherever that may be. Mental health services have traditionally been delivered in office or hospital-based settings where the client comes to the mental health professional at a pre-arranged time. In assertive outreach, the worker goes to see the client in his or her environment - be that home, a cafe, a park or in the street wherever it is most needed and most effective. Housing departments, police stations, social security offices and inpatient units can also be suitable locations for meetings between client and assertive outreach team workers. This flexibility of approach allows services to be provided to people who may not otherwise receive them, where they feel most comfortable. Workers may also visit or accompany clients when they use other services. This encourages a two-way engagement that helps to develop trust and rapport and to establish links with other agencies. Assertive outreach staff expect to see their clients frequently and to stay in contact, however difficult that may be. The long-term aim is to build a relationship between the individual and mental health services. Assertive outreach workers aim to establish a trusting relationship with each client in a flexible, creative and needs-focused way that enables the delivery of a health and social care package that fits each client's own specific needs. Depending on local needs, assertive outreach staff may work together in a dedicated team, or they may be specialists working in a more generic community mental health team. However assertive outreach is configured it will be essential that each assertive outreach worker takes responsibility for the overall package of care a client receives. Assertive outreach must therefore take place within an integrated system of care.

2
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

2. Aims
Assertive outreach services aim to help clients to: reduce their number of hospital admissions (especially for social rather than psychiatric reasons), in frequency and duration; find and keep suitable accommodation; sustain family relationships; increase social network and relationships; improve their money management; increase medication adherence; improve their daily living skills; undertake satisfying daily activities (including employment); improve their general health; improve their general quality of life; stabilise symptoms; prevent relapse; receive help at an early stage.

3. Core characteristics
Assertive outreach involves targeting clients with severe and enduring mental health problems who have difficulty engaging with services: it is multi-disciplinary, comprising a range of professional disciplines (nurses, psychiatrists and social workers at a minimum; also, depending on user needs, support workers, workers who have also been service users, psychologists, occupational therapists, housing workers, substance misuse specialists and vocational specialists); there is a low ratio of service users to workers, usually ten clients per caseload; there is intensive frequency of client contact compared to that of standard community mental health teams (ideally an average of four or more contacts per week with each client); an emphasis on engaging with clients and developing a therapeutic relationship; offers or links to specific evidence-based interventions; time unlimited services with a no drop-out policy; work with people in their own environment, often their own home; engages with the users support system of family, friends and others; a team approach that provides flexible and creative support to the individual case coordinators.

3
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

4. Origins
USA Assertive outreach originated from the USA in the 1970s and the USA approach has remained a strong influence on current UK practice. Assertive outreach was initially designed to help mental health inpatients develop a level of independent living. This model, known as 'training in community living' (TCL) was developed by Leonard Stein and Mary Test, who created an intensive system of support for inpatients who proved hard to discharge from hospital. Treatment was tailored to individuals, focused on helping them develop independent living skills and took place in the community rather than hospital. Ward staff developed new ways of working when they relocated to a residential house and were available 24 hours, seven days a week. In the USA, assertive outreach has become accepted practice and the debate has moved on towards which elements of assertive outreach are essential and which can be modified to meet local circumstances. This has led to a debate on 'fidelity' to the model. Proponents of fidelity argue that any shifts away from a pre-defined model will water down its effectiveness. Important US research: Test, M.A. & Stein, L.I. (1978) The clinical rationale for community treatment: a review of the literature. Alternatives to Mental Hospital Treatment (eds. Stein, L.I. & Test, M.A.). New York: Plenum. Teague, G. B. Bond, G.R. & Drake, R.E. (1988) Program fidelity in assertive community treatment: Development and use of a measure. American Journal of Orthopsychiatry, 68 (2) 216 232. Australia Australia has significantly developed its expertise in the delivery of assertive outreach. Assertive outreach services have become known as mobile community treatment teams (MCTs) in New South Wales and mobile intensive treatment teams (MITTS) in Queensland. These terms distinguish them from other generic community mental health teams and 24-hour crisis resolution teams. The composition of MCTs and MITTs are usually of around eight to ten multi-disciplinary staff, which target difficult to engage clients with severe mental health problems. Caseload sizes are typically 1:10, with an increase in frequency of contact between keyworker and service user in comparison with standard CMHTs. Important Australian research: An early Australian contribution to research on assertive outreach treatment was conducted by Hoult, J., Rosen, A. & Reynolds, I. (1984) Community oriented treatment compared to psychiatric hospital oriented treatment. Social Science and Medicine, 18, 1005-1010. Hoult, J., Reynolds, I., & Charbonneau-Powis, M., et al. (1984) Schizophrenia: A comparative trial of community oriented and hospital oriented psychiatric care. Acta Psychiatrica Scandinavica, 69 359 - 372. Hambridge, J.A. and Rosen, A. (1994). Assertive community treatment for the seriously mentally ill in suburban Sydney: A programme description and evaluation. Australian and New Zealand Journal of Psychiatry, 28 438-445. UK UK experiences of approaches similar to assertive outreach have been more mixed. Stein and Test's Daily Living Programme in the USA contained assertive outreach as an element. Although positive findings in terms of cost-effectiveness were reported, the model was not taken up more generally at the time. Many recent studies have not reported the same overall benefits. This may be due to lack of fidelity to the original assertive outreach model. Marshal et al. have summed up the evidence [Marshall, M., Gray, A., Lockwood, A., et al. (1997) Assertive community treatment. Schizophrenia Module of the Cochrane Database Systematic Reviews (eds. Adams, C.E., Duggan, L., de Jesus Mari, J. et al.). Oxford: Update Software]. They report that the assertive outreach approach can engage 95% of people, that the use of inpatient beds can, under the right circumstances, be reduced and that users prefer the approach to standard services. Other benefits
4
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

have been demonstrated in individual studies. These benefits appear to be associated with the types of services that people are linked to. Important UK research: Burns, T., Creed, F., Fahy, T., Thompson, S., Tyrer, P., & White, I. (1999) Intensive versus standard case management for severe psychotic illness: a randomised trial. The Lancet, 353 21852189. The 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. London: The Sainsbury Centre for Mental Health.

5. Clients
Assertive outreach clients will often have a history of severe mental illness with: sporadic non-engagement with mental health services that may not meet their needs; sporadic or non-compliance with medication resulting in their impaired mental health; frequent unplanned psychiatric admissions; frequent involvement with the police because of mental illness; complex multiple problems in addition to severe mental illness, (such as alcohol/ drug misuse, frequent homelessness, personality disorder, or learning disability). Severe mental illness The Department of Health has defined people with 'severe mental illness' as individuals who: are diagnosed as suffering from mental illness (typically schizophrenia or a severe affective disorder, and including dementia); are substantially disabled because of their illness, e.g. they are unable to care for themselves independently, sustain relationships or work; are currently displaying florid symptoms or are suffering from a chronic, enduring condition; have suffered recurring crises leading to frequent admissions/interventions; may at times present significant risk to their own safety or that of others.

6. Statutory and voluntary settings

Assertive outreach can be carried out by different multi-disciplinary services. The examples below are non-prescriptive. It is important that a detailed needs assessment be carried out first and that 'form then follows function': specialist assertive outreach: statutory services that include professional mental health staff such as nurses, social workers, psychiatrists; specialist assertive outreach staff working in generic community mental health teams; a mix of statutory and outreach workers who work in a statutory setting where professionals may come from both statutory and community-based backgrounds; voluntary-based teams who liase with statutory and standard community mental health teams.

7. Background research
Results supporting assertive outreach: The assertive outreach approach is built on robust evidence. Two evaluations, both over 12 months, have shown the following results: 35% decrease in hospital admissions; 62% reduction in the number of bed days;
5
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

Increase in the number of users in stable accommodation (Hambridge & Rosen, 1994).

Another study demonstrated: more users maintained in treatment longer than in routine case management; users experienced fewer admissions involving the police; fewer involuntary admissions; significant improvement in functioning over 12 months in Living Skills Profile Scales (Sanderson et al., 1996). Results against assertive outreach treatment: The UK 700 Study (UK700, 1999) shows that assertive outreach treatment teams do not make a significant difference compared to standard community treatment teams. (Thornicroft et al., 1998). PriSM published ten papers, which appeared to show that intensive case management produced no better outcomes than standard care. References Hambridge, J.A. and Rosen, A. (1994). Assertive community treatment for the seriously mentally ill in suburban Sydney: A programme description and evaluation. Australian and New Zealand Journal of Psychiatry, 28 438-445. Sanderson, K., Issakidis, C., Johnston, S., Teeson, M., Salkeld, G. & Buhrich, N. (1996). Costeffectiveness of intensive case management for people with serious mental illness. Darlinghurst, NSW: CRUFAD. Thornicroft, G. & Goldberg, D. (1998) Has community care failed? London: Maudsley Discussion Papers, Numbers 1-10. London: Institute of Psychiatry. UK700 Group (1999) Comparison of intensive and standard case management for patients with psychosis. Rationale of the trial. British Journal of Psychiatry, 174 74-78.

8. Future development
In the UK, The NHS Plan (section 14.32) has stated that an additional 50 assertive outreach teams will be established between (2000 2003) in addition to the 170 teams that will be in place by April 2001. The NHS Plan has called for all 20,000 people estimated to need assertive outreach to be receiving those services by 2003. In the US, the National Alliance for the Mentally Ill (NAMI)(See: www.actassociation.com/News/nami.htm), is encouraging the establishment of assertive community treatment programmes in every US state by the year 2002.

6
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

Part Two: Setting up a Service

1. Setting up a service
Once the need for an assertive outreach service has been established, there are three key steps to setting up a service: The first step is to decide on the model of service delivery, based on the findings of the local needs assessment. For example, in an area with over 100 difficult to engage severely mentally ill clients, more than one assertive outreach team will be needed. In a locality where there are only a small number of potential assertive outreach users, the service can be delivered by specially identified staff (but never just one person) within an existing community mental health team. The second step is to identify existing resources and those, which are needed to cover: staffing team base premises training longer-term funding. Thirdly, there is a need to consult and build support with local interested parties. This will include informing service commissioners and providers, users, families and carers about: realistic outcomes how assertive outreach can be integrated within a comprehensive mental health service how to balance user-centred services with an occasional need for restriction or community treatment. Initial links with other agencies When establishing formal links with local organisations it is vital to identify what the key statutory and voluntary sectors are. There will invariably be widespread interest in the new team from relevant organisations and individuals. While it is essential to gather the widest possible view of all organisations and individuals that may become involved with the team and clients, the team also needs to know who is likely to maintain that involvement and help the team support their clients in the longer term. It is essential to be honest with other agencies about the changes the new assertive outreach service will bring, up to and including new ways of delivering mental health services.

2. Needs assessment
The starting point for successful assertive outreach is needs assessment. It is not difficult to identify local individuals who have severe mental health problems and might benefit from assertive work to help them establish an effective relationship with mental health services. Typically, staff in the local mental health services could contact people who meet the following criteria: diagnosis of severe mental illness; history of erratic or non-engagement with mental health services; history of erratic or non-compliance with medication resulting in their impaired mental health; frequent unplanned psychiatric admissions; frequent involvement with the police because of mental illness; complex, multiple problems in addition to mental illness, such as alcohol/drug misuse, frequent homelessness, personality disorder or learning disability.

7
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

It will also be important to gather as much information as possible about: people potentially in need of assertive outreach who are not known to the statutory services; the reasons why people are excluded from (or unwilling to use ) mainstream services; particular issues affecting the uptake of services by black or ethnic minority users and women; gaps or shortfalls in local service provision, which will have a bearing on the assertive outreach service. Workers need to consult as widely as possible to gather this information. Local community and religious organisations and groups that represent service users and carers will have a particularly important role to play. A simple needs assessment should give sufficient detail of how many people might benefit from assertive outreach and the nature of their problems. On the basis of this information decisions on structure can be taken, for example will a separate specialist team be needed? What staff-mix will best match the client needs identified?

3. Team approach
The 'team approach' idea is one of all workers acting together, making joint decisions and sharing responsibility for clients. This means that clients are not allocated to one worker but may be seen by any team member. This approach is feasible because of assertive outreach teams have smaller caseloads. It means that workers can realistically get to know all current clients. Key advantages of the team approach are in ensuring continuity of service and preventing clients from becoming dependent on individual workers who will at some point move on. This approach also benefits staff, reducing levels of burnout, and enhances thoughtful practice (Navarro & Lowe, 1995). A variation on the above is keyworking within a team approach. While overall responsibility for the caseload is still shared by the whole team, each client is allocated a keyworker with lead responsibility for his or her care. When this worker is absent other members of the team provide cover so that service continuity is still guaranteed. This way of working retains many of the benefits of the team approach while allowing clients to build up a relationship with a particular worker, which may assist the initial process of engagement. References Navarro, T. & Lowe, J. (1995) The TULIP Approach: a working paper. London: TULIP, Haringey (unpublished paper).

4. Leadership
Effective leadership will be critical to the success of an assertive outreach team. A team leader needs diverse skills, which should include the ability to motivate staff, plan and advocate for the service and cope with crises as well as finding solutions for more mundane daily problems. Above all, an understanding both of service users and the stress facing staff is essential. The essential elements of team leadership can be summarised as follows: to understand the critical components of assertive outreach and of implementing team practice in way that is faithful to it; good team building skills; effective managerial and clinical supervision; the ability to recognise and deal with the signs of staff burnout; to anticipate and diminish any resistance against or within the team . Setting up a new, innovative service may be seen as a threat by some staff; to inform key stakeholders about assertive outreach;
8
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

to develop partnership and networks with other agencies; to hold a small but active caseload; to be available to frontline staff; to be accountable for the team's work.

It is essential for team leaders to be able to integrate the team's work within a comprehensive local mental health service. This includes developing adequate referral systems for direct access to safe, 24-hour care and inpatient beds. Good leadership also involves being able to ensure that the principles are understood by all team members and that all staff meet daily to keep up to date with client issues. A final crucial function for leaders is to be able to clearly define the roles and relationships between the team and psychiatrists. This is important whether or not the latter are team members.

5. Staffing
Multi-disciplinary issues In statutory teams there will usually be a mix of: outreach workers with statutory backgrounds. Most often health or social services (nursing, social work, occupational therapy, psychology, housing); outreach workers with relevant, non-statutory background experiences (welfare benefits, employment); specialist staff such as psychiatrists, substance misuse workers and counsellors; service or ex-service users who are also team members. It is important to provide services that are relevant to local needs. Services might take a variety of forms, ranging from: teams comprising exclusively statutory mental health staff (nurses, social workers, psychiatrists, etc.) generic community mental health teams which include specialist assertive outreach staff; statutory-based teams including both statutory and outreach workers who work in a setting where professionals may come from both statutory and community-based backgrounds; voluntary-based teams with predominantly outreach workers, who are in partnership with statutory community mental health teams.

9
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

Part Three: Running a Service

1. Liaison
Working with family and carers Family and carers play a vital part in the improvement of the client's quality of life. Family and carers should be involved, where appropriate in all client treatment planning. Staff should also be aware of the conflicting demands that may be placed upon them by family/carers and clients. Family work involving patterns of interactions and education of mental health can be useful. Such work can help to bridge the gap when distinct demands are placed on the worker or pressures are placed on the client by the family or carer. Statutory and voluntary agencies Effective liaison with benefit, housing and other agencies can be of enormous benefit to users and substantially improve their quality of life. Housing is often an important issue to clients' and workers may be involved in liaison with housing departments, landlords or neighbours who are concerned about them. In the latter case, there are often testing ethical issues in terms of balancing confidentiality with the need to involve neighbours in relevant discussions about clients, particularly relating to deterioration in their mental health. Other key groups the police solicitors GPs.

2. Staff training
Team building can ensure uniform ways of working. It can also help team members to understand the importance of a system that instils good practice, skills and knowledge development and the ability to provide mutual support. Communication skills are an essential part of training on three levels: Client communication skills: engagement is key to this. All other skills relating to support, planning, and treatment follow on. Team communication skills: discussing issues with other team members, feeling able to ask for help, and negotiating differences between team members. Inter-agency communications skills: effective communication with external agencies. Medication awareness All team members, whatever their professional status, should have a broad awareness of 'old' and 'new' psychotropic medication. The more knowledge they have about such drugs the more they will be able to support their clients. An understanding of clients' medication will help all staff and give them more confidence when discussing treatment plans for clients with medical staff. Treatment planning Staff should be aware of a range of interventions for effective case management. These should include such areas as: engaging clients assessing client needs awareness of the broad psychiatric diagnoses working with families and carers awareness of local and national client resources
10
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

welfare benefits training.

3. Client engagement
Effective client engagement is fundamental to the assertive outreach model. This involves the development of a trusting relationship with the service user, sometimes referred to by health professionals as the 'therapeutic alliance'. Working with users on their own territory is essential to the development of such a relationship. This is a significant shift from traditional mental health services that have often been institutionally based. Successful therapeutic relationships very rarely just happen, but need to be carefully worked on from the first meeting. Assertive outreach workers should be prepared to spend a lot of time engaging service users and will need to be highly flexible and creative in their approach to this. It is particularly important to pay attention to the needs and priorities expressed by the user, rather than operating from a pre-set agenda. Getting involved in their daily living activities, such as shopping or cleaning, or sorting out problems with welfare benefits and utility payments can often be highly effective as a means of initial engagement.

4. Referral Criteria
There should be a written policy on acceptance and exclusion criteria for referrals. The team should follow this when negotiating with potential referrers. Acceptance criteria would include clients who have: a severe and enduring mental health problem; a history of erratic or non-engagement with mental health services; a history of erratic or non-compliance with medication resulting in impaired mental health; frequent unplanned psychiatric admissions; frequent involvement with the police because of their mental illness; complex multiple problems in addition to mental illness, such as alcohol/drug misuse, frequent homelessness, personality disorder or learning disability. Rejection criteria would include clients who: have substance misuse as their primary diagnosis; have learning disabilities or personality disorder as their primary diagnosis; have predominant forensic issues over psychiatric issues; are no longer mentally ill and/or who cope independently with little or no support; are already living in high-support residential or institutional settings (such as hostels, forensic or inpatient accommodation) and who are likely to stay there for the foreseeable future; live outside the defined catchment area. Exclusion criteria may vary depending on the available expertise: within the team within the network of available services. Consultation Consultation with relevant parties while developing policy is essential. For example, it is essential for newly formed assertive outreach teams to negotiate with local NHS trust dual diagnosis teams about the circumstances in which new teams would and would not accept dual diagnosis referrals (i.e. the team has a pre-determined caseload level). Client assessment Structured assessments should be used to assess clients referred for assertive outreach. This will both ensure a consistent way of working and avoid ideological disputes about the value of different approaches amongst team members.
11
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

5. Records
A clear written policy on the team approach to recording client and agency contact will ensure better standardisation of practice. This policy should also mention how recording in external agency files (e.g. inpatient ward visits) is to be done. Periodic random audits of case recordings should be performed to ensure quality and up-todate recording as an ongoing practice. To avoid staff misinterpretation of management intentions an external department on a corporate level should do this.

6. Access to other services

Co-ordination of the care package that the user receives from both the team and other agencies is a key responsibility of assertive outreach workers. Their client group of severely mentally ill adults is often least confident at negotiating with services and yet most likely to be discriminated against when seeking help from them. For this reason assertive outreach workers need excellent liaison skills with relevant agencies (such as housing, benefits, vocational).

7. Risk issues
Safety There should be a clear written policy on safety for clients and staff as well as periodic training and discussion of current ongoing practices. Workplace health and safety issues should adhere to overall health trust and/or local authority policies. Violence Policies on dealing with aggression should consider pairing workers when they do initial assessments of clients who may be violent or who may become so when their mental health deteriorates. Team leaders must be sensitive to issues around clients with known histories of violence, especially if they have patterns of violence towards women or have a history of violence related to racial issues. Team leaders must take staff concerns around potential danger from clients seriously. Self-harm, violent attacks, suicides and homicides Risk assessment tools and practices should be ongoing and reviewed regularly. Staff should receive training in the distinctions between clients who may self-harm and those who have suicidal tendencies. Written policies should exist on how to minimise attacks on staff and what to do if they occur. In addition: Adequate support should be given to staff that experience the loss of clients through suicide. Staff should be aware of the importance of keeping records and know what corporate policy is when a suicide or client homicide occurs. Management should be supportive when a suicide or client homicide occurs and make an effort to convert any potential 'blame-culture' into that of a 'learning culture'.

12
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

8. Medication
Assertive outreach teams with a statutory brief often have duties that involve prescribing, administration and management of medication. The most difficult issues will arise with clients who experience serious relapses as a result of erratic or non-compliance with medication. If the team is involved in administering medication, it could provide a daily and observed medication routine for users known to be poor compliers. The team has a duty to keep up to date with recent developments in pharmacology. Team members should continually monitor and listen to each client's reactions to and experience of medication.

9. Reviews and quality assurance

In summary, the quality of any mental health team will be helped by: establishing an operational policy from the start; setting short (three to six months) medium (six to 12 months) and long (12 to 18 months) targets and quality standards for staff and service performance; evaluating targets formally every year; clear procedures for comments and complaints; carrying out critical incident reviews, so that lessons are learned and put into practice; regular, systematic, clinical supervision of all staff, to help maintain and improve individual standards; regular, systematic, multi-disciplinary reviews of all cases and care plans; organising regular staff support sessions; ensuring that all mental health review tribunals are attended and that tribunal reports are distributed to the trust's Mental Health Act co-ordinator well in advance of the tribunal meeting date. Staff and managers need to review targets and operational policy regularly in team meetings. This means checking that policies are being adhered to and that the policies are relevant. It is essential to update policy elements that are not working. It can also be helpful to plan how to collect data regularly in a simple, systematic and useable way. Complex data collection will load down staff who are already too busy to gather or use it. Data collection should integrate with staff routines of necessary data gathering and assessment, such as for the Care Programme Approach.

10. Discharge
The duration of assertive outreach work required by each service user will vary widely and is frequently long term. However, in some cases, intensive input over a relatively short or distinct period will be sufficient. There should be a written policy that outlines the criteria for discharging a client from the assertive outreach service. Specific criteria to determine when a client is ready to 'move on' Many of these will be time based, involving a pre-determined period of: years without unplanned psychiatric admissions; improved and sustained relationships; sustaining employment or other meaningful daytime activities; abstinence from severe substance misuse;
13
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001

 avoidance of previous patterns of police / forensic involvement. When clients become more well and sustain an improved level of coping they should be referred on to: their local community mental health team; their local GP (but only if they are already making use of local GP service and are comfortable with this). Endings It is extremely important to start preparing clients for discharge several months in advance. Clients should be encouraged to express any fears and feelings of sadness they have about the move. Their successes while engaged with assertive outreach should also be reviewed. Crises sometimes emerge during this period and may reflect a fear of 'letting go' of the therapeutic relationship. Depending on the nature of the crisis, discharge from the service may need to be postponed.

14
Mental Health Topics: Assertive Outreach The Sainsbury Centre for Mental Health 2001