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B R I T I S H J O U R N A L O F P S YC H I AT RY ( 2 0 0 5 ) , 1 8 7, 4 3 8 ^ 4 4 3

Processes of disengagement and engagement (f) absence of a primary diagnosis of


substance misuse and dependence;

in assertive outreach patients: qualitative study (g) not requiring an interpreter.


Assertive outreach team workers pro-
STEFAN PRIEBE, JAY WAT TS, MIKE CHASE and ALEKSANDRA MATANOV vided patients who fulfilled these selection
criteria with verbal and written information
about the study and asked them to take
part. Seventy-three participants who volun-
teered for the study formed the strategic
sampling pool. From this sample pool, 44
participants were contacted and inter-
viewed through liaison with their assertive
Background Assertive outreach has In England, assertive outreach teams have
outreach workers. Four patients were later
been established to care for‘difficultto been widely established to reach patients
excluded because it became clear in the
who, in mainstream services, are ‘difficult
engage’patients, yet little is known about interview that they did not fulfil the inclu-
to engage’ (Department of Health, 2000).
how patients experience their sion criteria. Purposive sampling was used
Research has so far focused on how service
to select patients for interviews. Emerging
disengagement with mainstream services configuration, for example a low staff–
themes were tested by interviewing coun-
and later engagement with outreach patient ratio, influences outcomes (Burns
terparts, e.g. patients of different gender,
teams. et al,
al, 1999; Priebe et al,
al, 2004); yet little is
age and ethnic background. Once the type
known about what staff should actually
of patient for the next interview was identi-
Aims To explore the views of do to engage patients and what psycho-
fied, the interviewee was randomly chosen
logical processes might cause previously
disengagement and engagement held by from the sub-sample of patients with the
disengaged patients to engage with assertive
patients of assertive outreach teams. desired characteristics, and the keyworker
outreach teams (Lang et al, al, 1999). This
was approached to initiate contact with
study therefore explored with qualitative
Method In-depth interviews were the patient. Patients were recruited until
methods the reasons why patients first
conducted with 40 purposefully selected saturation was reached.
disengaged with mainstream services and
patients and analysed using components of Of the 40 patients whose interviews
later engaged with assertive outreach. Parti-
were analysed, 11 were women and 29
both thematic analysis and grounded cular emphasis was put on the experience
men. The mean age was 40 years. Thirty-
theory. of patients from an African–Caribbean
two patients were single and 36 unem-
background, as this group has been shown
ployed. The ethnic background was
Results Patients reported a desire to to be most dissatisfied with services (Park-
African–Caribbean for 18 patients (7 first-
be independent, a poor therapeutic man et al,al, 1997) and overrepresented in
generation and 11 second-generation),
the case-loads of outreach teams (Sainsbury
relationship and a loss of control due to White UK for 16 patients, African for 4
Centre for Mental Health, 1998; Priebe et
medication effects as most important for patients and ‘other’ for 3 patients. Thirty-
al,
al, 2003).
three patients had been diagnosed as having
disengagement.Time and commitment of
schizophrenia or psychosis-related disorder
staff, social support and engagement METHOD and 7 as having psychotic symptoms as part
without a focus on medication, and a Sampling of a mood disorder. Only 2 participants
partnership model of the therapeutic had no experience of hospital, and 24
Patients were recruited from nine specia-
relationship were most relevant for reported experiences of sectioning.
lised assertive outreach teams across
engagement. London (Wright et al, al, 2003). Teams were
selected to cover inner-city and suburban Material
Conclusions The findings underline the areas, and both statutory and voluntary Patients were interviewed by a trained
importance of a comprehensive care services. Inclusion criteria for patients were: researcher who was not involved in treat-
model, committed staff with sufficient ment. The researcher explained the nature
(a) previous disengagement with secondary and purpose of the study and obtained
time, and a focus on relationship issues in mental health services; informed consent. Twenty-five participants
dealing with‘difficultto engage’patients. were interviewed in their own home and 15
(b) later engagement with an assertive
outreach team; in the base of their assertive outreach team.
Declaration of interest None. Participants were asked to recount their
(c) a diagnosis of functional psychosis experiences of using mental health services
according to ICD–10 (World Health from the time of their first contact. Special
Organization, 1992); attention was paid to episodes of disen-
gagement and engagement with services,
(d) the ability to give informed consent;
the circumstances surrounding them, and
(e) absence of a significant organic mental patients’ explanations as to why and how
disorder; they disengaged and engaged. Emerging

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A C H PAT I E N T S

themes were explored throughout the data Processes of disengagement ‘They saw that I was becoming ill and . . . it hap-
gathering process. These themes were speci- pened two or three times, my mum and dad
Desire to be an independent and able person could see it coming on but I couldn’t [because] I
fically addressed in further interviews, and
Twenty-six patients identified a difficulty was ill. I thought that I weren’t ill but I was’
re-analysed and further developed in an
in accepting mental illness and the role of (Int.10, man aged 47).
iterative process. The length of interviews
the patient as main themes in the break-
ranged between 25 min and 75 min. All
down of their relationship with mental Lack of active participation and poor
interviews were audiotaped and fully
health services. The patient role required a therapeutic relationships
transcribed for analysis.
shift in their perception of themselves as
Twenty-two patients specifically mentioned
independent individuals:
Analysis not being listened to by clinicians and a
‘It was a kind of state where you think you are
lack of active participation in treatment
We analysed the material using a method aware of things but you don’t know what you
are doing’ (Interview 6, man aged 51).
decisions as a reason for disengagement.
comprising components of both thematic
Patients felt alienated when clinicians failed
analysis (Boyatzis, 1998; Flick, 2002) Often, this led to a period of adjustment
to acknowledge their experience and their
and grounded theory (Glaser & Strauss, during which the patient tended to avoid
view of illness:
1967). The QSR*Nudist, 4 database mental health services and tried to carry
‘I felt like they never
neverlistened
listened to me and they were
software was used for managing and on with life as before in order to ‘prove just making choices for me and if they listened to
analysing data. Themes, categories and them wrong’. A patient who described me a bit more then I might have felt a bit more
memos were coded into a database, which himself as ‘having a good head on his like I was. I just felt that my life was out of control
was used for continuous comparisons and shoulders’ prior to illness said: and I didn’t have a say in what I was doing’
referencing across interviews. The first (Int.20, man aged 28).
‘I think that a major problem mentally ill people
25% of interviews were coded line by face is their having to accept their diagnosis. . . . If Communication with psychiatrists was seen
line. Once assumptions about themes to they tell you you have cancer and you have about as especially difficult and marred by power
be further explored were reached, longer 6 months to live, you feel much better than
thanififthey
they issues. Eleven patients mentioned not being
tell you you have a . . . mental illness’ (Int.9, man
passages were coded, unless there were listened to by their psychiatrist as an
aged 32).
statements of particular interest, when important reason for disengagement:
coding reverted to line by line. One A psychotic mental disorder can affect all ‘I just felt I was fobbed off . . . it was definitely a
important aspect of the analysis was aspects of a patient’s life: case with some psychiatrists of ‘‘Them and Us’’.
to identify which themes out of the range ‘the kind of identity of like who you are, like And you couldn’t talk on the level at all, so in the
reported by patients were actually linked your job and other things that define, kind of end you just didn’t say very much . . .I used to
disappear [because] you are just trying to get think who it benefits, and thought, not me’
to processes of disengagement and
better. . . you become your sickness’ (Int.34, (Int.23, woman aged 48).
engagement. For example, a negative man aged 33). It is also the manner in which mental health
experience in a hospital might have been
However, even when patients accept that staff behave towards patients:
significant, but not necessarily have influ-
they are ill, the desire to be ‘as normal as ‘It’s like just general gestures they give out with
enced the patient’s decision to disengage
possible’ may persist and is often the reason their bodylanguage and their posture, itjust sug-
or engage with services.
why some people disengaged after several gested that they didn’t want to hear what you
The interviewer carried out analyses had to say. . . start answering the question and
years of regular use of medication in a bid
of all interviews. Two researchers of you’d be in the middle of what you were saying
to regain their old identity:
second-generation African–Caribbean eth- and they’d catch on to one particular word out
nic origin helped to analyse interviews ‘probably that 6 months where I stopped the of what you were saying and start talking about
injection is more likely me trying to get out of something they want to talk about, which was
with African–Caribbean patients. Two
the system and getting my life back to nor- very insulting’ (Int.36, man aged 22).
other researchers separately analysed the mal. . . it’s been 8 years on the injection, seeing
interviews to check the validity of the ana- Nine patients mentioned patronising by
doctors’ (Int.20, man aged 28).
lysis – one of them re-analysed the first mental health workers:
This sometimes happens after a switch of
20% of interviews in the initial phase of ‘In other words they are trying to take over your
medication, which may increase a sense of life, treating you like a kid and some of them are
the study, and the second researcher
well-being and a belief in one’s ability to younger than you’ (Int.16, man aged 35).
reviewed all interviews at the end of
cope without medication. Patients also have The issues of poor relationships and the
the analysis. Findings and emerging
to deal with a changed perception by other passive role of patients were amplified
themes were discussed – in both one-to-
people. Relationships with partners, family further when it came to the experience of
one and group meetings – by an interdisci-
and friends are altered or break down. The hospitalisation, which 11 patients reported
plinary team comprising researchers with
stigma attached to mental illness and the as a reason for disengagement. Fourteen
psychiatric, psychological and nursing
complexity of changes patients face can patients described the first admission as a
backgrounds and both with and without
lead to a disengagement from services: negative experience which affected their
clinical experience.
‘Sometimes you are scared thatthey will find out view of mental health services for a long
you have a mentalhealth
mental health problem and they won’t
time:
RESULTS want to know you anymore. I mean schizo-
‘So our relationship started out really badly, just
phrenia is quite a frightening world, because the
me and psychiatric services, it was just so violent
Three main themes emerged from the media made it that way’ (Int.4, woman aged 48).
so . . . it’s taken me a long time to develop any
analysis of patients’ accounts of disengage- However, relatives can sometimes facilitate sort of trust between me and psychiatric
ment and engagement (Table 1). acceptance of illness and treatment: services’ (Int.28, man aged 45).

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PRIEBE E T AL

T
Table
able 1 Frequencies of themes (including combinations) reported by participants as reasons for disengagement with mainstream services and engagement with
(n¼40)
assertive outreach teams (n 40)

Disengagement Engagement

Theme Patients Theme Patients


n n

D1 Desire to be an autonomous and able person 26 E1 Time and commitment 22


Single theme 12 Single theme 7
With D2 7 With E2 12
With D3 2 With E3 0
With D2 and D3 5 With E2 and E3 3
D2 Lack of active participation and poor therapeutic relationships 22 E2 Social support and engagement without a focus on medication 31
Single theme 6 Single theme 9
With D1 7 With E1 12
With D3 4 With E3 7
With D1 and D3 5 With E1 and E3 3
D3 Loss of control due to medication and its effects 15 E3 Partnership model of therapeutic relationship 11
Single theme 4 Single theme 1
With D1 2 With E1 0
With D2 4 With E2 7
With D1 and D2 5 With E1 and E2 3

It also can be an isolating experience: ‘I stopped hearing voices but the side-effects show more commitment to the care of
were so bad I’d prefer to hear voices’ (Int.39, patients. They were described as easy to
‘By not being in an environment I knew, under-
man aged 43). contact and able to visit patients at home:
stood, I had never been in hospital before, I felt
completely alienated from everyone, from Patients found that their experience of ‘Well, the outreachteam are better because they
society’ (Int.8, woman aged 23). adverse effects was not acknowledged have more people around.I mean if I need some-
Thirty patients reported their dislike of the enough by clinicians. Losing control over thing, I just pick up the phone and they come
some important area of life owing to this down. I don’t have to make an appointment or
rigid rules, regulations and restrictions on
neglect led to disengagement: anything which is good’ (Int.1, man aged 46).
freedom they face in hospital, with 14 of
them using the word ‘prison’. Ten patients ‘I can’t do things that I want to do. I want to come Staff’s willingness to listen to problems and
reported incidences of perceived injustice off this depot . . . it makes me put on weight, it help was appreciated:
stiffens the joints, it’s affecting my fertility, my eja- ‘Well, the mainthingis theylisten and you cantalk
and even abuse, including rape and beat-
culation system.I want
wantto to have children but I can’t to them when you need someone to talk to’
ings, and 25 reported they were subjected have children if I am on depot. So I think it has (Int.30, woman aged 46).
to enforced medication: taken over my life sort of thing’ (Int.29, man aged
31).
Time and commitment invested in care
‘I did not like it one bit, they treat you bad and
gave assertive outreach team staff the
they hold you down on the floor and they inject Patients in education reported a wish to
you.
you . . . they lock you in your room, you can’t go potential to build mutually trusting rela-
discontinue medication because of adverse
outside, it was horrible’ (Int.33, woman aged tionships, and the consistency over long
effects on concentration:
27). periods of time appeared particularly
‘When the exams were fast approaching, when I
However, bad hospital experiences on their important:
have to study. . . you feel drowsy and everything
own did not necessarily lead to disengage- like that’ (Int.26, man aged 37). ‘I think, because what the team and I have been
through, they have seen me in a good position
ment. Fear of hospitals motivated some Although interrelated with the themes of and the team have seen me in bad conditions, so
patients to cooperate with services and poor therapeutic relationships and the they have an idea, a much better idea and under-
comply with medication to avoid further desire to be an independent person, com- standing of my moods and how to reactto things,
admissions. plaints about the effects of medication and so we have a good working relationship’ (Int.9,
resulting loss of control were often focused man aged 32).
Loss of control due to medication on a single and potentially negotiable issue. The time and commitment of team staff are
and its effects When these problems were left unattended, particularly valued in comparison with
The side-effects of medication and asso- patients felt alienated when they were previous experiences:
ciated loss of control were discussed by 28 otherwise willing to engage. ‘I’ve done a lot of intense work with one of my
social workers before I was in the assertive out-
patients, and 15 said or inferred that this
Processes of engagement reach team, but since I have been in the team
was a main reason for them to disengage.
there is always someone to talk to, if you want to
Sometimes, unpleasant effects were so over- Time and commitment
talk to someone. Even if one of the people is off,
whelming that they defeated the intended Twenty-two patients reported that assertive there is always someone else there to talk to’
therapeutic purpose: outreach workers invest more time and (Int.2, man aged 28).

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A C H PAT I E N T S

Social support and engagement without a workers to negotiate reducing the contact break in with police and they arrest me and take
focus on medication if requested. me in. But now I openly talk to them’ (Int.25,
man aged 31).
The social and practical nature of the asser-
tive outreach service was perceived as The partnership model for therapeutic
a positive distinguishing feature by 31 relationships Findings in African ^ Caribbean
patients, and 11 reported receiving social A need to be treated seriously and afforded
patients
support in a form of companionship, joined an active role in making decisions about African–Caribbean patients did not men-
outings and activities. Team workers were their treatment was emphasised by many tion qualitatively different views to other
frequently described as being interested participants and explicitly outlined as the patients. If differences appeared, it was
and friendly: reason for engagement by 11 patients. rather the degree and frequency of some
‘They talk about day-to-day stuff with me you However, examples of positive experiences experiences that varied between ethnic
know. It’s interesting really, they take an interest as reasons for engagement were harder to groups. Some African–Caribbean patients
in my life’ (Int.1, man aged 46). (4 out of 18) particularly emphasised the
come by. Nine patients acknowledged their
They were willing to see patients as persons relationship with their psychiatrist as a effects of stigma and peer-group pressure
not just as ‘illness on legs’: facilitating factor in their engagement with for disengagement. Twelve patients of this
‘I talk to him about films and theatre and books services. They reported that assertive group expressed views suggesting they had
and arts, and which balances it out because I outreach team psychiatrists, like other a compliant rather than an engaged
don’t really want someone coming to my flat members of the team, listened to them relationship with the psychiatrist (com-
making me feel mad’ (Int.19, woman aged 39). pared with 6 out of 15 White UK patients):
and saw them as people, not just sets of
Patients saw an option to engage with ser- case notes: ‘I’ve been taking my medication just for the fact
vices in a way that was not entirely focused ‘He wants to know about everyday things, not that I don’t want to go back to hospital. . . but, if
on medication: just how are your pills. . . . It is broader. That I had a choice of taking the depot or not taking
makes up you know, it’s a better relationship and it,I wouldn’t take it’ (Int.29, man aged 31).
‘You
‘You don’t talk to them purely about how I have
taken my tablets and this. I mean it is broader you feel oh, you know I wouldn’t mind sharing
than that’ (Int.23, woman aged 48). what I do. . . .But
. But when it was very patronising I
Contradictory evidence
just put shutters up’ (Int.4, woman aged 48).
Patients stressed that mental illness often The analysis did not reveal substantial
led to a breakdown of close relationships Patients felt that their experience of illness
evidence that contradicted the reported
and was a very isolating experience. The was taken on board and that they were
themes. Yet, as already mentioned, negative
attempts of the assertive outreach team to acknowledged as active participants in
hospital experience can be a reason for en-
increase their social activities by taking therapeutic decision-making:
gagement when compliance with treatment
them to restaurants and organising leisure ‘When I suggested that I wanted to stop medi-
cation for a while, he actually let me and he did
is motivated by the desire to avoid further
activities and outings was frequently hospitalisation. Also, the experience of con-
actually come across as if he were concerned
discussed: about me hallucinating again and he wasn’t too sequences of disengagement might have
‘Sometimes we might just go out and have a cup pushy about things . . . he warned me I may contributed to a willingness to engage:
of tea or coffee at the cafe ¤ , we might go swim-
cafe, become delusional again, but he did not come ‘Y
‘Yeah,
eah, I have stopped taking it . . . and then I
ming, we might go on an outing or whatever, across as though he was trying to prevent me become ill so now I know I have got to stay on it
that’s what I like, that’s what’s good about them from doing it . . . he wanted me to be more completely’ (Int.10, man aged 47).
they are quite, like sociable’ (Int.7, man aged18). involved in my own health’ (Int.8, woman aged
Help with practical day-to-day issues was 23).
also appreciated and mentioned by 20 The gradual building of relationships DISCUSSION
patients. Help with financial matters such enables assertive outreach staff to win the Despite a high individual variability in the
as dealing with the social services, housing trust of people and communicate effectively circumstances and experiences involved in
department and banks was most popular. about treatment: engagement and disengagement with ser-
Assertive outreach teams were also credited ‘I trust him to do what’s best for me even when I vices, the study identified a small number
with bringing more structure to the lives don’t know what’s best for me. . . . It took time,
of fundamental processes. The identified
of participants by organising educational initially I was very suspicious of him when I first
themes appear plausible, clear and partly
got put in contact with him. I was mostly in
opportunities and paid or voluntary linked.
crises. . . . I did think initially he was like another
employment, and by helping with organis- CPN [community psychiatric nurse] that I had,
ing housing and necessary repairs, shopping that he’d bin me for the smallest reason, butthat’s Methodological issues
and escorting participants to appointments: not been the case actually’ (Int.19, woman aged
39). The study had some methodological limita-
‘You’ve
‘You’ve got to realise that apart from being sick,
you’ve got your financial life as well which is dif- tions. Most importantly, it focused on
This sort of trust enabled some patients to
ferent from your medication, you know, because patients who had originally disengaged
stop hiding symptoms for fear of being sent
social security tend to mess you around. You You from services and later engaged with asser-
to hospital and to assume a more active role
need someone to stand up for you, give you your tive outreach teams. Thus, patients who
giro’ (Int.39, man aged 43). in managing their health:
even the assertive outreach teams failed to
‘I always tell them, when I have a difficulty in
Two patients complained about assertive engage were not included. Such patients
sleeping now I talk to them, I tell them my prob-
outreach teams encouraging dependency lems. Before I used to deny that, . . .I’m not ill, I might have different reasons for disenga-
by offering this type of support, but don’t want to go to hospital, I don’t want to know ging from services, and obviously were
acknowledged the willingness of the team you, I didn’t want to open my door, you’ll have to not motivated by the processes described

4 41
PRIEBE E T AL

here leading to engagement. However, even


for patients who do accept assertive out-
CLINICAL IMPLICATIONS
reach team care, the sample was probably
not representative. Only patients who were & A comprehensive care model with social and practical support, an avoidance of an
prepared to participate in research and con-
exclusive focus on medication, and committed staff with sufficient time, help to
duct an interview with a researcher were
engage ‘difficult to engage’ patients.
included. Moreover, the study was con-
ducted in London, and assertive outreach & Relationship issues are central to disengagement and engagement, with patients
team patients in other areas and other ser- preferring a partnership model and an involvement in clinical decision-making.
vices may have had different experiences.
The study placed users’ views and testimo- & African^Caribbean patients do not have qualitatively distinct processes of
nies at the centre of the methodological disengagement and engagement.
approach. In the vast majority of cases,
LIMITATIONS
the researchers believed the participants’
accounts to be accurate and pertinent. Clin- & Patients who engaged with neither mainstream services nor assertive outreach
icians may have expressed different views
teams were not studied.
and stated good reasons for their behaviour
that was criticised by the patients, but their & Only patients who were able and willing to participate in research were
views were not assessed in this study. interviewed, so that the sample was not representative of all assertive outreach team
patients.
Disengagement & The study was conducted in assertive outreach teams in London and results
The key themes that emerged in our study cannot necessarily be generalised to other areas and services.
are often interrelated and coexistent in the
experiences of individual participants and,
to some extent, reasons for disengagement
and engagement are two sides of the same STEFAN PRIEBE, FRCPsych, JAY WATTS, MA, MIKE CHASE, BSc, ALEKSANDRA MATANOV, BSc, Unit for
Social and Community Psychiatry, Queen Mary, University of London, London, UK
coin. Disengagement was often a result of
the struggle against loss of autonomy and Correspondence: Professor Stefan Priebe,Unit for Social and Community Psychiatry, Newham Centre
identity as a part of the experience of men- S.Priebe @qmul.ac.uk
for Mental Health, London E13 8SP,UK. E-mail: S.Priebe@
tal illness. Not all clients with a history of
disengagement were people who resented (First received 29 July 2004, final revision 14 January 2005, accepted 28 January 2005)
mental health services. In fact, when asked
to describe the characteristics that made a with medication are disregarded despite welcome antidote against patients being
bad keyworker, 9 out of 20 participants profound effects on important areas of a reduced to their symptoms, and efforts to
answered that they had never had a bad patient’s life (Sainsbury Centre for Mental increase social activities and organise
keyworker. In line with research related to Health, 1998; Gerber & Prince, 1999). educational and work opportunities were
chronic physical illness (Charmaz, 1997), important. Practical help with housing and
this finding would indicate that identity welfare was also seen as an aspect of recog-
issues are vital for coming to terms with Engagement
nition of the reality of participants’ lives
the impact of mental illness (Watts & The results indicate that patients whose (Hannigan et al, al, 1997; Billings et al, al,
Priebe, 2002; Tait et al,al, 2003). Moreover, relationship with mental health services 2003). The comprehensive care approach
issues around psychological adjustment has broken down can become more of assertive outreach should help to avoid
may still be dormant in some patients with engaged if they feel listened to and have a a sense of being confined to the role of men-
long-established illness and not just occur genuine say in decisions about their care. tal patient. The practical support enabled
in the newly diagnosed (Spencer et al, al, The current approach of assertive outreach patients to regain control over their lives.
2001). Some participants had been in a with small case-loads seems useful as it The sense of autonomy, the loss of which
compliant relationship with services for enables keyworkers to put in time and com- has proved so important in disengagement,
many years before they made their ‘bolt mitment, which is appreciated by patients is further strengthened if people are given
for freedom’. (Sainsbury Centre for Mental Health, the chance to be actively involved in making
Autonomy was also compromised by 1998). It enables staff to form trusting rela- decisions about their treatment and the best
the powerlessness patients felt in their tionships with patients and familiarise them- ‘anticipatory action’ to avoid relapse (Wea-
relationship with services in general and selves with the particular circumstances of ver et al,
al, 2003). Building the necessary
psychiatrists in particular. The study their lives. This facilitates the making of relationship often requires time and reliable
demonstrated that feelings of not being informed decisions about treatment options. commitment.
listened to can often lead to a fundamental For many participants, moving away from
breakdown in the therapeutic relationship an exclusive focus on medication was a cru-
and consequently to disengagement. This is cial element in improving their therapeutic Potential clinical dilemma
especially true when a patient’s complaints relationship. The interest of team staff in To feel supported by staff through ‘ups and
about undesirable side-effects associated the patients’ lives was regarded as a downs’ helps to establish a ‘working

442
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A C H PAT I E N T S

relationship’, and the psychiatrist who was the views of the clinicians involved and Lang, M. A., Davidson, L., Bailey, P., et al (1999)
Clinicians’and clients’ perspectives on the impact of
prepared to stop medication in line with the relate them to those of the patients.
assertive community treatment. Psychiatric Services,
Services, 30,
30,
wishes of the patient was perceived as gen- 1331^1340.
uinely concerned and caring – but might ACKNOWLEDGEMENTS Parkman, S., Davies, S., Leese, M., et al (1997) Ethnic
have agreed to a treatment that differences in satisfaction with mental health services
was incompatible with evidence-based The authors thank Rose McCabe, PhD, Gemma among representative people with psychosis in South
medicine. This example highlights a poten- Jones, BSc, Cecilia Faduola, BSc, and Louise-Marie London: PriSM study 4. British Journal of Psychiatry,
Psychiatry, 171,
171,
Harding, BSc, for their help with data analysis. Most 260^264.
tial dilemma around current policies on
of all we thank all the patients who assisted with the
‘difficult to engage’ patients who might Priebe, S., Fakhoury,
Fakhoury,W.,Watts,
W.,Watts, J., et al (2003)
study. Assertive outreach teams in London: patient
pose a risk to themselves or others (Watts
characteristics and outcomes: Pan-London Assertive
& Priebe, 2002). A strong focus on risk Outreach Study, Part 3. British Journal of Psychiatry,
Psychiatry, 183,
183,
containment and an insistence on interven- REFERENCES 148^154.
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model of care that – over time – helps and perceptions. Pan-London Assertive Outreach Study, with outcomes of patients in assertive outreach. British
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