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Welcome to the Oxford Psychology Podcast series brought to you today by Daniel Mawn, I'm an advance trainee in psychiatry here, the Oxford Dictionary.

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Today, I've got David Thurston with me. Thank you for coming, David.

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David is a consultant in general psychiatry and he heads up the assertive outreach team here in Oxford.

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David, maybe we could begin by talking a bit about how an assertive outreach team differs from a general community mental health team.

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Thank you. The fundamental difference is the way of working and the sense of outreach team works as a team and rather than as case management.

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For instance, in the same H.T., a care coordinator will have that list of patients and basically nobody else in that team will know these patients.

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On the other hand, in the 30 year average team, given that there is a much less caseload,

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everybody in the team will have met and will be able to give me a picture of every patient in the team.

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So the more we work more of the team than a community mental health team in that we meet every day,

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we used to meet twice a day as a planning meeting in the morning and a feedback meeting in the evening.

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But we move to just having a feedback and planning meeting in the evening.

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So we make every day and every patient, every patient is briefly mentioned during that feedback mission meeting.

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And anybody who is of concern, we will have a longer discussion about it.

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So it really is a team working in the extreme.

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Everyone knows about every patient.

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There's a meeting every day and maybe rich discussions of how to bounce back management from the new members of the team.

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What's the reason for that? That team working? Because this sort of outreach managed quite a different type of patient.

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They? Yes, I think so. The I came from the sort of the way people disengaged from normal mental health services

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and why they disengaged and what it was we could do to try and engage them again.

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And it in Australia and America and the forerunners have developed this team approach.

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And we are a tertiary service.

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We only have referrals from community mental health teams of people who are difficult to engage, who go in and out of hospital.

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The old revolving door people, often the people have been admitted many times under the Mental Health Act,

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then disengaged from services and stopped their medication. There are complex social problems.

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More often than not, they have what is known as dual diagnosis. That is, they probably use substances in a fairly indiscriminate way.

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The housing is often problematic and they have difficulty in accessing benefits if anything problems.

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So the whole nature of research, which was to do everything in-house so that you might engage with somebody better by helping them

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with their benefits than banging on about their medication or whatever it was or their symptoms.

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And so we have a variety of what we used to be able to have a variety of ways of doing this.

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We might put some of these blinds up in their flat or or something very practical,

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go for a walk or go downtown or do something that is just different from their usual engagement.

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So when you talk about these patients, it seems to me that there the people with high disability and struggle to maybe maintain independent lives.

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And for that reason, the care delivered by the assertive outreach team is is multifaceted.

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You don't just think in one dimension application, you actually think of every aspect of their lives.

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And most important, from my point of view and the philosophy that we've adopted, we think, who is this person?

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What is it they want out of their life and what is there in this world?

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That recovery is used widely now, and recovery is not about me thinking you've recovered.

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It's about the person reaching a level that they feel that they can manage their lives in a way that they want to.

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And so the whole whole philosophy is trying to help people find where they want to be in life and where they want to go.

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So even though we're aren't we we we manage a high risk population, we're sort of in between adult mental health care and forensics.

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So we have a number of people who buy into society and sort of criminal justice way and quite high.

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Obviously, people with serious injury, mental illness have higher risk than other people.

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So we work in a sort of high risk way with people.

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But essentially what we're trying to engage with them is trust that there is something about what we do with them that is different from what the.

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Done to them before I emphasise the word done.

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We don't want to do things to people, even though, yes, we do detain people and we do keep people on long term.

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Section 17, extended Section 17 leave.

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I'm not a big fan of years, but that's a different issue on a community treatment orders mandated treatment in the community.

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My my issue with that is that they're not very honest unless people are still coerced into having treatment.

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So let's be honest about it. I've never had any problems in managing people this way.

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And in fact, over the years, we have less people on an extended section, certainly than we used to.

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Whereas since the community treatment orders have come in, that's been a great increase in the number of people who are coerced into treatment.

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Yes, in the recent evidence isn't in favour of community treatment orders.

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And a randomised controlled trial by Tom Burns did not come to trial.

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Yes. What I'd like to talk to you about it is, is actually your perspective on mental health care.

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Because what today's mental health care?

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Because you've been working in Oxford as a as a psychiatrist for many years.

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I don't know how many years on and off. I came to Oxford in the 90s for trying this in psychiatry.

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And then I was in general practise for quite a long time, but still have the high it was in the days before community care.

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So I had to hide. As I was known, I had a high mental health caseload and in Section 17, Section 12 work.

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And so I was set up a day, a day service for people with serious mental illness when I was a GP.

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So I sort of been involved in in mental health care in Oxford over that long time.

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So when I first came to Oxford, I think a little more hospital had about 700, 800,

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900 patients from the one field hospital here that I only got three wards has had 250 patients.

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And it was just a different world and completely different.

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But I think there's been more change since 2000 or thereabouts when I sort of came back in the last 10 years or for 15, 14, 15 years.

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And they were in the 20 years before that.

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I mean, the whole approach to how we see people with mental health problems, it's more of a process now.

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It's more of a sort of seeing somebody is a risk. And I find that quite difficult.

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Seeing somebody is a risk. I wouldn't like to be considered to be a risk if I was a patient.

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And this emphasis on process and seems to me to be somewhat to the detriment of all of us rather than a lot of things.

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People don't think that mental health care please don't get me wrong. I think there's some very, very good mental health care.

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But it's maybe the sort of the society's change.

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Maybe that's what it is.

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And that we the referral rates have gone up a great deal into psychiatric care and patients that in years ago GPS would have managed.

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But they seem to have the time building or whatever it is, I don't know.

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But there's lots of changes there really from for maybe societal attitudes to professional practise and and

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to to maybe the asylum era coming to an end and community care developing that you've touched on there.

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But I guess the question I'm interested in specifically looking at your work in assertive outreach is how

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do you think the care has been has changed with all those developments or changes that you've mentioned?

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How do you think that has changed for those with severe and enduring mental illness,

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those patients you've mentioned with disability, with with comorbid problems?

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I think that's a very difficult question, because on the one hand,

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we don't want to go to the world of paternalism and patronage and locking people up in silence.

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But there was a sense, certainly for some people that they belong somewhere in the world and that that in that sense they were more felt more secure,

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whereas asking people to go and share houses with other people with their mental health problems in the middle of nowhere,

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united nice estate seems to me asking a lot of them that we you know,

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we will remember when we were students or that we gunshots flatwoods somebody and the

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difficulties that arise just in us sharing flats and getting on and dealing with people.

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But for people with serious mental health, they do have you know, we talk about personality, all that sort of personality disorder and all that stuff.

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But everybody who has serious mental illness has that effect on their personality and.

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The way they relate to themselves and the world, so we ask a lot of them and then they services or whatever we want to call them,

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community resource is more sort of targeted, that everything has to be measured.

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Somebody can't just go and be and chat and be and have a cup of tea.

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They have to go to a group or they have all this has to be measured in terms and the non-statutory

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services over the centuries it's called I linked into all this tendering and targets.

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And so that I think changes the whole sort of emphasis on how we how we help people to find themselves in the world.

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Certainly from a particular service. We worked without any psychology input for about six months as a part time psychologist.

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We have had no psychology input at all into people with serious mental illness.

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It just seems I've tried, tried, I've tried to try, but there is a big gap.

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So somebody with an anxiety disorder has no chance of getting psychological therapy them than if you've got serious mental illness.

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That's not to say we can't do it. That's not to say we haven't developed people who who in our team who have CBT cognitive

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behavioural therapy skills or that we have counselling skills and all those sort of things,

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and we try to offer that as well. And from the end of this week, the assertive outreach team is no longer going to be alone in Oxford.

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And you might think I'm sad about that. But yes, I am in terms of it was something we built up and I think we've delivered a very good service.

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But I think we're going to a system that is more accessible to people, more flexible.

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So we have people on the assertive outreach caseload who don't need us.

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They could be managed in the more traditional way. But to transfer somebody on and we don't we don't want to we just, you know,

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got them better in inverted commas and said we don't want to pass them on.

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But if we had a bigger system where people were able to, we could meet people's needs more.

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So somebody came into the service. They might need three contacts a week.

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Well, let's give them three contacts then. In six weeks, they need one.

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So let's do that in a much more flexible way. Let's respond to patients needs rather than here's our system.

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Where can we fit you in? So I'm quite excited by the changes, even though I'm losing something.

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And I'm so within these larger teams, we can develop more specialist skills that,

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as I mentioned, cognitive behavioural therapy for people with psychosis.

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We can develop motivational interviewing with people who who have substance misuse problems and and other problems.

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And we can develop each individual in the teams skills that they have.

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So that potentially is coming out. They're not just fixed into whatever care coordination.

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Well, it is I'm not very keen on this generic mental health professional working.

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I, I would love occupational therapists to do to do what they were trained to do.

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I would love social workers to be more involved in in the sort of wider societal

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aspects of what we use rather than being fixed into this role that I have a moment.

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So I think it's exciting and I think it's better for everybody. But obviously the transition is extremely difficult.

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OK, thank you, David.

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Well, it seems that when you when you're talking about services and how they've changed, it seems that those things have become more formalised.

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There's been less. And in that you're concerned that some of the care or the the ability for service to really meet the patient's needs is lost,

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potential potentially lost if we become too focussed on on process and systems.

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And actually the focus needs to be on the patient and meeting the needs of the patient and that actually

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there needs to be a certain degree of informality in that care provision because because of that very.

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And and with their carers and has anybody else involved in them.

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And why sadly, why has the carers why is the carers movement there?

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Because we didn't talk to parents and they're about for some reasons that I find, except I just don't understand it.

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Why are the things like think family come in,

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which is a sort of service of patients or surely that's a role for social workers within our team is to and for all of us to think,

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oh, we just sort of blinded by just the sort of biomedical model that here's somebody with depression, let's give them answers to questions.

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Here's somebody with bipolar. Let's put them to the bipolar treatment.

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Here's somebody with a psychotic schizophrenic illness. Let's give them the list.

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Everybody is the same as us. Everybody has the same feelings and the same emotions that we do is sitting here and let us

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recognise that they're sort of blind people out of that because he's got schizophrenia.

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So. And that's because of this and that. And it's not because they're human beings.

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And we have to try and find that way of being and be a bit more informal about it and maybe spend a bit more time listening.

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Listening is something that is just so vital in our work and maybe it gets forgotten.

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People are already thinking about what they're going to do at the beginning of the consultation,

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how they're going to go on from it, rather than just letting the person be and be listened to.

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And sometimes we don't need to do anything. And I spent many years in practise where maybe I just that people wait for 10

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minutes or turn around and saw them again and and didn't actually do anything,

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but they were glad to have that. Yeah, that's that's really good to hear the fact that, you know,

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actually that there's something about the time spent with a patient as a as a psychiatrist,

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which is of value in itself without needing something to be done to the patient necessarily.

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What I like to ask you about, if it if it's okay, because in your work with any sort of outreach, you deal with a lot of risk.

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You deal with patients who are often very unwell and often very unwell with having taken substances, not sometimes in a very high risk category.

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And I was just wondering about your thoughts on managing that risk in the community and how how you go about doing that,

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what your thoughts on on that are. I suppose I'm seen as somebody who's a positive risk taker.

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What does that mean really?

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From my point of view, it means that I want to give people another chance, another opportunity, another one and another one and another one.

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That's a bit like a set of philosophy, which we just hang in there.

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Nothing will deter us from. Somebody doesn't turn up.

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Then we'll find ways of finding them. So what positive risk taking?

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For one thing, most people with mental health problems don't have an enormously greater risk

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than the rest of the population or certain areas of the rest of the population.

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For me, it's more risky to walk down George Street in Oxford on a Friday or Saturday night and see all my patients.

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So we all do risk assessments all the time.

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That's what we do in life. We will cross the road if we see some people we think might be healthy.

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And so we'll just look in that short window and let them go past that.

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Yes, we do all the time. So every time I see a patient, I'm doing a risk assessment.

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I don't need a better form to to look at it,

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to remind me that sometimes people become more risk and usually the times for that

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of their meds may be or they're drinking more or they're using stimulant drugs.

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And one has to sort of balance that. And I think be honest with people that fundamentally I think what you need to be is honest and not.

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Patients don't want you to be frightened.

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They don't regard if you went to see a doctor and you thought he was anxious about what you want to say, you'd run a mile, wouldn't you?

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I would. So patients do not want to see fear and anxiety, even though we are dealing with things that may turn out badly.

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But most people we see have choices in life. It's their choice.

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You point out those choices to them. And so as long as you share these risks and talk to your colleagues about patients,

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that's what's so good about teamwork that we can talk about somebody every day if we're worried about them.

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And then we can all have you know, some people might say, oh, I think you need a mental health assessment now or we might discuss.

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Let's see what we can do over the next couple of days. And so I think this sort of risk thing generates fear in people.

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And I think fear is not a great way to standpoint, to work from.

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And yes, if things happen, they need to be investigated because they do.

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But if you allow this sort of wave for myself, if I behave honourably.

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I mean, it is sort of in the way it's meant,

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and I've written down everything and I have discussed it with all the people, I have nothing to fear, nothing.

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I really good to hear you talking about that. The positive risk taking approach and being honest with patients and and seeing the

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patient in that context rather than the tick tick on on a risk assessment form.

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And having that that that rich focus allows you to really think about the whole risk assessment business is there's no evidence.

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We all go on about evidence based medicine. There isn't any evidence.

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My guess is as good as a scare.

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I take box and my you know, it's a sort of I think the thing that's gone away from is the art of medicine.

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People don't really talk about the art of medicine anymore,

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but it is it's a way of how your experience and your and your knowledge and combines and your knowledge of

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the person in your relationship combines for you to have a sort of wider picture of how to manage them.

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In the same way we might think of one medication is good for one patient.

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I couldn't explain to you why exactly, but somehow it is.

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So it's it is a bit of a mystery and it can't really be measured, sadly.

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But I do think if we could all try to be a bit more reflective about what we do and try and see the person as as an individual,

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the world would be in all sorts of ways with their. There is so good to hear your thoughts and your reflections and some of your great

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experience has been it's been really good to spend time with you here today.

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Before we go, I'd just like to ask you a question about the fact that you were GP and now you're a psychiatrist.

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And I know in my experience, there are quite a number of junior doctors who are debating about whether to go into the general practise or psychiatry.

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What would you say to people who are taking that choice and what would you say psychiatrist, given years in your career?

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I love being oh, I've always loved being a doctor. I think it's a fantastically privileged job.

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And I think it's amazing that people just sit down and trust me and talk to me and then I help them and try to make a difference to them.

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So being in general practise where you didn't know, you might know the person who is coming in the door, you didn't really know why they come.

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And I, I only recently I've discovered that the way I love being a doctor is that I like being a detective.

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And when I was a boy, I wanted to be a detective. And it is a sort of detective thing.

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You're trying to piece out the evidence that is put in front of you.

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However that's presented. So I love being a GP, but it was it became somewhat remorseless.

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It was relentless. Yes. And the whole business side of it didn't really attract me greatly.

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And I become more and more doing more and more mental health work.

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So I think of experience in general practise is great for everybody.

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Hmm. I love psychiatry basically because I wanted to try being a proper doctor, whatever that was.

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And I did discover what being a proper doctor was,

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the sort of experience of knowing that the parameters of normal are so wide as to be just immeasurable that people are so completely different.

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But the scale in general practise is to have that tweak of thing. That's a bit unusual.

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That's a bit strange. We better look at that more and helping people through terminal illnesses.

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I love doing that.

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And people with chronic diseases that how one person with rheumatoid arthritis is different from another person terms that is a bit older.

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But those people don't realise in general practise is a very lonely job.

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You go to where you do see your 30 percent, whatever it is, and you got your visits,

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you come back to your apartment and see another 20 or 30 and you don't really meet your partners in any sort of clinical way.

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And the and the refreshing thing I find about returning to psychiatry was this openness, this conversation with.

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North of some of the best chemical discussions I had may be in the corridor or maybe over a cup of coffee or at the end of a meeting,

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we've gone on chatting and this constant flow of meeting all sorts of different

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people and having a real multidisciplinary view of things and and that sort of so,

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yeah, it's not a lonely job at all. And that's all. And so that's what I love.

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Coming back to psychology in some ways, I think I should have come back years ago.

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Yes. Yes. Ago, just a little bit as an apprentice. And that as some people have done.

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It really I think it's a fantastic career. David, it's been so good to speak to you today,

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so interesting to hear your views and thank you for tuning in to another episode of the Oxford Psychiatry podcast.

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I you listen to some more. Thank you and goodbye.