June Andrews Scottish Board, Royal College of Nursing, 42 South Oswald Road, Edinburgh EH9 ZHH, Scotland

Development of a drop-in service in a small community team: continuing care to clients with long-term mental health problems

Last year the Clunis Report (Ritchi et al. 1994) was published along with much discussion of the setting up of supervision registers. In this debate there is an assumption that in-patient treatment, under a sec- tion of the Mental Health Act (HMSO, 1983) can be extended to provide some form of care in the community. The practical realities of this task suggest that care in a community setting is a collab- orative enterprise, requiring equality of power in relationships and respect for individual autonomy.

I work in a small team with professionals from a variety of backgrounds. We provide a community- based service, employing a psycho-social approach to care for clients who have long-term mental health problems and complex needs. We use the strengths model of case management, pioneered by Professor Charles Rapp of the University of Kansas, USA (Kisthardt & Rapp 1989). Research and Development in Psychiatry, now relaunched as the Sainsbury Centre for Mental Health, researched our development and provide objective information on our work (Ford et al. 1933).

One practical difficulty I experienced was in attempting to find the clients who had been referred to me. They could not be found at their home addresses and would not answer correspondence. I met clients by talking to people at a charity-run drop-in, or in the local cafe. I met one woman at the bus stop where a fellow client introduced us. I became aware that existing psychiatric services had not offered much to these people that had meaning or value for them. Being removed to hospital under a section of the Mental Health Act (HMSO 1983) was not viewed as a desirable service. My clients could not be viewed as customers of a health care service in that context.

The process of helping clients develop ownership of our service was fraught with difficulty. In order

to develop mutual trust between ourselves and the clients, as a team we planned to allow more open access to our offices. So, as clients got to know me and invited me to join them for a cup of tea and a chat, I returned the compliment and invited them to our office. This arrangement created difficulties, with time and resource management, and clerical staff were bemused as to why these clients were coming, and what to do with them when I was out.

In order to address this problem, clients were asked to come to the office during given periods when a worker would be available. For a long time it appeared that clients felt that it was necessary for them to have a problem in order to justify their visit and, consequently, they would address themselves only to workers. They also tested our boundaries with disturbed behaviour, abusive language, fre- quent requests for money, wandering in and out of offices disrupting work. Workers managed this challenge by leading discussion, and moved clients towards accepting principles similar to those they might expect in a therapeutic community. Demo- cratic decision-making and group responsibility were facilitated.

Once established, the service became a time- efficient means of meeting with, and assessing, clients. Mixing with service users in a partly social setting, and gaining a broader understanding of them as people, enabled workers to think beyond their psychiatric presentation and evaluate more accurately clients’ overall ability to manage their own lives in the community.

We worked to provide support to clients in ways that they found beneficial. This meant spending our time in pursuits such as arranging benefits, helping with weekly shopping, or even cleaning the toilet if it helped the client to cope better on that day. We also expressed interest in social activities, along with domestic and housing arrangements. Mean- while mental health and safety issues were moni- tored discretely, without obvious intrusion or formal questioning. Breakdowns in clients’ mental

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health could be avoided or compensated for so that in-patient care was reduced. Support networks remained more intact than through previous periods of disruption.

The Sainsbury Centre for Mental Health recorded a significant reduction in clients’ symp- toms (Ford et al. 1993). Improved use of medica- tion may have been the reason for this reduction, as clients were encouraged to consider the benefits of medication and to attend out-patient appointments. Clients were not required to demonstrate their dis- tress or illness in order to gain access to the service but, instead, were encouraged to feel welcome. Our drop-in centre aims to provide an environment in which workers and clients can enjoy each others company while doing practical things which matter to clients.

Most clients are familiar with the control of vio- lence in hospital, described to me graphically as

a bunch of nurses jumping on you and injecting you with something which slows you down.

This form of control would certainly not be ethical in the community, or elsewhere, and is not even practical with our staffing levels. We developed a crisis procedure, and a buzzer alarm system was installed, for police assistance in an emergency. Clients know that we expect them to be responsible for controlling their behaviour and our buzzer has been used only once.

It is often difficult to persuade professional people to change from a long-established way of working, and I recall general uncertainty over the newness and unpredictability of attempting to provide an unproven service to people who had so often resisted the interventions of fellow service providers. We were opening our door to people who were accustomed to being kept at arms’ length. Slowly, I became more relaxed in this new service and noticed that clients would continue to &scuss issues even if I left the room to attend to other business. It was clear to me that significant progress had been made when, one afternoon, fellow workers called my attention to noise coming from the drop-in room. I thought it would be an

argument between clients but discovered, in fact, that the 10 clients present were singing at the tops of their voices and stamping their feet. As workrrs, we are taught to manage disturbed clients who can be depressed or unmotivated, but it has become apparent to me that we also need help in working with the strengths and joys of a group of people who can hold a positive attitude and outlook in the face of very difficult lives.

Our agency now benefits from working with a more organized and empowered client group who collaborate in our service provision. Having acted as a keyworker under Section 117 of the Mental Health Act (HMSO 1983) for many clients I may, soon, be a keyworker for clients whose names appear on a supervision register. I believe that lust putting names on lists will not guarantee access to appropriate treatment. It is only the ability of workers to tackle practical problems, such as those I have described above, that will prevent the cre- ation of more sad, and unfortunate stories, for the media to bring before the public.

References Department of Health (1994) The Report of the Inquiry

into the Care and Treatment of Christopher Cluvis. London, North East Thames Regional Health Authority, South East Thames Regional Health Authority and HMSO.

Department of Health (1983) Mental Health Act 1983. London, HMSO.

Kisthardt W., Rapp C. (1989) Bridging the Gap benven Principles and Practice. Implementing a Strengths Perspective in Case Management. Shifting Paradigms or the Creation of Straw People? University of Kansis. School of Social Welfare, Lawrence. U.S.A. Research paper partially supported by the National Institute of Mental Health Grant MH18807-03.

Ford R., Cooke A. & Sutton F. (1993) The Efficac) of Case Management in Hastings. The Sainsbury Centre for Mental Health. Journal of Advanced Nurszg 19,

SIMON WHARWE Case Manager, Bolton Tomson House,

49 Cambridge Gardens, Hustings, East Sussex TN34 1 EN, England

1096-1104.

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