Across the South East Partnership, Fulfilling Lives has gathered clear data and client reflections about how the assertive outreach approach taken by the service delivery team is seen as beneficial, providing a unique offer of support that positions us well when it comes to relationship based practice with those with multiple complex needs.  This piece considers an alternative view of ‘assertive outreach’, and asks us to reflect on the motivations, drivers and ethical dimensions behind this and where it fits with those often deemed to be ‘hard to engage’ and their right to autonomous decision making.

‘People who choose to withdraw from support are exercising their own rights’

When critically evaluating the assertive outreach element of supporting those with enduring mental health conditions, Graham (2006) makes the contentious statement that the assertive outreach approach taken by workers is ‘therapeutic stalking.’ He considers the possibility that people who choose to withdraw from support are exercising their own rights. Workers subsequently increase their efforts at contacting clients through letters, phone calls, unannounced home visits (and in our case persistent street outreach) – a response he deems as ‘hyperactive conduct.’ 

This is an interesting point to consider and one I can relate to as a worker.  A client with significant health needs refused to engage with the project for some time.  Rather than accept his decision, over a period of months I continued to try and engage with him through assertive outreach, and at times this felt uncomfortable and bordered on what I felt was ‘therapeutic stalking’ as Graham refers to it.  Of course, the decision to persevere in trying to engage a client is complex, as often the intentions are well placed and underpinned by key organisational duties and safeguarding responsibilities, which can in themselves obscure and even take over the needs of the client in such moments.

The Four Dilemmas

Claassen and Priebe (2007) also look specifically at the ethical dimension of assertive outreach in healthcare and recognise the difficulties in promoting independence with people who are reluctant to engage with support.  They identify four dilemmas:

• persistence versus coercion
• public protection versus risk aversion
• empowerment versus negligence
• support versus harassment 

It feels that often these elements come into play in my own practice and go some way to explaining the internal wrangling I face as a frontline worker working with people with complex needs, whose motivation and levels of engagement are prone to change, yet for whom the risks of coming to serious harm are extremely high.

A Trauma Informed Approach?

This alternative viewpoint feels important to recognise and discuss, particularly when considering a trauma-informed or person-centred approach to our work. It is about being able to offer support whilst respecting individuals’ rights to make their own decisions.  If their adverse childhood experiences mean that they have often felt ‘out of control’ or ‘disempowered’, then being able to make decisions around which services they chose to engage with or not could in itself be of significant therapeutic value to the individual.

This post has lightly touched on an alternative consideration regarding the assertive outreach model, and some of the ethical dilemmas that come with it.  I hope this piece provides an opportunity to discuss engagement within both our own service and the wider partnership, and I feel it is useful to keep the ethical dilemmas in mind in our approach to working with those who may find it ‘hard to engage’. 

References

Claassen, D. and Priebe, S., 2007. Ethical aspects of assertive outreach. Psychiatry, 6(2), pp.45-48.

Graham, J.H., 2006. Community Care or therapeutic stalking: two sides of the same coin?. Journal of psychosocial nursing and mental health services, 44(8), pp.41-47.

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Giles James is a Multiple and Complex Needs Worker with Fulfilling Lives South East Partnership. He is based in Eastbourne and is currently completing an MSc in Public Health.

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