Not discharging service users from service – a disservice?

In the twenty years that I have been a clinical supervisor, delivering both individual and group supervision, one of the most consistent issues brought for discussion, or emerging from the reflective discussions, is that of clinicians’ difficulty in discharging individuals from mental health services.  This is generally a community issue when, either a single clinician is the only practitioner working with a service user, or they are the care coordinator and the last clinician still working with an individual after other members of the multi disciplinary team have discharged the person from their own caseloads.  A recent literature search found many papers that discuss the discharge process from hospital for those with mental health problems, but nothing examining discharge from caseloads, or from services in the community. 

Just in case

One of the most cited reasons in supervision for not discharging from service is the ‘just in case’ position.  Here, the service user is often doing well and has little need for input from services, but the clinician still holds them on their caseload ‘just in case’ there is a change.  Whilst this is done with the best of intentions, it is the antithesis of recovery.  By not discharging when appropriate, an implicit message can be given that the service user is frail and needs support.  The progress that a service user has made, and how hard they have worked, can be devalued with a sense that, ‘whatever you do it will never be good enough’.  Not discharging a service user loses the momentum of hope, of which workers should be the bastion.  The chronic retention of individuals on clinical caseloads, signals to service users that they are always going to need services and that they will never be able to manage totally on their own.  Whilst this might be done with the impression of being service user focused, it hints at clinicians’ needs being put first – to manage their concerns about what might happen if they discharge someone.  

Dependence, the new institutionalisation?

Thirty years ago many of the old psychiatric asylums were still standing and in use and institutionalisation was viewed as a secondary diagnosis, one that was caused by the very services that provided care for those with mental health problems.  Whilst institutionalisation is now less of an issue, dependence upon services, and also on others who provide support, is well recognised.  Dependence upon services is often viewed as something that service users, especially those with particular diagnoses, have deliberately created.  Frequently there is a lack of consideration about how workers and teams may have had a significant role in creating the situation.  When discharged from mental health services, many service users need an appropriate, rapid and easy route back to care.  Often these routes do not exist, or are difficult to navigate, and service users and carers are understandably anxious about being able to access help should it be required in the future.

New ways of working

Holding on to service users is often described by workers as wanting to keep the things the same as they always have been because the ‘old’ ways of working with individuals in the community were the best and these provided the optimum support for service users.  Whilst this might have been the case to a certain degree, it is possible that workers use this way of keeping long term consistent caseloads as a method of managing and controlling their own anxiety about the changes in practice that are being asked of services and those who work in them. 

Many clinicians and service users are nervous or sceptical about care clustering in mental health but one positive aspect of care clusters might be that they will outline care pathways for people to move through mental health services, receiving the care they need and with reviews at appropriate points.  Care clusters give criteria that indicate when discharge should be explored and a return to primary mental health services considered (DoH, Mental Health Care Clustering Booklet).  If clear and responsive access routes back to services are made available, if needed, this could really support recovery for individuals.  Care clustering may help all concerned to be clear about the processes during treatment delivery, discharge from services, re-referral and return, should these be needed.  Care clustering could also enable clinicians to feel confident to discharge people from their caseloads.  

How we feel about those we work with

Reflecting upon and discussing our feelings about those on our caseloads is difficult. Hawkins and Shohet’s (2006) Process Model of supervision supports supervisors to explore with their supervisees their feelings, thoughts about and interventions with those they work with.  A useful question to ask a supervisee is, “Do you like the individual?”  This is often difficult for workers to answer as they can believe they shouldn’t have human responses to those they work with, although feelings are inevitable when we work at deep levels with other human beings.  When co-teaching a clinical supervisors course, with a social work colleague, we explore this tricky issue of asking supervisees how they feel about their service users.  Our students very often recognise that they can hold on to service users longer than they might because they like the individual.  This positive feeling results in workers wanting to protect the service user, and we come back to the ‘just in case’ position.  More concerning is that clinicians might be holding on to service users as they enjoy working with them as they give clinicians a feeling of job satisfaction.  This idea is not a new one as research, now old, by White and Brooker (1990) highlighted that a client group described as the ‘worried well’ were more likely, at the time, to be attractive to work with for Community Psychiatric Nurses as this group of service users provided more job satisfaction for professionals than did those with severe and enduring mental illness.  When this happens clinicians are meeting their own needs, not those of the service user, and this does not align with a recovery approach. 

My co training colleague has an interesting view on how clinicians feel about those they work with.  He proposes that there is a risk that clinicians will retain on their caseloads service users that they don’t like or about whom they don’t feel positive.  Clinicians can believe such feelings of dislike are inconsistent with their role and this dissonance may cause the clinician to retain the service user for longer than necessary and work harder with them to compensate for their feelings.

How we feel about our service users can be a ‘taboo’ subject.  However these emotions are inevitable and normal when we build significant therapeutic relationships with others and use ourselves as the most important tool in our practice.  We walk alongside service users as they have so many experiences, many of them extraordinary.  We are honoured to be confided in, when service users tell us things that they may have never told anyone before and we are often the keepers of these confidences.  Skilful, reflective clinical practice can support recovery, but when there is a lack of self awareness and openness by clinicians it can build unhealthy relationships, and caseloads, creating dependence and loosing the important principles of recovery.

Therefore, it could be suggested that holding on to our service users for too long is a natural temptation for all practitioners, for a variety of very human reasons.  We should not be ashamed of our feelings about those we work with, rather we need to be open, reflective practitioners and confident to seek space to honestly and professionally explore these.  Clinical supervision is one of the essential support mechanisms in which to do this.  If we do not address these issues within ourselves we cannot be working in a recovery focused way and we, at the very least, do our service users a significant disservice.

Originally published in The Approach (Care Programme Approach Association)

With thanks to my co training colleague Keith Noble for some of the ideas explored within this article.


White E. & Brooker C. (1990) The care programme approach. Nursing Times. 87, 12, 66–67.

 Hawkins,P. and Shohet, R. (2006) Supervision in the Helping Professions. 3rd edition. Berkshire: Open University Press.

Department of Health. Mental Health Care Clustering Booklet 2013/2014.   (last accessed 27.8.13)




The Place of Animals in Mental Health Recovery

The following is an article published in the Care Programme Approach Association journal, The Approach. It is reproduced here, with kind permission from the CPAA, in a slightly shorter form.

The Place of Animals in Recovery

Half of UK households own a pet (Reynolds, 2006), therefore many people experiencing mental health problems will have companion animals and their relationships with these are often significant and important.  Owners will each have a different level of attachment to their animals and where several are owned it is likely that the individual will have a different connection with each one (Peacock, Chur-Hanson and Winefield, 2012).  However, mental health services very rarely consider the significance of animals in people’s lives, their role in recovery or how they impact on risks.  Understanding an individual’s relationship and attachment to animals could be a significant element in recovery that is being missed.  Whilst animal assisted therapy for mental health, as well as other health problems, has been fairly well researched, examination of the significance of actual animal ownership and effect on mental health has had little consideration (Walsh, 2009; Peacock, Chur-Hanson and Winefield, 2012).

Owning a companion animal can allow us to have an important relationship, one that is safe, trusting and uncomplicated.  It brings responsibility and a role, as well as an opportunity to focus on another living being.   Animals provide unconditional love and affection which, for those who are isolated and stigmatised due to mental health problems, can be highly important and affirming and can also provide physical contact and reassurance.  For many, companion animals are considered to be a member of the family, may be included in celebrations and given presents (Walsh, 2009).

Mental health workers are required to collate a great deal of information about service users, starting at the first assessment, but individuals’ relationships with their animals are rarely asked about, or considered to be important, therefore they are unlikely to feature in care plans or reviews.  If workers do not understand, or even acknowledge a service user’s animals in assessments, in conversations and in care plans there can be a significant gap in holistic care.  Peacock, Chur-Hanson and Winefield (2012) identified that any psychological assessment should include information about attachment and relationships with animals.  At the very least talking about a person’s animals is a good method of building rapport and engagement, often helping someone to start to talk about them self.

Recovery based care is an important and recognised approach but when services do not consider a person’s animals and their significance, care cannot be truly individualised and recovery focused.  Animals can be helpful in building resilience to mental illness and can provide a routine that supports important coping strategies.  If we are to use a truly holistic approach which considers every aspect of peoples’ lives, their animals should feature.  For many, both those who are experiencing mental health problems, and for those who are not, animals can give meaning to their lives.  Therefore care plans need to take in to account the part played by any animals in service users’ lives.

For many, animals can reduce risks, as they can be protective factors for those who self harm or are suicidal.  The thought of leaving their animal behind has been shown to prevent individuals from harming themselves, can give them a focus (Walsh, 2009) and animals can be a comfort which provide solace and affection.  In these situations a companion animal can offer hope and help a service user develop a belief that they can cope with life and Walsh (2009) identified that animals can support individuals through difficult events and transitions.

For many, animals provide a purpose and a structure to the day by giving them a sense of worth and control over part of their life (Slatter, Lloyd and Kind, 2012).  Those with poor motivation may find that they will get up and out for their animals when they would not do so for themselves.  Routines based around animals can support the development of coping strategies for difficult times.

Where animals provide livelihoods there will be different attachments to them by their owners but these are no less important than those with companion animals.  Farmed animals are often given names (Brown, 2006) and the impact on mental wellbeing for farmers and others when they lose their stock can be profound as demonstrated in the last foot and mouth epidemic, the ongoing tuberculosis infections of cattle and the recent losses of stock in the severe weather of spring 2013.

For some individuals the owning of animals can increase risk.  As circumstances change, due to factors such as illness and reduced finances, owners can become overwhelmed with the care that their animals require.  Physical risks in the form of trips and falls can be a problem with those who are physically infirm; however owners with dogs and who walk them have been shown to be physically fitter (Smith, 2012).  Owning an animal can expose previously unidentified issues.  When they first own an animal the nurturing that it requires can be overwhelming for some individuals due to their own experiences of poor nurturing or neglect by their families.

For some, the thought of being separated from their animals will lead them to delay treatment (Peacock, Chur-Hanson and Winefield, 2012) or prevent them from moving to appropriate accommodation (Morley and Fook, 2005).  This has been the case for older people needing a care setting and also for homeless individuals who will not take up accommodation if their animal is unable to go with them (Slatter, Lloyd and King, 2012).  Concern about one’s home, including pets, has been identified as a factor in absconding from hospital (City University, 2003).

For many owners the loss or death of a companion animal will cause a grief reaction that is often experienced similarly to the death of a loved person (Brown, 2006; Walsh, 2009).  The level of grief experienced will be related to the level of attachment to the animal (Donohue, 2005).  This is normal especially as companion animals are generally considered to be family by owners.  What often causes problems are the responses from others, including health workers, who give trite reassurances such as pointing out that it was only an animal or that another can be obtained.  Responses such as these further compound the individual’s grief and sense of loneliness (Brown, 2006).  Sometimes the death of an animal has a wider significance when it is a last link to a human that they have lost.

Women in abusive relationships have delayed or not left the situation due to either, not being able to take their animals or their children’s animals with them, or due to threats of harm to the animals from the abuser (Krienert ,et al 2012; Allen, Gallagher and Jones, 2006).  The abuse of animals has been identified as a possible indicator for domestic and child abuse (Blewett, 2008) with agencies in some USA states routinely sharing information where animal abuse has been identified (Patronek and HARC, 2001).

The responsibility, time and cost of caring for a companion animal will increase risks for some individuals but will reduce them for others.  Caring for an animal can become overwhelming and can be costly which may result in a service user ‘going without’ to provide for their animal.  For some individuals caring for animals runs out of control, in worst cases producing animal hoarding situations (Williams, B. 2014).  Here numbers of animals are kept in conditions that not only do not meet their needs, but significant cruelty, suffering and death are caused.  The impact on humans in animals hoarding situations is also enormous as children and vulnerable adults can be living in the household.  Animal hoarding situations are often driven by changes in circumstances including physical illness, but it is very likely that there will be comorbid mental health problems (Patronek, Loar and Nathanson, 2006).  Animal hoarding is more common than many think but is often ignored by agencies as it is seen as a ‘lifestyle choice’ (Reinisch, 2008).

It is important to consider if there is an impact on carers when those they support have animals.  Carers can experience an increased burden by having to take responsibility for animals when a service user is unable to do so.  For some this may be something that they are willing and able to do, but services should not just assume that a carer is able to meet the welfare needs of someone else’s animals, including the financial implications.  The role of the care coordinator and good care planning is essential to identify what is the best for a service user, carers and the animals should there be a crisis or if circumstances change.

In the current times of economic austerity some may feel that taking the time to understand and support service users’ relationships with their animals is inappropriate, but if we are to work in a truly recovery based way we need to understand what is important to service users.  Those with mental health problems are stigmatised enough without services ignoring or dismissing an element of their lives, which may be immensely important and helpful to them.

Workers, services and others may believe that those they work with do not have the ability or resources to care for a pet.  As long as the animals’ welfare needs are sufficiently met as required by law (Animal Welfare Act, 2006, see box 1), there is a positive impact for the service user and the responsibility is manageable for them, why would there be a problem?  We can work with service users to ensure they chose appropriate animals for them and their circumstances.  We can care plan with crisis and contingency plans including details of how their animals can help or increase symptoms and risk when they are becoming unwell.  We can also support the drawing up of clear plans for where animals should go should the service user become unwell.

Box     1

An animal’s needs shall be taken to  include;

(a)     its need for a suitable environment,

(b)     its need for a suitable diet,

(c)     its need to be able to exhibit normal behaviour patterns,

(d)     any need it has to be housed with, or apart from, other animals, and

(e)     its need to be protected from pain, suffering, injury and disease.

(The Animal Welfare Act, 2006, section 9)

Mental health workers are already pressured for time and may consider discussing a service user’s animals as a waste of time or unnecessary, however this then misses an opportunity for aiding engagement, for understanding what is really important for the individual and their life. It also can mean that certain risks and protective factors are missed.  Many mental health workers own animals that are hugely important to them, so why should our service users be treated any differently?  For many their relationships to animals are important, life affirming and profound. Recovery approaches cannot be authentic if workers and services chose to ignore this significant aspect of service users’ lives.

In summary, there is a significant part of people’s lives that is often missed by services and if we are to really deliver supportive, meaningful and individualised care we need to consider the role of animals in peoples’ lives.


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Blewett, J. (2008) The link between animal cruelty and child protection. Community Care. 1745, 26-27.

Brown, K. (2006) Pastoral concern in relation to psychological stress caused by the death of a companion animal. Mental Health, Religion and Culture. 9, 5, 411-422.

City University Department of Mental Health and Learning Disability (2003) Anti-Absconding self-training package for ward staff.

(Last accessed: April 15 2013).

Donohue, D. (2005) Pet Loss: Implications for Social Work Practice. Social Work. 50,2, 187-190.

Krienert, J., Walsh, J. & Mathews, K. et al (2012)  Examining the Nexus Between Domestic Violence and Animal Abuse in a National Sample of Service Providers. Violence and Victims. 27, 2, 280-295.

Morley, C. & Fook, J. (2005) The importance of pet loss and some implications for services. Mortality. 10, 2, 127 -143.

Patronek, G. & HARC (2001) The Problem of Animal Hoarding. Municipal Lawyer. 19, 6-9.

Patronek, G., Loar, L. & Nathanson, J. (Eds) (2006) Animal Hoarding: structuring interdisciplinary responses to help people, animals and communities at risk. (Last accessed February 15 2013).

Peacock, J., Chur-Hansen, A. & Winefield, H. (2012)  Mental Health Implications of Human Attachment to Companion Animals. Journal of Clinical Psychology. 68, 3, 292-303.

Reinisch, A. (2008) Understanding the Human Aspects of Animal Hoarding. The Canadian Veterinary Journal. 49, 12, 1211–1214.

Reynolds, A. (2006) The therapeutic potential of companion animals. Nursing and Residential Care. 8, 11, 504 – 507.

Slatter, J., Lloyd, C. & King, R. (2012) Homelessness and companion animals: more than just a pet. British Journal of Occupational Therapy. 75, 8, 377-383.

Smith, B. (2012) The ‘pet effect’. Health related aspects of companion animal ownership. Australian Family Physician. 41,6, 439-442.

Walsh, F.  (2009) Human-Animal Bonds 1: The Relational Significance of Companion Animals. Family Process. 48,4, 462-480.

Williams, B. (2014) Animal Hoarding: devastating, complex and everyone’s concern. Mental Health Practice. 17, 6, 35-39