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How patients in New Zealand view community
treatment orders
ANITA GIBBS
1
, JOHN DAWSON
2
, CHRIS ANSLEY
3
,&
RICHARD MULLEN
3
1
Department of Community and Family Studies,
2
Faculty of Law, and
3
Department of Psychological
Medicine, University of Otago, Dunedin, New Zealand
Abstract
Background: New Zealand operates a well-embedded community treatment order scheme for patients
with serious mental disorders. A similar scheme may be enacted for England and Wales.
Aim: To explore the views of patients with recent experience of community treatment orders.
Method: All patients in one region under an order in the last 2 years, not readmitted to hospital for at
least 6 months, were included, subject to their capacity and consent. Forty-two patients out of 84
potential participants were interviewed.
Results: The majority of patients were generally supportive of the community treatment order,
especially if the alternative was hospital. Many valued the access to services and sense of security
obtained, and attributed improvements in their health to treatment under the order. They also
experienced reduced choice about medication and restrictions on residence and travel. For a minority
this meant they were strongly opposed to the order, but for most the restrictions did not unduly hinder
them. The majority of patients viewed the order as a helpful step towards community stability.
Conclusions: The usefulness of community treatment orders is accepted by most patients under them in
NZ, as well as by most psychiatrists. Critical factors include the quality of therapeutic relationships and
the structure provided for community mental health care.
Keywords: Mental health, patients, community treatment orders, outpatient commitment
Introduction
This paper explores the experiences of 42 involuntary outpatients under NZ’s community
treatment order (CTO) regime. This requires patients to accept psychiatric treatment
outside hospital, subject to regular, independent review. The core requirements are to
maintain continuing contact with community mental health professionals and to accept
medication as prescribed.
A similar regime was recently enacted in Scotland by the Mental Health (Care and
Treatment) (Scotland) Act 2003. In England and Wales, involuntary treatment of ‘‘non-
resident’’ patients would also be authorized if the Draft Mental Health Bill 2004, now before
the UK Parliament, was enacted in its present form (Department of Health, 2004),
enhancing the powers available under supervised discharged orders since 1995 (Pinfold,
Bindman, Thornicroft, Franklin, & Hatfield, 2001).
Correspondence: Dr. Anita Gibbs, Department of Community and Family Studies, University of Otago, PO Box 56, Dunedin,
New Zealand. Tel: + 64 3 479 5677. Fax: + 64 3 479 7653. E-mail: anita.gibbs@stonebow.otago.ac.nz
Journal of Mental Health,
August 2005; 14(4): 357 – 368
ISSN 0963-8237 print/ISSN 1360-0567 online Shadowfax Publishing and Taylor & Francis Group Ltd
DOI: 10.1080/09638230500229541
Some advocacy organizations have strongly opposed CTOs in the name of patient
autonomy (MIND, 2004). Little comprehensive research into patients’ experience of this
form of treatment delivery has been published, however. Researchers have given more
attention to patients’ experience of involuntary hospital care. Contrary to what might be
expected, some studies have found that compulsory inpatients subsequently hold generally
favourable views of their hospitalization and treatment (Gove & Fain, 1977; Edelsohn &
Hiday, 1990; Kaltiala-Heino, 1996), and many will later agree it was required (Spence,
Goldney, & Costain, 1988; Conlon, Merskey, Zilli, & Fromhold, 1990; Edelsohn & Hiday,
1990; Kaltiala-Heino, 1996; Gardner et al., 1999).
Qualitative research on patients’ views of compulsory outpatient care has now been
undertaken in Britain, Australia and New Zealand. In Britain, studies reported that
compulsion helped patients maintain contact with health professionals and also that patients
felt compelled to accept medication (Atkinson, Garner, Dyer, & Gilmour, 2002; Canvin,
Barlett, & Pinfold, 2002; Pinfold et al., 2001). In Australia and New Zealand, patients
report both advantages and disadvantages of CTOs. Advantages include the accessibility of
mental health professionals, ease of readmission to hospital when desired and the
opportunity for discharge from hospital to community care. The disadvantages include
reduced liberty, control over medication and restrictions on decision-making capacity
(Carne, 1996; Gibbs et al., 2004; Power, 1999).
New Zealand’s CTO Regime
A person may be placed under a CTO, under the NZ’s Mental Health (Compulsory
Assessment and Treatment) Act 1992, if they: (1) have a serious mental disorder
(characterized by delusions, or by disorders of mood or perception or volition or
cognition); plus (2) they pose a serious danger to the health or safety of themselves or
others, or have a seriously diminished capacity for self-care. Adequate outpatient care and
social support must also be ‘‘available’’ (sections 2, 27, 28). In addition, the NZ Act
precludes a patient’s involuntary treatment ‘‘by reason only of intellectual disability’’ (s
4(e)), and those with personality (or ‘‘psychopathic’’) disorders may only be treated under
the Act if they present one or more of the specified disorders of mental function listed
above. In practice, the scope of the NZ regime is therefore limited to patients with serious
mental illness.
Either the responsible clinician can transfer a patient to a CTO from an involuntary
inpatient order, or a CTO can be made by a judge, after a hearing, following the patient’s
compulsory assessment. The order has an initial maximum term of 6 months, although it
may be continued following review by a court. At the time of this study, the NZ regime was
well-embedded, having operated for nearly 10 years.
The order requires the patient to accept treatment as directed by their responsible
clinician (section 29). In practice, medication is not administered over a patient’s objection
in a community setting, as that is widely considered unsafe and unethical, but if the patient
does not comply with treatment as directed, the legislation authorises their rapid return to a
hospital or clinic. The Police are empowered to assist community clinicians in that ‘‘recall’’
process, though in practice that is rarely required.
We have previously reported that a quarter of patients placed under involuntary
psychiatric assessment went on to be treated under a CTO in the region studied (Dawson &
Romans, 2001).
358 A. Gibbs et al.
The usual conditions of a CTO in NZ are that the patient shall:
.permit visits to their residence by members of the community team (often weekly)
.attend outpatient appointments as required (often a monthly psychiatric appointment)
.take medication as prescribed
.remain at a specified kind of residence
.not travel beyond certain geographic boundaries without permission
.avoid substance misuse.
Whether the patient will be returned to inpatient care for breach of those conditions is a
matter of discretion for the clinical team. Critical factors in the exercise of that discretion are
the relapse profile of the patient, the potential consequences of their relapse, and the likely
impact of their recall to hospital. A bed must also be available. The conditions of the CTO
and the clear enforcement mechanisms are somewhat more controlling than those provided
by the supervised discharge regime in England and Wales (Canvin et al., 2002).
The attitudes of clinicians
A recent national survey of NZ psychiatrists found a high level of endorsement of CTOs
(Romans, Dawson, Mullen, & Gibbs, 2004). Most psychiatrists considered them a useful
tool in pursuit of core clinical goals for the seriously mentally ill. They were considered to
work in a largely structural and indirect fashion, binding into place necessary community
services, facilitating contact with the patient, and promoting medication compliance and
early identification of relapse. They were considered to support the involvement of families
and other agencies in patients’ care and to have a significant impact on patients’ attitude to
their illness.
Compulsion was not seen by respondents as a substitute for adequate service provision.
On the contrary, success was seen to depend on the quality and extent of services provided.
There was even the perception that compulsion may enhance service provision, with those
under CTOs receiving priority for care in poorly resourced systems, whether or not that
should be the case.
With regard to the impact on the therapeutic alliance, the predominant view of
psychiatrists was that, while compulsion can harm relations with patients in the short term,
the advantages of continuing treatment usually outweigh this problem, and when greater
insight follows treatment, therapeutic relations will often improve in the end.
Our study: Methods
We targeted for inclusion all patients in the NZ province of Otago who had been under a
CTO, without readmission to hospital, for more than 6 months in the previous 2 years. One-
hundred-and-three patients met those criteria. Six months’ continuous treatment under the
order was stipulated to try to ensure that the patients could clearly distinguish their
experience of the CTO from their experience of surrounding periods of involuntary
inpatient care.
Otago, in the South Island, has 180,000 people (roughly 5% Maori) and a significant rural
component. Approval for the study was obtained from the Otago Ethics Committee.
The key workers (or case managers) of those 103 patients were then approached, with an
initial request to assess the patient’s capacity to participate in the research, in consultation
Patients’ views of CTOs in NZ 359
with their psychiatrist, in accordance with the usual capacity criteria those clinicians would
employ. Nineteen patients were considered to lack capacity to participate at the outset and
were excluded. Of the remaining 84, who were approached personally, 42 agreed to take
part and fully completed the process, 34 declined to participate, and in 8 cases the research
process was incomplete, due to withdrawal by the patient, their relapse during its course, or
breakdown in communication. Hence, the 42 represented a participation rate of 50%. It is
unfortunate that the number of participants was not higher but as all had a serious mental
disorder, and had recently experienced involuntary treatment, it is not surprising many did
not wish to be interviewed or were considered too unwell. It is possible that patients who
agreed to participate had benefited more from the CTO, or had more positive attitudes to it,
than those who did not. This may affect our results.
Of the 42 patients recruited, 20 had been discharged from the CTO by the time they
were interviewed, while 22 remained on it at interview. The interviews were carried out
during 2001 and 2002. Patients’ key workers and psychiatrists were also interviewed, plus at
least one family member if they could be found and they agreed. Permission to conduct all
the interviews, and to inspect patients’ files, was obtained from patients in advance. Within
the sample, 8 patients identified themselves as Maori. A separate analysis of their
experiences has been published (Gibbs et al., 2004). We are only reporting on the
patient views in this study and further pieces are planned for family and mental health
professional views.
The semi-structured interviews with patients drew upon themes highlighted in previous
studies of CTOs, and discussion with stakeholder groups. The interviews focused on
patient understandings of the CTO regime; why the order was required; its impact on
social and clinical relationships; the order’s benefits and limitations; compliance with
treatment; indicators for discharge; and the impact of the CTO on their health and well-
being. Interviews were taped and transcribed. The transcripts were entered onto a
NU*DIST database for preliminary coding and analysis. The research team then
analysed the interviews using a general inductive approach (Thomas, 2004). This
involved deductive reasoning from the themes already developed in the interview
schedule, and inductive reasoning from new themes identified from several readings of
each transcript.
A separate attempt was made to score the patients’ global attitude to the CTO in their
case. To this end, two researchers independently reviewed each interview transcript as a
whole, then negotiated solutions if they disagreed. Particular weight was placed on the final
question put to each patient: ‘‘Overall, do you think the advantages of being on the
community treatment order outweigh the disadvantages?’’ The patient’s overall attitude to
the order was then rated as: wholly favourable, generally favourable but noted disadvantages,
equally for and against, generally opposed but noted advantages, totally opposed.
The patients interviewed
The demographic and diagnostic characteristics of the patients interviewed are presented in
Table I.
In addition, the 42 patients interviewed had the following clinical characteristics recorded
at least once in their notes: co-existing substance abuse, 60%; incident of self-harm, 40%;
incident of aggression to others, 86%; experienced delusions, 76%; experienced hallucina-
tions, 77%. Over half (22, 52%) had more than one diagnosis, 4 (9.5%) had one previous
hospitalization, 15 (36%) had 2–4 hospitalizations, 15 (36%) had 5–9, and 8 (19%) had
10 or more.
360 A. Gibbs et al.
There was therefore considerable variation in the personal characteristics and prior mental
health careers of those interviewed, but as their average age was 38 years and their average
time since first contact with mental health services was 14 years, and nearly a third had
previously been under the care of the forensic service, many were clearly long-term users of
mental health services.
Table I. Demographic and diagnostic profile of participants.
Discharged n= 20 (%) Active n=22 (%) Total n=42 (%)
Gender
Male 15 (75) 17 (77) 32 (76)
Female 5 (25) 5 (23) 10 (24)
Primary diagnosis
Schizophrenia 10 (50) 13 (59) 23 (55)
Affective psychosis 7 (35) 3 (14) 10 (24)
Schizoaffective 2 (10) 5 (23) 7 (17)
Personality disorder 1 (5) 1 (2)
Other 1 (5) 1 (2)
Ethnicity
European 16 (80) 15 (68) 31 (74)
Maori 4 (20) 4 (18) 8 (19)
Pacific Islander 2 (9) 2 (5)
Other 1 (5) 1 (2)
Living situation
Supported housing 7 (35) 7 (32) 14 (33)
Renting a home 6 (30) 6 (27) 12 (29)
Own home 3 (15) 3 (14) 6 (14)
House sharing 3 (15) 1 (5) 4 (10)
With parents 4 (18) 4 (10)
Other 1 (5) 1 (5) 2 (5)
Age (years)
520 1 1 (2)
20–29 2 8 10 (24)
30–39 8 6 14 (34)
40–49 3 4 7 (17)
50–59 3 3 6 (14)
60 and over 3 1 4 (10)
Average age (years) 39 37 38
Time since first contact with
mental health services (years)
55 3 2 5 (12)
5–9 5 7 12 (28)
10–14 2 5 7 (17)
15–19 5 2 7 (17)
20–24 2 4 6 (14)
25 and over 3 2 5 (12)
Average (years) 15.2 13.6 14.4
Forensic background
Under forensic team 5 (25) 8 (36) 13 (31)
Under criminal justice
legislation
3 (15) 5 (23) 8 (19)
Patients’ views of CTOs in NZ 361
Results: Key themes in patient interviews
Patients’ overall assessment of the CTO
The 42 patients’ overall attitude to use of the CTO in their case was assessed as follows:
.wholly favourable: 8 (19%)
.generally favourable but noted disadvantages: 19 (46%)
.equally for and against: 9 (21%)
.generally opposed but noted advantages: 3 (7%)
.totally opposed: 3 (7%).
The majority of patients interviewed specified significant outcomes and improvements from
treatment under the order, in terms of quality of life or lifestyle, reduced time spent in
hospital, increased stability, and better understanding of their illness. Nevertheless, most
were able to articulate clearly both advantages and disadvantages of the order (see below)
and some patients were more negative about the order at its commencement than at the end,
or after discharge. Ultimately, most patients recognized the order had conferred benefits.
Advantages for patients of CTOs
Some patients said the CTO had ‘‘saved their lives’’, by preventing suicide or serious self-
harm. ‘‘Safety’’ and ‘‘security’’ were mentioned many times. Andrew, for example, a 33-
year-old Maori man, with a long history of contact with mental health services and
homelessness, said the CTO: ‘‘Saved my life. It got me off the streets. It helped me
communicate with people’’. Edith, a 60-year-old European with a diagnosis of major
depressive disorder, said, ‘‘I was pretty much into self-harm and attempting suicide. I don’t
think I would be here now if I wasn’t on it’’.
Some patients said CTOs ensured they got the services needed, and enabled them to
return to hospital for short breaks or treatment, as desired. Robert, a 40-year-old, noted: ‘‘If
you needed a hospital bed you were more likely to get one straight away’’. He admitted he
would not return voluntarily, so the CTO helped make the decision for him. In his view, he
had improved over time due to a change in medication. He also had significantly reduced his
alcohol intake and stopped smoking. He said of the CTO, ‘‘I realized I needed help in some
way. It was a good means to an end’’. Helen, a Maori woman in her 40s, with a diagnosis of
schizophrenia, said: ‘‘You can get in quick. You don’t feel like you are still floating. There
are no loopholes. I can get help straight away’’. Helen likened the CTO to ‘‘an umbrella over
someone that is mentally ill, and it gives them the opportunity of getting help’’.
Compared with long-term hospitalization, imprisonment or homelessness, CTOs were
considered by virtually all patients to be less restrictive. Typical comments included: ‘‘It’s
more beneficial than an in-patient order’’; ‘‘It’s better to be in the community than in
hospital, there’s much more freedom’’.
Dave, in his late 30s, with many prior hospitalizations, said the CTO was a ‘‘back-up’’ in
case he became unwell. It was a ‘‘step to freedom’’ because it allowed him to gradually
increase his independence from hospital. Anna, in her early 20s, felt the order had got her
‘‘well enough to sort of make my own decisions’’, even though she resented the order
initially. She felt it had lessened her self-harming behaviour and increased her quality of life;
it enabled her to become more independent before she achieved her eventual discharge.
Despite the low ranking given by psychiatrists in our survey (Romans et al., 2004) to
reducing substance abuse, as a reason for using a CTO, perhaps due to doubts about the
362 A. Gibbs et al.
prospects of success, several patients said the order had that effect, particularly in
combination with their placement in a supported accommodation service. James, for
instance, a 20-year-old with a history of serious substance misuse, said he reduced his habit
while on the order until he considered it no longer caused serious harm. He said the CTO
‘‘forced me’’ into needed treatment.
Disadvantages for patients
The perceived disadvantages of the CTO fell into four broad categories:
.the sense of control by others and loss of freedom
.coerced medication compliance and unpleasant side effects
.restrictions on residence and travel
.the sense of stigma.
Chi, for example, a Maori man in his 30s with bipolar disorder, viewed the CTO as taking
away his freedom. He hated the order and when he did not comply he had been returned to
hospital and forced to take medication. He said, ‘‘I didn’t think it helped me. I hated having
my freedom taken away from me’’.
Loretta was a 50-year-old European mother of three living in her own home who had
been hospitalized regularly throughout her long contact with mental health services. She
placed great emphasis on loss of liberty. She said of the CTO: ‘‘I have no choice so
therefore I am not just an autonomous individual, I am answerable to people for my mental
health’’.
Many patients felt they had ‘‘to do what I am told’’ by mental health professionals. They
had to comply with medication, even if they considered it was harmful, or had unpleasant
effects. Jeff, said the side effects reduced his motivation and made him lethargic. This
affected his ability to get work because he was so ‘‘blobbed out and not capable of working’’.
Helen also complained that the medication ‘‘dragged her down. I don’t like being numbed
and it can make you feel really dopey’’.
Connor, in his 40s, said the order required fortnightly injections of medication, which
impaired his alertness and energy. It stopped him hunting and hiking in the surrounding
forests for extended periods. Connor described his psychiatrist as ‘‘authoritarian’’ and the
CTO as ‘‘like a prison sentence’’.
Others described restrictions on their place of residence. Fred, Merry and Chi all
considered they were deprived of the ability to live alone, or were directed to supported
accommodation, as a consequence of the CTO, or failure to comply.
For a number of patients the pain of stigma and others’ negative perceptions gave them a
negative view of the order. Chi said, ‘‘There was a stigma. I suppose that was always in the
back of my mind. I was restricted in certain ways’’. Fred, a man in his 40s, said the CTO
lowered his quality of life, and put him in a ‘‘category hole’’, and a ‘‘little box’’.
Neutral comments
There were also a substantial group of patients who considered the CTO made little or no
difference to their lives. In many cases, these were long-term CTO patients. Typical
comments were: ‘‘it makes no difference’’, ‘‘it does me no harm’’, ‘‘I can come and go as I
please’’, ‘‘it’s just out there in the distance’’. Gary, in his 30s, noted there were rules he had
to follow but it didn’t bother him: ‘‘I am a psych. patient but I have my freedom . . . . I still
Patients’ views of CTOs in NZ 363
want it [the CTO] and I want to stay on it’’. He said the CTO was ‘‘just a piece of paper’’ to
get him to take his medications, which he did, and felt better for it.
Heather, a Maori female in her 20s, was adamant that the CTO was ‘‘not her life’’ but it
was ‘‘connected to my life’’. It had significance but was not a big influence in her everyday
life. She felt it was a means of getting back to hospital, and that ‘‘I knew it was there but it
was just sort of in the background’’. The CTO was just something that was there and she
didn’t think about it much. A number of other patients mentioned that they hardly thought
about the CTO and that the research described here had provoked them to think about it
more than they had in recent months.
Impact on relationships
The few patients who felt the CTO made a difference to close family relationships
considered it reassured their relatives and enhanced their sense of safety and security. Anna
said, ‘‘My family felt safe’’. Sasha said her parents viewed the CTO ‘‘as a protection for me;
it was less stressful on them to have to be concerned for me’’. Connor said the order had
brought him ‘‘back into society as a normal Dad’’. It also lifted the burden of monitoring his
condition from his wife, improving their relationship.
CTOs appeared to have a greater impact on patients’ relationships with mental health
professionals. Many patients viewed those professionals as controlling and wielding
considerable power. ‘‘They dictate the rules and you have to abide by them’’, said Jeff.
Psychiatrists were usually viewed more negatively than other health professionals. Fred
noted how afraid of his psychiatrist he was, ‘‘I haven’t got that much to say to the doctor
each time...I am just a bit scared of what I should say to him’’, lest it be taken the wrong
way. Nevertheless, many patients said the CTO made no difference to their therapeutic
relationships. They felt able to access health professionals’ advice and found them helpful.
Their keyworkers (usually experienced community nurses) were viewed most positively,
perhaps because they had more time to spend with patients during regular visits to their
residence. Chi’s keyworker was viewed as ‘‘fantastic’’ because she helped him get off
medications: ‘‘without her help I would be on the injection right now. She is someone I can
really open up to’’. Heather said her key worker ‘‘has just got more positive input. He has got
the skills that he can teach me. Psychiatrists, in the past, they haven’t really taught me
anything. All I do is tell them my problems, they write it down, and then bye bye, oh, here
are some drugs’’.
Generally, CTOs were not seen by patients to damage therapeutic relationships even
when health professionals were quite directive in their conduct.
The dilemma of discharge
Discharge from a CTO was viewed by patients as an important indicator of ‘‘success’’. It
meant they were getting better and could be free of some constraints the order imposed. The
CTO was often viewed as a ‘‘stepping stone’’ to full independence.
Some patients felt they had to achieve a great deal to be discharged. Sasha, for example,
said, ‘‘a CTO imposes rules; to get off it you have to show you are capable of being adult
about medication and not being suicidal’’. Others felt they would never get off the order.
Connor said, ‘‘if it’s not broken then why fix it’’. He felt he would never be discharged
because he had been so stable under compulsory treatment. Sasha commented that she did
not know what was expected of her by health professionals to achieve discharge. She asked,
‘‘what level of wellness do they want the patient to be before they can come off?’’. Fred, who
364 A. Gibbs et al.
had a previous history of sexual offending, was unsure as to why he was still on the order,
although it was obvious from his case notes and the comments of his psychiatrist that he was
considered high risk in terms of re-offending, and the order was required to continue his
medication and ensure regular monitoring. Fred said, ‘‘I don’t understand why I am still on
it. Why do I have to stay on it for so long?’’ He had been on the order for 2.5 years.
Factors that patients considered favoured their discharge from the order were: a
considerable period of stability outside hospital; compliance with medication; keeping
appointments; gaining knowledge and awareness of the impact of their illness on themselves
and others; taking responsibility for their health and self-care; doing what clinicians expected
of them; achieving goals in relationships, work or study; and reducing self-harm. Dave said
the CTO ‘‘changed things to a point where I was 99% sure of myself’’. He felt he had been
discharged because he had worked hard while on the order, had showed some insight and
made good progress.
Some patients were very clear, however, that they did not want to be discharged.
Heather noted, ‘‘I am quite thankful I am on the order because I know I am not quite
strong enough to look after myself completely’’. Without it she would have felt like ‘‘a boat
in the middle of the ocean without an oar’’. She had seen improvements in her
situation, but needed more time to attain stability and confidence. Sasha, a young
woman with a history of suicide attempts, was reluctant about the CTO when first on it
but came to value its impact, particularly reduced self-harm. Over time, some patients had
become, in effect, volunteers for compulsion. They accepted the constraints the order
imposed, acknowledged it was necessary in times of crisis, and valued the sense of safety
it gave.
Other patients, however, were extremely pleased to be discharged. They said they were
involved to varying degrees in planning and consultation about the discharge. Some felt they
had been fully involved; others felt they had merely been informed discharge would happen
or that it was almost a ‘‘non event’’. There were also comments that appointments with
health professionals tailed off slightly once discharge occurred.
Overall, discharge was the aim of most patients but a small group wished the order to
continue. There was a general view that discharge was not easy to obtain, with patients
having to prove that significant changes had occurred. Staying on the CTO was not
necessarily considered a failure, however, because periods of stability while outside hospital,
on the order, could also be considered a success. Anna said that discharge was a positive
experience for her and she had ‘‘got her life back’’. She felt she had been discharged
‘‘because the CTO wasn’t necessary anymore, I was fine, I was taking my meds, I wasn’t
self-harming’’.
Discussion and conclusions
Our central finding is that NZ’s CTO regime was viewed in a generally positive light by most
patients with recent experience of it who were interviewed. Most patients could articulate
clearly both the benefits and drawbacks of the order, but, contrary to our expectations, only
a minority of those interviewed strongly opposed its use in their case. It seems it would be
easy to over-rate the degree of opposition to CTOs likely to be found among patients with
recent experience of a well-embedded regime.
This is a small study, however, of a particular regime in one part of NZ. The manner in
which CTOs operate clearly depends on the resourcing and practices of local community
mental health teams. Even within Otago there is variation in the services available between
rural and urban areas.
Patients’ views of CTOs in NZ 365
The fact that only 42 patients in the original target group were interviewed is
another limitation. Due to the requirements of capacity and consent, it was inevitable
that a proportion of patients with recent experience of involuntary treatment would not
take part. This introduces the chance of bias, as it is likely that patients who benefited
more from treatment under the CTO, or had a more favourable attitude to it, were enrolled.
Nevertheless, only 6 of the 42 patients interviewed were generally opposed to use of the
order in their case. It would therefore require a high degree of opposition among the 34
patients who refused to take part to reverse the finding that most patients held generally
favourable views.
Some patients interviewed strongly opposed coerced community care, however,
particularly control over their medication and the timing of discharge from the order.
Others were ambivalent, even if they considered the benefits predominated overall (Dawson,
Romans, Gibbs, & Ratter, 2003). As Connor said, ‘‘it’s good but there’s handcuffs on it’’.
Much discussion in the patient interviews revolved around the themes of autonomy and
dependence, freedom and control, power and powerlessness, medication and its side effects,
and the desire of patients to achieve stability, meaningful relationships and a better quality of
life. The same themes have been identified in other qualitative studies of compulsory
outpatients’ experience (e.g., Canvin et al., 2002; Scheid-Cook, 1993).
Many patients expressed their dislike of restrictions placed on them. Yet, the same
patients would express their need for structure, discipline and stability, which they
acknowledged could only be supplied by the CTO. Many praised the availability of
resources, and their access to hospital and care from professionals, which they considered
was more readily available at critical times. For them, the CTO facilitated intervention when
they experienced a ‘‘crisis’’, and so provided an ‘‘insurance policy’’ or a ‘‘safety net’’.
Viewing this material as a whole, we consider patients held generally favourable opinions
of this CTO regime because:
.they assessed their experience under the order against their prior patient careers,
especially in light of negative experiences in institutions
.they considered community treatment allowed them more freedom and control over
their lives than hospital care
.they appreciated the sense of security provided and enhanced access to services in poorly
resourced systems
.they valued the ongoing support of mental health professionals and accommodation
providers
.they often viewed the order as a transitional step from a chaotic to a more stable life.
For some patients who remain firmly opposed to the CTO, its use may be so antagonizing as
to be counter-productive in their case. Assertive community treatment can still be attempted
with such patients (Petrila, Ridgely, & Borum, 2003; Stein & Diamond, 2000), and they
may be more amenable to it when compulsion is removed, but there is no guarantee that
such voluntary approaches will reach patients who persistently refuse medication and remain
seriously unwell. When such persons pose serious risks to themselves or others, the CTO
seems likely to remain the tool of choice for clinicians in NZ (Romans et al., 2004).
Mental health professionals can still seek to enhance patients’ sense of participation in
decisions about their treatment, even about matters over which authority has been
transferred by law to the clinical team. They may try to increase progressively, during the
order, the range of decisions over which patients can exert control. Helping patients identify
areas where they retain some control may also help reduce their sense of loss.
366 A. Gibbs et al.
A number of patients saw their lives divided into parts: into a mental health life, where
restrictions were in place, and a non-mental health life, where they had more control. They
were able to dilute the negative experience of compulsion by viewing the order as limited in
its impact to discrete parts of their lives, leaving other parts untouched. It is important to
recognize that serious mental disorder affects many parts of patients’ lives, but we should
understand that in distinguishing aspects of their identity in this way some involuntary
patients find hope and choice. Empowering patients to identify areas within their control
may enhance their overall experience of mental health services, even if they remain under a
CTO (Rapp, Shera, & Kisthart, 1993): being in charge of the care of children, for instance,
or maintaining their homes, or participating in recreational or educational activities.
Community treatment orders are flexible instruments. There is room for considerable
discretion to be exercised within them by clinicians and for continuing negotiation with the
patient. The orders may impose immediate restrictions, but they may also enhance a
person’s autonomy in the longer term. The experiences of the 42 patients interviewed in this
study show compulsory community care represents both a restriction on personal liberty and
an opportunity for improved health and social functioning. It is usually assessed by patients
in a longitudinal manner, against the backdrop of their prior psychiatric career.
Acknowledgements
Many thanks to all those interviewed, and to Healthcare Otago, Nikki Ratter, Sarah
Romans, Hine Forsyth and Te Oranga Tonu Tanga (Maori Mental Health Team). For
funding, we thank the Health Research Council of New Zealand.
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