Purpose

Explain the dilemma of an outreach service, when others want the child taken into hospital or social care - suggest ways to manage this

Theory

It is explicit in this model that referral to the Team is assumed to have arisen at the point at which the existing network is no longer able to provide containment for the symptoms. This means that it is not unusual for families and local networks to feel as though they have held on for as long a possible, and there will often be an assumption that the only possible next step is admission to hospital.

When an outreach assessment and treatment package is offered this can lead to significant divergence of opinion between the Team and the family and network as to what should happen next.

Faced with high levels of anxiety in a patient, the family and the network, who may have all reached the limits of their endurance, the outreach team will often be confronted with strong opinions about how it should act. The strength of these opinions (or projections) can have the effect of narrowing the range of responses that can be thought about, and this is to the detriment of patient care.

It is important for the team to maintain an open stance to the dimension of "actions and intentions", acknowledging the wide spectrum of options that are available:

At one end:

Admit to Hospital and hand over a problem that can no longer be borne safely, accepting the risks of stigmatisation & negative peer group pressure that may result from this manoeuvre

At the other end:

Offer intensive Outreach support in the community, working to strengthen the coping capacities of existing networks, and to avoid the risks of stigmatisation and negative peer group pressure.

If these opposite outcomes are represented as two ends of a scale (like the x-axis in a graph) they can be set against a different axis (like the y-axis in a graph), this time in the realm of the moral/ethical spectrum:

At one end:

Caring, responsible (this can easily become 'stuck' to the 'Admission' axis.)

At the other end:

Callous, reckless (this easily gets 'stuck' to the 'Outreach' axis.)

In the heat of the assessment there is a very powerful tendency to collapse these two sets of dimensions onto each other, so that 'Admission' becomes conflated with 'Caring', and 'Community treatment' is conflated with 'Callous and reckless disregard' (or vice versa.) If this were a graph, it would be as though the two axes ('x' and 'y') had ceased to sit at right angles to each other, but had 'scissored' down onto each other, to form just a single scale with these (artificial) conflations at each end. If this is allowed to occur without explicit acknowledgement of the fact that all parties seek a caring and responsible resolution, then confrontation and escalation are likely to follow.

The KeyWorker's job, therefore is to keep these axes prised apart, allowing for the possibility that either outcome may represent the caring and responsible manoeuvre, and using her own access to SupervisoryStructures to help her in the task of KeepingYourBearings and arriving at the best evidence-based conclusion for the particular case, following the Multi-Domain Assessment.