Assertive Engagement is a term used in a variety of fields to indicate a persistent and active approach to an interaction. It has an obvious use in military terminology (though it would be hard to imagine a military ‘engagement’ which wasn’t assertive!) but it is a term most keenly employed in a particular approach to psychiatric care. However, even in this field, assertive engagement is a concept requiring definition. It is a term born out of the move towards community treatment within psychiatric services in America with the development of ACT (Assertive Community Treatment) in the Seventies. It finds its expression in the UK through the development of Assertive Outreach Teams within psychiatric services. These are teams following strict and pragmatic models of intervention which concern themselves with the mechanisms that must be employed for effective treatment of patients within their own homes and without the assurances that hospital treatment engenders in the nurse. The literature on these models details at some length the importance of the conditions under which the teams must operate – the teams must be multi-disciplinary, must have a high worker to patient ratio, and hold home visits as the central tool for therapeutic work.
Within this, assertive engagement as a concept is often used but rarely, if ever, defined. Assertive engagement is seen as a by-product of the employment of these mechanisms – I.E. if you have a multi-disciplinary team, a small caseload and you visit someone in their home you are inevitably assertively engaging. There is some truth to this, the shift from working within the hospital to working in the community is a shift towards assertive engagement, but for the purposes of inculcating AE into a therapeutic framework we can all employ it is worthwhile developing an understanding of the concept in its own right and independent of pragmatic mechanisms.
Here we’ll seek to define the concept through a series of underlying ideas laid out in steps. This we will call the Presuppositions of Assertive Engagement.
The presuppositions of Assertive Engagement
1. That there are people who want to, or need to, effect some change in their lives because they recognize, or it is recognized, that aspects of their present lifestyle are damaging in some capacity.
There can be little doubt that this is true. There is frequent discussion of the distinction between wanting to change and needing to change. It is a valid discussion, however, it is a reasonable starting point for any care or support worker to assume that the purpose of the role is to effect positive change in someone else (who would seem to need it). Consequently the second presupposition holds that:
2. That lives can be changed for the better and that professional support workers can be a part of the process towards change.
Again, this is a statement that is true enough not to require formal evidencing. Understood within this is that change is difficult, that success in changing behaviors can be fleeting, and that a process towards positive change can be mired in a wealth of damaging coping strategies to the point that the support worker might themselves (let alone the client) lose sight of forward progress. It is understood that if we are working with the most vulnerable in society change is not easily come by and a worker (here we primarily talk about Assertive Social Intervention workers [ASI], a collective term we are using for a range of workers from prison workers to street outreach) may see no change in a client over years and years of effort. However, to focus on the positives, everyone knows someone that has changed and everyone, if a support worker for long enough, will have had some part in the improvement of a client’s quality of life. We are not so naive as to imagine that we will bring about massive change in the most vulnerable but small, incremental improvements in a person’s standing is always possible. These first two presuppositions are givens, the basis for any kind of therapeutic work or psychological therapy.
3. That change requires processing, decisions need to be made, and this processing is best achieved in certain circumstances and environments (i.e. environments that are safe, free from stress, supportive, with few other demands and needs to be met – roughly, those environments that we would term therapeutic).
There are by and large two conceptions of how change occurs. They are not mutually exclusive but rather dwell on different aspect of the change process. They are best viewed as passive and active. Here we are particularly concerned with active change, or a will to change* (an active belief that change must occur and action must be taken to enable that change). When this will to change is present, particularly in substance users, we often arrange for the clients to access therapeutic space – rehabs at the more encompassing end of the spectrum and therapist’s interview rooms at the other. They are safe environments and irrespective of the particular modality of a given therapist tend to be very similar environments. We hold it to be reasonably true that if a person is to commit energies to a process of reflection and change then there are environmental factors which are clearly accommodating of the process. They must be supportive, the impact of external stressors must be limited, basic needs should be met; there should be sufficient time; there should be sufficient evidence that positive change can occur (i.e. there should be some social proof) and on. We tend not to think too greatly about why we are often so keen to push our clients in the direction of therapeutic institutions but it is useful for us to sit and ponder a while what we expect to achieve through it. A therapeutic environment must ultimately amplify forward progress in challenging negative behaviors and then give the client space to consolidate newly emerged patterns of behavior. But, this is a step ahead of the work of workers engaged in Assertive Engagement whose work environment is by definition lacking these positive factors. Thus we say as step four:
4. That most vulnerable people do not live in environments and circumstances that are conducive to change. And most workers will encounter their clients in environments that are by and large untherapeutic.
Assertive engagement finds its origins in psychiatric outreach into the community but the barriers to working with someone in their own home are not hugely challenging as compared to prison inreach, street outreach, or working in houses of multiple occupancy. These are genuinely challenging environments to carry out change-driven therapeutic work in. These environments lack most of the qualities that are necessary for adequate reflection and change processing. If we hold it to be reasonably true that most vulnerable persons (I mean this as a euphemism for substance users, prolific offenders, the homeless, the mentally ill, people with personality disorders etc rather than the physically handicapped) already struggle to carry out the effort needed to effect positive change in their lives then it is surely of no great surprise to anyone that the environments they inhabit and move in further compound any positive efforts. Thus:
Given these things are true; Assertive Engagement then, is best understood as the process whereby a worker uses their interpersonal skills and creativity effectively to make the environments and circumstances that their service users are encountered in, more conducive to change than they might otherwise be, for at least the duration of the engagement.
Imagining the perfect circumstances for processing change, the perfect circumstances for carrying out therapeutic work of any modality one can then conceive of the shortfall between that idealized worker/client position and the particular context of a given encounter and begin to imagine what additional steps must be taken by the worker in order to bridge that gap.
(e.g. where a service user does not feel safe the worker will find ways of making engagement seem safe; where a client has limited time the worker will find ways of finding more time, or of making time spent with the worker more worthwhile through tangible reward, or of making the time available more useful through effective communication etc).
This definition is effective in that it allows workers to articulate the process they are engaged in when working with hard-to-reach clients. It anchors the basis of all efforts by ASI workers squarely in the field of therapeutic endeavor. It says that we are working in a similar manner to therapists but we are having to substitute the characteristics of their more ideal environment with heightened and dynamic interpersonal skills. It is effectively a paramedic analogy. There are circumstances and environments that are ideal for medical procedures which are, for example, clean, calm, with available specialized equipment etc, but these factors are by and large absent out ‘in the field’. There instead the paramedic operates similarly to a doctor but with their own specialized equipment and techniques to compensate for the shortfall. They work less perfectly than a doctor in a hospital but they prove to a greater or lesser extent effective. The essence of being a paramedic is not that they are out in the field in itself but in that they define themselves by virtue of how they compensate for the shortfall from idealized circumstances. Again we draw a parallel with the discussion of Assertive Outreach Teams and the assumption that by visiting a home they are necessarily assertively engaging – assertive engagement is the process of what they do when they visit not that they have visited in itself.
This gives us the opportunity to further articulate what it means to be effective when working with vulnerable or hard-to-reach groups. We are already good at articulating differing therapeutic techniques – a worker might say: ‘I am going to try some motivational interviewing now.’ Or, ‘the issue with my client is that she is precontemplative at the moment.’ But here we can now articulate further the task at hand and develop the intentions of the worker by saying for example: ‘I am going to try some motivational interviewing but I will have to be more directive in my approach than normal because I know we will be short of time.’ Or, ‘The issue with my client is that she is precontemplative at present and I am going to work additionally hard to establish a safe space for her to explore the consequences of this.’
A useful exercise
Detail the factors that you feel are the key environmental factors for effective therapeutic work, i.e. the factors you feel that are most suited to processing what steps need to be taken to achieve positive change (some are listed earlier in this article). Now take those factors and imagine how you bring them, or compensate for their lack, when you are carrying out your particular role. Dwell on the particular interpersonal skills you employ when working in, for example, a prison or the street. Time is always a good factor to think about. A key concern for most workers is that they do not get much time with their clients. The clients don’t turn up to keyworking, or are hard to find or when found often have something they would rather be doing. We are rarely creative about how we approach this issue but if you start brainstorming ideas you can explore new thinking on how we make time spent with us (workers) more worthwhile for the client, or how we buy client’s time with food or offerings, or how we use agencies and workers who are having contact with the client to achieve a particular aim. We can even look at how the client organizes their time. We can try and draw up a pattern of behavior so we know where a client is going to be and when. There are a wealth of different ways of solving the problem of getting time with a client but far too often clients are discharged from services for ‘failing to engage’. Yes, the client does have a responsibility to engage but ultimately the failure is on the behalf of any agency or worker who won’t be creative in trying to gain time with their client. It is when we start thinking: ‘What more do I need to do with my client to get some contact and make it valuable?’ That we are using Assertive Engagement.
Ultimately we can say that Assertive Engagement is the product of believing that solid therapeutic skills can produce positive change anywhere, and in any circumstance, and with anyone if allied to the creativity and determination of the worker.
o Assertive Community Treatment of Persons with Severe Mental Illness, Leonard I. Stein and Alberto B. Santos, 1998
o Assertive Outreach in Mental Health: A Manual for Practitioners, Tom Burns and Mike Firn, 2002
o Principles of Therapeutic Change That Work, Louis G. Castonguay (Editor), Larry E. Beutler (Editor), 2005
o Therapeutic Environment (Core Concepts in Therapy), Richard J. Hazler and Nick Barwick, 2001
o Psychiatry Takes to the Streets: Outreach and Crisis Intervention for the Seriously Mentally Ill, Neil L. Cohen, 1990
o Changing for Good, James L. Prochaska, 1998
o Motivational Interviewing: Preparing People for Change, William R. Miller and Stephen Rollnick, 2002