Assertive Outreach Teams Research Articles

Tackling hospital service burden of alcohol dependence in England: a service evaluation of alcohol care teams (ACTs) and care pathways for integrated care

Background Chronic alcohol disorder hospital admissions are increasing in England and present a huge cost to England’s health and social care costs. Hospital-based alcohol care teams (ACTs) aim to better meet these patients’ complex needs through assessment and targeted referral. This has the potential to work effectively within England’s newly established integrated care system. Methods The aim of this project was to identify in what ways ACTs can be effective in improving care pathways for complex care in a whole-system health and social care setting. We conducted semi-structured, tailored interviews with practitioners, managers and commissioners, across three hospital and community settings in one large urban region in England, comparing ACT working with non-ACT working. Results Effective pathways were enabled by the presence of an ACT, multi-agency community initiatives, assertive alcohol outreach and frequent-attender team meetings. Identified barriers were lack of systemic funding and commissioning, poor communication between agencies, lack of information-sharing and insufficient staff training. Conclusion Community outreach and in-reach between hospitals and community services enable effective care pathways when ACTs provide the point of contact. A well-resourced ACT with clear operational remit can create links between diverse agencies and enables improved wraparound care for alcohol dependent patients.

New ways in delivering services for people with dual diagnosis

IntroductionPeople with severe mental health disorders and concurrent addiction problems are one of the most challenges patients to treat within mental health and addiction. They often find themselves fallen between different chairs within mental health and addiction services and between spescialist and primary care. There is a need for new ways of delivering services for this group.ObjectivesThe objective of this presentation is to present how Flexible assertive outreach teams (FACT) are delivered in a densly populated country and the results on changes in use of spescialist services and detension. We will also present the results of changes in quality of life before and after entering FACT and which factors that might be associated with life quality.MethodsThe establising of FACT in Norway has been extecively evaluated both in the form of official reports to the health authorities and academic research papers. We will do a scoping review of the Norwegian research on the effect of FACT teams with a spesific attention to the results obtained in densly populated areas. The review will cover the years fra 2018 up til to day.ResultsThe results so far indicate that it is possible to deliver FACT services in densly populated areas and that there is an increase in qualty of life before and after entering a FACT team. The use of hospitalization days are reduced with about 50 % and the same applies for days in detention.ConclusionsFACT teams seems to be a viable way of delivering mental health care services to one of the most vulnerable groups in our society.Disclosure of InterestNone Declared

Ethical issues in assertive outreach and crisis intervention teams

IntroductionAssistance to people suffering serious mental illnesses has undergone large variations in the last twocenturies. After World War II, The community became a new destination for them.But hardly anyone knew how to cope with mental illness in thecommunity. Thus, several initiatives arose in the US. Both social work and psychiatry,moved towards a pragmatic point of view by the rising tide of patients seeking help: initiatives trying to providesolutions to themost basic needs of patients: accommodation, food,medical care, takingof medication, etc. By the 1970s, Mary Ann Test and LeonardStein had proven the effectiveness of theirLife Coaching in Madison, Wisconsin. In 1981 his program is disseminated by several states under the name of Assertive TreatmentCommunity and thus spread throughout the United Statesand Canada, Australia and Europe. Psychiatry has recognized it as the program that got the most for supporting the community model. 50 years later the basics of the TAC model remain more or less thesame. But home interventions caused a continuous conflict in the ethical field notwell addressed…ObjectivesWHY IS AN ACT team a fertile ground for ethicalconflicts?This approach is coercive or assertive?There are several reasons. There is a specific ETHICAL ENVIRONMENT in THE ACT team1.“Diffusion of Responsibility”-2. Mutual confirmation bias:3. There is a tendency to think that professionals areethical by nature.4. Biased search for information when problems arise.Sources are sought to confirm us before clarifying whathappened5. A special tendency to conformism.6.Repetitive responses.MethodsWe will analyze the main ethical conflicts arising in ACT teams:1. CONFLICTS OF AUTONOMY2. PRIVACY AND CONFIDENTIALITY ISSUES3. CONFLICTS OF DUTIES4. ASSERTIVENESS VERSUS COERCIONResultsThe great challenge is knowing how and when to intervenewith patients with variable decision-making capacity orwithout any insight, as well as the impact on theirautonomy. It is an exercise both in art and inphenomenological training: Because there are subtledeficits, difficult to appreciate, but there are otherdeficits that are obvious.ConclusionsThe challenge: balancing the needs and safety of thecommunity with the needs and safety of the individual.ACT teams staff must juggle both perspectives, whilemaintaining a therapeutic alliance.The continuous contact with the patient in an ACT teamgives, especially to clinicians, a privileged place ofobservation to act correctly in those situations and to be asupport so that whoever arrives lacking in affectivity orwith relational problems could grow until reaching a moreprudent and competent judgment.WHAT COULD HAPPEN IF WE TRAIN PROFESSIONAL IN BIOETHICS MORE IN PATIENT´S RIGHTS, A FIELD FOR LAWYERS??Disclosure of InterestNone Declared

Physical Healthcare, Health-Related Quality of Life and Global Functioning of Persons with a Severe Mental Illness in Belgian Long-Term Mental Health Assertive Outreach Teams: A Cross-Sectional Self-Reported Survey.

Research shows that care delivery regarding somatic health problems for patients with a severe mental illness (SMI) in community and mental health is difficult to establish. During the last decade, long term mental health outreach teams in Belgium were implemented to provide treatment and follow-up at home. This study aimed to map physical health status, care professionals, health related quality of life and global functioning in persons with SMI in Belgian long term outreach teams for mental health. Using a self-administered questionnaire, 173 persons, 58.1% female with a mean age of 48.3, were questioned. Our findings suggest an undertreatment of somatic comorbid conditions, with only half of physical health complaints being addressed. Although treatment rates for hypertension, when detected were high, treatment of respiratory complaints, pain and fatigue was lacking. Although the majority of respondents responded to have a GP or psychiatrist, contact rates were rather limited. Other disciplines, such as primary care nurses, when present, tend to have more contact with people with SMI. Notably, having regular contacts with GPs seems to improve physical health complaints and/or treatment. Being treated by an outreach team did not show significant correlations with physical health complaints and/or treatment suggesting a more proactive approach by outreach teams or primary care providers is desirable.

Theoretical approaches to the engagement with patients in case-management programmes and assertive outreach teams: A systematic review of the literature.

WHAT IS KNOWN ON THE SUBJECT?: It is generally accepted that all interventions carried out by mental health nurses involve engagement with the patient; this engagement is a process that is gradually constructed and is not immediate. In Spain during last decade, nurses working in assertive outreach teams have gradually replaced the traditional institutional setting in favour of environments that are more familiar to the patient. In contrast, when patients and nurses interact outside institutional settings, a new approach and skillset is required in order to adapt to the new environment. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We have systematically identified and assessed the available evidence on how nurses work in assertive outreach team programmes. The therapeutic link is not just assistance; it is actually a construct, which is established between nurse and patient, with the aim of favouring, fostering and strengthening the therapeutic relationship. Only a few studies have discussed the nurse-patient therapeutic link in assertive outreach services. However, it seems important that nurses use a standardized language, that is, a language promoted as a model of correct use and used for functions of greater prestige, especially in public administration and teaching, to integrate it into the theoretical framework. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: With the synthesis that we present, we hope that it promote a more consistent use of the engagement concept in research on this topic. In turn, this will enhance staff support and training and will foster evidence-based practice. The conceptualization of nursing language and its use by professionals helps to improve practice and the lack of a theoretical framework with a nurse perspective. It is necessary to establish a consensus between mental health nurses around the engagement' meaning in the programmes of assertive outreach teams. ABSTRACT: Introduction During last decade in Spain, nurses working in assertive outreach programmes have replaced the traditional institutional setting in favour of the patient's own environment. Engagement with patients requires a different skillset when the axis of the nurse-patient interaction is the patient's own environment. The engagement alone could be associated with the innate concept of patient's care and the helping relationship. However, in the individualized care models, the engagement seems to be an instrument with its own characteristics for the purpose of providing mental health care. Aim/Question To systematically identify and assess the empirical evidence on the relationships and engagement between patients with mental illness (schizophrenia, psychotic disorders, schizoaffective disorders, mood disorders and disorders of adult personality) and nursing mental health nurses. Method Systematic literature review based on PRISMA guidance. Results We identified and reviewed seven primary research studies. Following the analytic processes, three themes emerged: existence of different engagement levels, training needs and skills in the creation and consolidation of the engagement, and engagement as process. Discussion The engagement of nurse and patient is understood as a process that incorporates different stages. Whilst it is established, the engagement is subject to positive and negative influences. For the creation of the engagement and its maintenance specialized skills, knowledge and personal attributes (resilience, psychosocial skills, compressive knowledge of mental health illnesses, capacity to build effective relationships, adaptability and problem-solving) are necessary, but the main focus is on context where it develops, selected by the patient himself, for example, his home. Implications for Practice Administrators may have questions about appropriate hiring practices for assertive outreach teams since certain skills are necessary to obtain un engagement process, and staff training should be considered a key issue to provide specific skills for enhancing engagement and the therapeutic relationship. Conclusion The engagement must be understood as a long-term process. For the creation of the engagement and its maintenance, specialized skills, knowledge and personal attributes are necessary.

Accessibility of substance use treatment: A qualitative study from the non-service users' perspective

IntroductionDespite having effective treatments for substance use disorders, the majority of people with a substance use disorder do not receive treatment, which leads to adverse personal, health, and social consequences. Experiences of non-service users have hardly been investigated in the literature. This study, which we conducted in the Netherlands, assessed the barriers to and facilitators of accessibility to substance use treatment for non-service users with substance use disorders. MethodsThe study team conducted a total of 10 individual, semi-structured interviews with participants recruited with the help of assertive outreach teams and public health services. A topic list guided the interviews. The interviews were transcribed, and the study team performed a thematic analysis. ResultsSix main themes related to the health care accessibility of substance use treatment emerged: treatment factors, stigmatization, personal factors, consequences of use, knowledge deficits, and social support. Personal factors, especially the non-service users' motivation, was a central determinant of whether they accessed substance use treatment. Social support and consequences of the substance use were perceived as facilitating access to treatment. Stigmatization and knowledge deficits had an important negative impact on the substance users' intrinsic motivation and thus on their ability to access health care. Specifically, stigmatization by health care professionals contributed to suboptimal treatment and recovery. ConclusionsThis study recommends interventions for health care professionals aimed at decreasing their stigma toward and knowledge deficits about substance use disorder. This study highlights the key role that primary health care providers can have in identifying substance use problems and facilitating the pathway to health care services for those with substance use disorders.

Cervical screening in assertive outreach team patients

AimsTo assess the uptake of cervical screening in patients under Birmingham and Solihull Assertive Outreach Teams; this included a re-audit of patients under the Central Birmingham Assertive Outreach Team.BackgroundPatients with severe and enduring mental illness are known to have poorer physical health outcomes. In Birmingham and Solihull there are 6 Assertive Outreach Teams. These teams manage patients with a diagnosis of psychosis who have complex needs requiring intensive multidisciplinary input and often struggle to engage with health services. The national cervical screening programme aims to prevent cervical cancer by detecting and treating cervical abnormalities. Acceptable coverage is defined as screening at least 80% of people aged 25–49 years within the last 3.5 years and 80% of people aged 50–64 years within the last 5.5 years. In 2018 71.4% of women in England and 70.9% in the West Midlands were screened adequately. An audit of 15 patients under the Central Birmingham Assertive Outreach Team in 2014 showed 46.2% had taken up screening, measured in the last 5 years for those aged 50–64 years and the last 3 years for those aged 25–49 years.MethodA list was obtained of all female patients under the Assertive Outreach Teams with patients excluded if they were under 25 years or over 64 years or if they were known to have undergone a total hysterectomy. All GP practices with eligible patients registered to them were written to requesting the date of the patient's most recent smear test. Cervical screening was classed as in date if carried out in the last 3.5 years for patients aged 25–49 years or 5.5 years for patients aged 50–64 years.ResultOut of 127 eligible patients, 110 had correct GP details on their record. Responses were received regarding 101 patients, 48 of whom had in date cervical screening (47.5%). Of 58 patients aged 25–49 years, 26 had in date cervical screening (44.8%). Of 43 patients aged 50–64 years, 22 had in date cervical screening (51.2%).Conclusion13.4% patients did not have a known GP practice, increasing the risk of multiple poor physical health outcomes. The rates of cervical screening among Assertive Outreach Team patients are similar to the original audit in 2014 and fall significantly below the national standards and averages. These findings, along with the importance of working together to address the need for physical health monitoring in this population, will be communicated with the local Assertive Outreach Teams and GP practices.

Impact of community treatment orders on inpatient bed usage in assertive outreach team

AimsTo examine the impact of using Communty Treatment Orders (CTO) of the Mental Health Act on use of inpatient care in Assertive Outreach team.BackgroundCurrently there is little evidence of the efficacy of community treatment orders (CTOs), and in particular with patients who use the Assertive Outreach service. One large randomised controlled study found no impact on use of inpatient care while a naturalistc study found significant impact.MethodOur primary outcome was the number of admissions with and without a CTO comparing each patient with themselves before CTO and under CTO(“mirror-image”). Our secondary outcomes were the number of bed days, and the percentage of missed community visits post-discharge. We also looked at the potential cost savings of a reduction in inpatient bed usage.ResultAll the 63 patients studied over period of 6 years had a severe and enduring mental illness. The use of a CTO was linked to a significant reduction in the number of admissions (mean difference = 0.89, 95% CI = 0.53–1.25, P < 0.0001) and bed days (mean difference = 158.65, 95% CI = 102.21–215.09, P < 0.0001) There was no significant difference in the percentage of missed community visits post-discharge. Looking at the costs, an average cost for an inpatient Assertive Outreach bed per day in the local Trust was £250, and there were 8145 bed days saved in total, making a potential saving of just over £2million, during the study period.ConclusionThis study suggests that the implementation of CTOs using clinical judgment and knowledge of patients can significantly reduce the bed usage of Assertive Outreach patients. The financial implications of CTOs need to be reviewed further, but this study does suggest that the implementation of CTOs is a cost-effective intervention and is economically advantageous to the local Trust.

Falling through the cracks’ – the role of assertive alcohol outreach teams in treating comorbid mental health problems in people with addictions

AimsInput from Assertive Alcohol Outreach Teams (AAOTs) reduces the ‘burden’ on already overstretched community mental health teams (CMHTs).AAOTs are specialist addictions services. This project focuses on an AAOT based in the London, which engages with people with severe alcohol and illicit substance misuse problems.Previous research has shown that input from AAOTs reduces hospital admissions. This project examined the impact of AAOT input on reducing the ‘burden’ on CMHTs.MethodThe full caseload of the Southwark-based AAOT was reviewed, including mental health records, general practitioner notes, hospital notes and discharge summaries. We collected data on diagnoses and previous hospital admissions. Patients were assessed to determine whether they met criteria to be open to a CMHT (the presence of complex or serious mental health problems, in addition to addictions).ResultThe caseload was made up of 39 patients, 85% of patients were deemed to meet criteria for being under the care of a CMHT. Only 15% of patients are currently under the care of a CMHT. 87% of patients had at least one comorbid psychiatric diagnosis. 72% of patients had had at least one emergency department or medical hospital admission due to mental health-related problems. 39% had previous admissions to mental health wards. 21% of patients has been admitted under Section of Mental Health Act.ConclusionThe majority of AAOT patients have severe mental health problems in addition to addictions. The patients are complex and often have a history of disengagement from standard mental health services. Formal diagnosis and treatment of comorbid mental health problems is challenging in the presence of protracted drug and alcohol misuse. AAOT input appears to address a serious ‘gap’ in supporting patients with complex mental health needs who are often ineligible for CMHT input or disengage from CMHT support.

The clinical complexity of cases of schizophrenia in a community mental health team: a 3 year comparison

AimsTo describe the changes in complexity and management of individuals with schizophrenia in a community mental health team (CMHT) over a three year period.BackgroundIt is often believed that individuals receiving care from CMHTs are those with low levels of complexity and risk, and are relatively stable, with more complex individuals being managed by assertive outreach or other specialist teams. Here, we describe changes in the complexity, comorbidity, service-usage and management, of patients with a diagnosis of schizophrenia in a CMHT between 2016 and 2019.MethodData were collected from an electronic patient record system (RiO) for all individuals with schizophrenia in a CMHT in Birmingham (n = 84 in 2016, n = 71 in 2019), examining demographic variables, comorbidity, use of mental health services and current management.ResultKey findings included: - •63% were managed through care programme approach (CPA) in 2016, compared to only 31% in 2019.•21% had required home treatment or inpatient care in the preceding 12 months in 2016; this had improved to 8.5% in 2019.•Significant levels of psychiatric comorbidity, including addictions with almost half of patients (46.5%) having a known history of substance use in 2019, compared to only 15.5% noted in 2016.•Pharmacological management has remained broadly similar; in 2016 21% patients were taking a combination of 2 antipsychotics compared to only 10% in 2019 and 25% were taking clozapine in 2016 (21% in 2019). 39% were prescribed a long acting antipsychotic injection in 2016, compared to 32% in 2019.•In 2016, medication was being prescribed in the majority of cases within secondary care (55%) patients and in primary care in only 21%. GPs have now taken on greater prescribing responsibility in 2019, prescribing in 44% of cases, with 47% being prescribed by the CMHT.ConclusionThe acuity and management of individuals with a diagnosis of schizophrenia under the care of a CMHT has changed over a 3 year period. It is positive to note the reduced use of crisis services and lower rates of polypharmacy. There is a reduction in the proportion of patients receiving management through CPA, and a move towards more medication being prescribed in primary care. The reasons for this change are however unclear and may reflect change in available resources, given that more than half of this group receive clozapine or long acting injections, and have high levels of comorbidity.

Coordinated assertive aftercare: Measuring the experience and impact of a hybrid clinical/non-clinical post-suicidal assertive outreach team

• Brief, assertive follow-up after a suicide attempt can reduce future risk. • Combined multidisciplinary clinical and non-clinical practical and emotional support. • Showed substantial improvements to suicidality, distress, coping and wellbeing. • Emergency healthcare use was also significantly reduced. • Experience of care through this model was found to be highly positive. The most significant risk factor for suicide is a previous suicide attempt. For individuals who present to hospital, accessing aftercare is essential to ameliorate this risk, but frequently discharge occurs without adequate follow-up. To improve post-suicidal aftercare, a hybrid team (Alfred Hope) was developed offering three-months of psychosocial and clinical assertive outreach support. This study aimed to measure change in distress, suicidal ideation and coping beliefs and experience of care. For 92 consumers, initial and end-of-contact measures were collected: Suicidal Ideation Attributes Scale (suicidal ideation), Patient Health Questionnaire-4 (distress), Outcome Rating Scale (wellbeing), State Hope Scale (current hopeful thinking) and Coping Self-Efficacy Scale (coping ability beliefs). Qualitative responses regarding experience of care were also collected. At initial contact, 79% of consumers reported at least moderate distress, 78% suicidal ideation suggesting high risk of suicidal behaviour and 83% impaired wellbeing. Large effects were observed for reduced suicidal ideation and distress and improved wellbeing, coping self-efficacy and hopeful thinking (all p <.001) and emergency department presentations reduced significantly ( p <.001). Qualities of staff, what was received, and outcome of engagement were themes summarising what consumers reported was helpful. Uncontrolled longitudinal study and not all consumers completed end-of-contact measures. Operation of a clinical/non-clinical assertive post-suicidal outreach team is feasible, highly valued and supported improvement for most consumers. With some participants displaying persistent high suicide risk, clinical and psychosocial expertise is needed alongside being collaborative and respectfully persistent to address stressors and build coping ability to better overcome future adversity.

Community-Based Mental Health Care in Britain.

Community mental health care in the UK was established by two influential mental health acts (MHAs). The 1930 MHA legislated for voluntary admissions and outpatient clinics. The 1959 MHA required hospitals to provide local follow- up after discharge, required them to work closely with local social services and obliged social services to help with accommodation and support. An effect of this was to establish highly sectorized services for populations of about 50,000. These were served by multidisciplinary teams (generic CMHTs), which accepted all local referrals from family doctors. Sector CMHTs evolved a pragmatic approach with an emphasis on skill-sharing and outreach, depending heavily on community psychiatric nurses. The NHS is funded by central taxation, with no distortion of clinical practice by per-item service fees. It is highly centrally regulated, with a strong emphasis on evidence-based treatments. Since 2000, generic sector teams have gradually been replaced or enhanced by Crisis Resolution Home Treatment teams, Assertive Outreach Teams and Early Intervention Teams. Assertive Outreach Teams were resorbed into CMHTs, based on outcome evidence. The last decade has seen a major expansion in outpatient psychotherapy (Improving Access to Psychological Treatments (IAPT) services) and in specialist teams for personality disorders and perinatal psychiatry. The traditional continuity of care across the inpatient-outpatient divide has recently been broken. During the last decade of austerity, day care services have been decimated, and (along with the reduction in availability of beds) compulsory admission rates have risen sharply. Mental health care is still disadvantaged, receiving 11% of the NHS spend while accounting for 23% of the burden of disease.

Mental health practitioner experiences of engaging with service users in community mental health settings: A systematic review and thematic synthesis of qualitative evidence.

WHAT IS KNOWN ON THE SUBJECT?: Engagement is regarded as important and beneficial for service users and mental health services A universal definition of engagement is not yet fully agreed upon. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Based upon their experience, mental health staff use varied engagement approaches to fit with the changeable and unique needs of people who use services (service users). Mental health staff demonstrate qualities such as persistence and adaptability to successfully engage with service users. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Irrespective of professional background, the role of community mental health staff is not restricted to any single approach. Practical help and social support are as seen as important as clinical treatment to establish successful engagement. Little is known about the engagement experiences of mental health staff working in early intervention settings as most studies in this review focused on the perspectives of staff based in assertive outreach or community mental health teams. There is a need to further understand staff experiences of engagement with service users in early intervention settings. Role descriptions and expectations of community mental health workers should account for the wide-ranging flexible approach required in order to deliver appropriate interventions. This may involve a focus on engagement in training programmes. ABSTRACT: Introduction Effective mental health care is dependent on engaging service users, but some individuals do not actively attend appointments, and may stop engaging with mental health services. Quantitative studies reveal some salient factors that seem to predict engagement, but these studies miss the nuances of good clinical practice in this area. A number of qualitative studies of health professionals' experiences and understanding of effective engagement have been published. Aim This review aimed to systematically identify, evaluate and synthesize results from these studies with a view to informing effective practice in this area. Methods Electronic databases MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched (PROSPERO systematic review protocol registry (www.crd.york.ac.uk/prospero/; ID CRD42017083976). Of 799 records, ten papers met the inclusion criteria. All papers were subjected to quality appraisal based on the CASP checklist and data systematically extracted. A thematic synthesis of included studies examining mental health practitioners' experiences of engagement in community mental health settings was conducted. Results Mental health practitioners see engaging service users as depending upon complex, multi-dimensional phenomena which should include individualized person-centred approaches as well as practical, social and clinical support. Mental health practitioners demonstrate qualities such as determination and adaptability to establish and maintain engagement with service users. Implications for practice As a core aspect of nurse education, registered mental health nurses and other professionals would benefit from systematic guidance regarding engagement strategies. Most studies in this review focused on assertive outreach or community mental health teams, more clarification is needed of practitioner's engagement experiences in early intervention settings.

Stigma and discrimination in individuals with severe and persistent mental illness in an assertive community treatment team: Perceptions of families and healthcare professionals.

To explore family member and staff perceptions of clients' experiences of stigma and discrimination, in those living with severe and persistent mental illness in an Assertive Community Treatment Team. This qualitative study used the Discrimination and Stigma Scale to conduct structured face-to-face and telephone interviews of family members and healthcare professionals, working with the Assertive Outreach Team (AOT) (an Assertive Community Treatment Team) of a northern inner suburban catchment of Sydney, New South Wales, Australia. Forty-one people participated in the study (23 AOT clinical staff members and 18 family members). Family and clinical staff commonly reported stigma and discrimination amongst their relatives and clients, respectively. Four overarching themes emerged from the data: (1) appearance and behaviour, (2) avoidance and being shunned, (3) key areas of life affected by discrimination and (4) impacts of discrimination and skills to cope with discrimination. Reports of stigma and discrimination were common, yet varied between groups with clinical staff commonly witnessing experiences and impacts of discrimination in everyday life, with families' reports being substantially less. Due to the strong advocacy and support provided by the AOT model, clinical staff often buffered experiences of stigma and discrimination. Further research is needed to explore effective interventions to reduce experiences of discrimination in this population group.

The construction of people with mental health problems as risk objects: Findings of a case study inquiry.

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and management in mental health services are contested and perceived as problematic by both professionals and service users. There is substantial emphasis on risk as a core component of professional practice. However, recovery for people with mental health problems emphasizes self-determination which seems to conflict with risk management. A critique is emerging of risk assessment and management. However, there is a lack of empirical evidence which seeks to explore how professionals manage the conflicts between recovery orientated practice and risk management. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research which highlights people with mental health problems are objectified and frequently associated with the potential for harm. Risk dominates the work of mental health professionals and undermines individualized care. Service users are subject to increased surveillance and medication as a result. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Service users' subjective experiences need to be prioritized in mental health care by renewed focus on the relationship between professionals and service users. Mental health professionals should question the centrality of risk to their practice. ABSTRACT: Introduction The emergence of recovery, alongside significant focus on risk management, creates potential for conflicting influences in mental health care. Although evidence has critiqued risk assessment, there is a lack of research that seeks to explore how professionals make decisions within these apparently incompatible agendas. Aim To explore how practitioners, experience potential tensions arising from delivering recovery-orientated care and enforcing containment. Method This paper reports on a case study inquiry, using interviews with mental health professionals and observations in an acute ward and an assertive outreach team. Results Risk governed the practice of mental health professionals to such an extent it defined how service users were understood and treated. Service users were constructed as objects of risk, first by being objectified and secondly by creating a link between that object and harm. Discussion Hilgartner's (1992, Organizations, uncertainties and risk (pp. 39-53). Boulder, CO: Westview Press) theory of risk explains how risk dominates the identity of people with mental health problems at the cost of recovery. This results in increased monitoring, surveillance and medication to enact control. Implications for practice To undermine the dominance of risk, professionals should reconnect with the subjective experiences of people with mental health problems and challenge the acceptance of risk as central to their role.

Team psychological formulations in assertive outreach teams: Evaluating staff experiences

Team psychological formulation meetings aim to provide a space for team members to reflect on the development and maintenance of service users' difficulties, including the potential impact of team members own interpersonal responses. The aim of this service evaluation was to explore assertive outreach team members' views and experiences of team psychological formulation and review meetings. Twenty-five assertive outreach team staff members who had experience attending formulation meetings were interviewed using a semi-structured approach. The interview data were analysed using thematic analysis. Themes identified were: ‘Valuing the meetings’ and ‘Barriers to the meetings’, along with sub-themes of ‘increased knowledge and understanding’, ‘empathy’, ‘structure’, and ‘input’. Four barriers as sub-themes were identified: lack of knowledge about the service user, staff thinking their opinion will not matter, attendance and time constraints. Staff members found formulation meetings useful and valued the process. Recommendations include team members taking on the preparation for the meetings, prioritisation of the meetings, and developing a Care Programme Approach-linked process for sharing and developing the formulation with service users.

Perspectives of cannabis use in the life experience of men with schizophrenia.

Substance use amongst people with schizophrenia is well-established: up to 50% report using illicit substances. The occurrence of both conditions can also induce people to disengage from mental health services. The research question sought to understand, from the perspective of both service users and clinicians, cannabis use within the experience of people with schizophrenia. The transcripts of the seven participants and the two focus groups were analysed using interpretative phenomenological analysis. Service Users and Clinicians were recruited from Assertive outreach community-based teams. seven male service users who described their ethnic identity as 'black', diagnosed with schizophrenia and a history of treatment disengagement and 12 clinicians who worked with this client group. The two component study involved semi-structured interviews with the Service Users and two focus groups with the Clinicians. Service Users perceived cannabis use as a means by which they could 'reestablish their identity' that had been damaged and the social consequences of diagnosis. Clinicians similarly perceived drugs, cannabis in particular, as a significant part of the service users' life. This study provides greater depth to understanding cannabis use within the experience of people with a diagnosis of schizophrenia.

Qualitative experiences of disengagement in assertive outreach teams, in particular for "black" men: Clinicians' perspectives.

Introduction Engagement with services is often poor amongst people with severe mental health problems, yet key to improving clinical outcomes. Aims This study explores the perception of clinicians on patients with severe mental health problems, in particular the experiences of black men, who disengage from mental health services. Method Two focus groups consisting of a combined total of twelve, mainly white, experienced clinicians in the UK were recruited. Transcripts were analysed using interpretative phenomenological analysis. Results Clinicians understood that patients' awareness of stigma impacted upon engagement with mental health services. Clinicians were aware that medication negatively impacted on engagement. The passage of time was perceived as impacting upon engagement. Discussion The perspectives of the clinicians in this study and the experiences of the patients in a former study converged. The participants had an understanding of the complexities that black men faced when engaging with mental health services. Implications for practice This is the first study to highlight that AOT staff need to be aware of the key role that stigma plays in engagement in treatment, continue to focus on efforts to reduce the stigma surrounding mental health, consider the significance medication and be aware of how patients' attitudes towards mental health services develop over time.

Have you seen My PAL?’Physical Achievement Log (PAL): A physical health tool for people with serious mental illness (SMI)

Background to the problem: The physical health of individuals SMIis a cause for growing concern (Robson et al. 2013). Individuals with a SMI have a reduced life expectancy of up to 10-15 years due to physical ill health, in comparison to the general population (Collins, Tranter and Irvine 2012). The physical health care of this cohort has been described by Hemingway et.al (2014) as a ‘silent sandal’. The interest toward the development of ‘My PAL’ emerged from the findings of ‘PHILIP’ (2014) a local study conducted within the Dublin South Central, Dublin North and Kildare West Wicklow mental health services. This study highlighted the increased prevalence of overweight and obesity within a small cohort (n=69) of mental health service users. My Physical Achievement Log is a pilot study currently being conducted within an Assertive Outreach Team within the Dublin South Central Mental Health service. My PAL is a service user held empowerment tool which is pocket sized, enabling to the individual to carry at all times. It acts as prompter or a guide for the individual when attending GP appointments or other health related appointments. It includes a checklist of the physical health markers which when are not checked or followed up on are contributing to the physical ill health of this cohort. This checklist is solely for the individual to complete however support is provided by the key Nurse. My PAL also includes an action planning section whereby when an issue relating to their physical health is identified; a plan is devised between the individual and their nurse. This plan is incorporated into their individualised care plan. My PAL is an educational tool used in partnership with the service user encouraging them to be an active participant within their physical health care. Workshop Objective: The objective of the workshop is to share My PAL with fellow health professionals in a bid to raise awareness and divert greater attention to the physical health of those with SMI. Target audience: This workshop is targeted at all healthcare professionals, specifically those working with individuals with SMI. Or anyone who has an interest in the physical health of this cohort. Conclusion: In the absence of local and national policies relating to the physical health care of this cohort, ‘My PAL’ aims to empower and activate individuals to take ownership of their physical health. It is recovery orientated and embraces service user involvement in its development. It may help improve the physical outcomes of this cohort.

The replacement of assertive outreach services by reinforcing local community teams: a replication study reporting comparative outcomes and patient reported experience

Background: This is the third in a series of papers on patient outcomes and other consequences of the withdrawal of specialist assertive outreach (AO) teams. We previously reported positive outcomes for patients receiving a less intensive service at up to four years, but had not systematically interviewed patients.Aims: To test the generalizability of earlier findings through replication in another service. To complement the analysis of service utilisation with patient reported experience between the two treatment models.Methods: Service level evaluation 12 months pre and post service change for 55 eligible AO patients. Thirty three consenting patients answered validated questionnaires.Results: There were no statistically significant changes in hospital bed use comparing the year before and the year after the change (850–712 bed days, median 34–20). No significant change in crisis activity occurred despite a highly significant reduction in face to face contacts from a mean of 90–40. There were no significant changes in patient reported experience.Conclusions: Results are consistent with earlier studies. Reinforcing community mental health teams can provide an integrated service model that is clinically effective and equally acceptable to patients, making this a viable and affordable alternative to orthodox AO teams.