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Family Perspective on Community Treatment Orders: A New Zealand Study
Abstract
People with serious mental disorders typically live with family members. Despite increasing interest in compulsory community treatment for such patients, the experience and views of their family members have been little studied.
Qualitative interviews with 27 family members, whose relatives have been subject to compulsory community treatment.
Family members are generally in favour of the use of compulsory community treatment orders. They perceive a positive influence on their relative, on themselves, on family relationships, and on relations with the clinical team. Family members are aware of the ethical and other dilemmas that attend the use of compulsory community care.
... There is now increased focus on families as partners in service delivery and their home as a locus of care. Health professionals are often encouraged or even required to involve patients' family members in decisions [3][4][5]. There has been a gradual development towards labelling the assistance family members provide for one another as 'care' and those performing it 'carers'. ...
... There is a suggestion that although some carers become more involved under the CTO, many experience insufficient consultation, unmet information needs, and are not listened to or ignored [4,[15][16][17]. Some studies indicate that that carer involvement may harm family relationships [4,5]. A lack of understanding of the legal mechanisms on behalf of carers has been observed [13,18]. ...
... However, many carers also experience being excluded, inadequately consulted, having their views ignored, or receiving insufficient information, including legal documents. Again, this is reflected in international studies [4,5,14,16,25]. ...
Background
There is an expectation in current heath care policy that family carers are involved in service delivery. This is also the case with compulsory outpatient mental health care, Community Treatment Orders (CTOs) that were introduced in England in 2008. No study has systematically investigated family involvement through the CTO process.
Method
We conducted qualitative interviews with 24 family carers to ascertain their views and experiences of involvement in CTOs. The transcripts were subjected to thematic analysis that incorporated both deductive and inductive elements.
Results
We found significant variation in both the type and extent of family carer involvement throughout the CTO process (initiation, recall to hospital, renewal, tribunal hearings, discharge). Some were satisfied with their level of involvement while others felt (at least partly) excluded or that they wanted to be more involved. Some wanted less involvement than what they had. From the interviews we identified key factors shaping carers' involvement. These included: perceptions of patient preference; concern over the relationship to the patient; carers’ knowledge of the CTO and of the potential for carer involvement; access to and relationships with health professionals; issues of patient confidentiality; opportunities for private discussions, and; health professionals limiting involvement. These factors show that health professionals have many opportunities to facilitate, or hinder, carer involvement. The various roles attributed to carers, such ‘proxy’ for patient decision, ‘gatekeeper’ to services, ‘mother’ or ‘expert carer’, however, conflict with one another and make the overall role unclear.
Conclusions
There is a need for clarification of the expectations of carers in individual care situations, for carers to be equipped with the information they need to in order to be involved, and for services to find flexible and innovative ways of ensuring continuous, open communication. The introduction of CTOs in England has not been successful in its ambition for carer involvement.
Electronic supplementary material
The online version of this article (10.1186/s12913-017-2716-z) contains supplementary material, which is available to authorized users.
... Others reported having an increased voice subsequent to the CTO process and feeling that their caring role was more recognised [36]. Interestingly, some carers reported increased involvement at the initiation of the CTO with less communication from mental health services over time, which was the opposite to reported consumer experiences of increased involvement with time [48,54]. Issues related to confidentiality were cited as barriers to carers receiving information about their relative [28]. ...
... CTOs were seen as favourable to most consumers over hospital stays and often seemed to account for their positive view [28]. Reported benefits included increased support, a sense of security, improved access to services and hospital avoidance [6,29,48,53,54] with some consumers viewing CTOs 'as a transitional step from a chaotic to a more stable life' (p.366) [35]. One study found no association for consumers between being on a CTO and recovery beliefs [64], however negative impacts for consumers on CTOs were significant and included, 'side-effects of enforced medication…an enduring sense of stigma; restrictions on place of residence …limited social and work opportunities; the feeling that others made key decisions about their lives; and not getting better, merely existing' (p.822) [28]. ...
... Conversely, references to engaging with families were made in the majority of studies, with family members often study participants. Family members were aware of potential dilemmas and tensions that came with CTO use including differing opinions between them and their relative [42,54], though often reported positive benefits of CTOs, such as increased stability for their relatives and increased connection with services and support for them and their family member [6,7,48]. Whilst the CTO gave carers evidence that their relatives illness was being taken seriously by services, they remained the primary caregiver with the major responsibility for care. ...
Background
Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders’ perspectives and experiences of care planning for consumers’ on CTOs. Methods
An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management. ResultsForty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions. Conclusions
Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the ‘control and care’ dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.
... In Ontario, the enactment of Bill 68 in December 2000 led to amendments to Ontario's Mental Health Act and the introduction of CTOs as a prescribed treatment option for the persistently mentally ill. It is viewed by many as a means of providing care and treatment for individuals diagnosed with serious mental illness that is less restrictive and intrusive than involuntary hospitalization [25]. CTOs authorize legally mandated outpatient treatment for individuals diagnosed with severe or serious mental illness usually requires that the subject of the order interact with a variety of service providers including physicians, case managers, and in some cases, stakeholders. ...
... Participants likened treatment to being on probation, even associating it with the criminal justice system. While the impressions of participants have been addressed in previous studies [37,25], no study has specifically explored participants' feelings of ambivalence. ...
... Participants frequently talked about feeling disempowered by the coercive nature of the process, but somewhat felt empowered by the improved functioning that compliance sometimes facilitated. Existing literature on CTOs does not explicitly discuss issues of disempowerment among participants; rather, most of the studies explored the subject from the perspective of service providers [25]. The insight provided by participants in the current study illuminates the feelings and impressions about the disempowering nature of treatment. ...
IntroductionThe prevalence of Community Treatment Orders (CTOs) in the Western world has generated considerable discussion regarding best practices in the outpatient treatment of the seriously mentally ill. Although problems encountered by ethnic minority communities in the various health care systems have been studied to some degree, there is an acute dearth of information on the effects of CTOs on minority individuals. This paper presents findings from research on the lived experiences of individuals from ethnic minority backgrounds who have been the subjects of CTOs in Toronto, Canada, and their perceptions of its impact on their lives.Methods
Using a qualitative phenomenological approach, in-depth semi-structured interviews were conducted with individuals who have experienced CTOs. Purposive sampling was used to recruit participants (n¿=¿24) from ethnic minority background in Toronto, Canada.ResultsParticipants perceived both positive and negative impacts of CTOs. The positives included affirmation of experiences with the mental health system; improved rapport with the case management and clinical team, increased medication compliance and feelings of empowerment. The negative feedback included feelings of being coerced and the stigma associated with it.Conclusions
The findings of this study suggest that although CTOs are not a panacea for every mental health problem, they can be effective with a specific group who choose to follow through with the expectations of the treatment. The author, however argues that for these individuals to be on a CTO before getting better treatment, brings to the fore a number of issues with the mental health system. This is particularly concerning as it pertains to individuals of ethnic minority background.
... While many studies have examined the situation for relatives of people with severe mental disorders, few have specifically examined relatives' experiences when a family member is under OC (Mullen, Gibbs, & Dawson, 2006). The relatively few studies published suggest that relatives are more satisfied than patients with OC, particularly because the scheme allows clinicians to more readily intervene in the patient's everyday problems. ...
... They nevertheless found that OC brought structure into the chaos created by the patient's lack of insight. Mullen et al. (2006) found that relatives felt that OC provided improved stability that helped the patient gain insight. This insight improved cooperation within the family and between family and clinicians. ...
The aim of this study was to explore relatives' experiences when their family member is under an outpatient commitment order. A descriptive and exploratory approach was used based on qualitative interviews with 11 relatives. The relatives felt they had responsibility for the patient, but experienced a lack of recognition for their contribution to the treatment. Relatives paid little attention to coercion, but were more concerned about whether the follow-up care improved the patient's social functioning. They further reported an unmet need for information and guidance from healthcare staff to improve cooperation in the patient's care and treatment.
... Current literature on personal experiences of CTOs is very limited and mostly descriptive. Overall, it suggests that patients hold ambivalent and sometimes contradictory views about CTOs, that family carers generally find them helpful, though limited, and that most psychiatrists find them useful [11][12][13][14][15][16][17][18]. Much less common is in-depth analysis of specific areas of interest such as the issue of insight and use of CTOs [19] or dilemmas experienced by clinicians using CTOs [20]. ...
... Despite small differences in the law and the context of its implementation, broadly speaking, our findings are not dissimilar to those of the small number of existing studies (mainly from the North America and Australasia) on experiences of CTOs [11][12][13][14][15][16][17][18]. Most notably, the literature and this study have repeatedly found that patients, clinicians and family carers consider CTOs to have benefits and disadvantages and that these lead to conflicting views (especially amongst clinicians and family carers). ...
Purpose Current literature on personal experiences of community treatment orders (CTO) is limited. This paper examines participants' experiences of the mechanisms via which the CTO was designed to work: the conditions that form part of the order and the power of recall. We also report an emergent dimension, legal clout and participants' impressions of CTO effectiveness. This paper will contribute to a fuller picture of how the law is implemented and how CTOs operate in practice. Methods In-depth qualitative interviews were conducted with a purposive sample of 26 patients, 25 psychiatrists and 24 family carers about their experiences and views of CTOs. Data were analysed using the constant comparative method. Results All three sample groups perceived the chief purpose of CTOs to be medication enforcement and that its legal clout was central to achieving medication adherence. Understanding of how the inbuilt mechanisms of the CTO work varied considerably: participants expressed uncertainty regarding the enforceability of discretionary conditions and the criteria for recall. We found mixed evidence regarding whether recall simplified responses to relapse or risk. The range of experiences and views identified within each group suggests that there is no single definitive experience or view of CTOs. Conclusions The (perceived) focus of the CTO on medication adherence combined with the variations in understanding within and across groups might not only have consequences for how CTOs are viewed and subsequently experienced, but also for broader goals in patient care and patient and carer involvement.
... Current literature on personal experiences of CTOs is very limited and mostly descriptive. Overall, it suggests that patients hold ambivalent and sometimes contradictory views about CTOs, that family carers generally find them helpful, though limited, and that most psychiatrists find them useful [11][12][13][14][15][16][17][18]. Much less common is in-depth analysis of specific areas of interest such as the issue of insight and use of CTOs [19] or dilemmas experienced by clinicians using CTOs [20]. ...
... Despite small differences in the law and the context of its implementation, broadly speaking, our findings are not dissimilar to those of the small number of existing studies (mainly from the North America and Australasia) on experiences of CTOs [11][12][13][14][15][16][17][18]. Most notably, the literature and this study have repeatedly found that patients, clinicians and family carers consider CTOs to have benefits and disadvantages and that these lead to conflicting views (especially amongst clinicians and family carers). ...
Purpose:
Current literature on personal experiences of community treatment orders (CTO) is limited. This paper examines participants' experiences of the mechanisms via which the CTO was designed to work: the conditions that form part of the order and the power of recall. We also report an emergent dimension, legal clout and participants' impressions of CTO effectiveness. This paper will contribute to a fuller picture of how the law is implemented and how CTOs operate in practice.
Methods:
In-depth qualitative interviews were conducted with a purposive sample of 26 patients, 25 psychiatrists and 24 family carers about their experiences and views of CTOs. Data were analysed using the constant comparative method.
Results:
All three sample groups perceived the chief purpose of CTOs to be medication enforcement and that its legal clout was central to achieving medication adherence. Understanding of how the inbuilt mechanisms of the CTO work varied considerably: participants expressed uncertainty regarding the enforceability of discretionary conditions and the criteria for recall. We found mixed evidence regarding whether recall simplified responses to relapse or risk. The range of experiences and views identified within each group suggests that there is no single definitive experience or view of CTOs.
Conclusions:
The (perceived) focus of the CTO on medication adherence combined with the variations in understanding within and across groups might not only have consequences for how CTOs are viewed and subsequently experienced, but also for broader goals in patient care and patient and carer involvement.
... The relatives of the people under CTOs convey often feeling isolated from the treatment process by health care providers (Stensrud, Hoyer, Granerud, & Landheim, 2015) but still perceive CTOs as having a positive effect for their loved one, themselves, and their family's relationships. For example, they report CTOs increase adherence to treatment and the feeling of safety, while decreasing stress (Canvin, Rugkåsa, Sinclair, & Burns, 2014;Corring, O'Reilly, Sommerdyk, & Russell, 2019;Mullen, Gibbs, & Dawson, 2006). ...
Introduction:
For people with a serious mental disorder, a community treatment order (CTO) is a legal response that requires them to undergo psychiatric treatment unwillingly under certain conditions. Qualitative studies have explored the perspectives of individuals involved in CTOs, including persons with lived experiences of a CTO, family members and mental health care providers, who are directly involved in these procedures. However, few studies have integrated their different perspectives.
Method:
This descriptive and qualitative study aimed to explore the experience associated with a CTO in hospital and community settings among individuals with a history of CTO, relatives, and mental health care providers. Using a participatory research approach, individual semi-structured interviews were conducted with 35 participants. The data were reviewed using content analysis.
Results:
Three themes and seven sub-themes were identified: 1) differential positions as a function of meaning conferred to CTOs; 2) a risk management tool; and 3) coping strategies used to deal with CTOs. Overall, relatives' and mental health care providers' perspectives tended to be in opposition to those who went under a CTO.
Conclusions:
In a context of recovery-oriented care, more research is needed to reconcile the seemingly contradictory positions of individual with experiential knowledge and the legal leverage that deprives them of their fundamental right to autonomy.
... Important to the context of the Otago CTO Study is that it was conducted at the time jurisdictions elsewhere (Wales) were looking to introduce CTOs and broader international inquiries were being undertaken into the clinical efficacy of CTOs, especially to reduce hospital readmission rates (Churchill et al 2007 , another on women's experience of being under a community treatment order (Gibbs 2010). A third publication focuses on the experiences of family (Mullen, 2006). ...
A literature review carried out by the University of Otago into perspectives on compulsory treatment, with a focus on the people who are subjected to compulsion and a focus on tāngata whaiora (people with lived experience of mental distress), has found there is little research in Aotearoa and globally that puts their story at the center.
The resulting report, commissioned by the Mental Health Foundation with funding from the former Like Minds Like Mine mental health programme, found there is almost no research about the experience of compulsory treatment in Aotearoa let alone indigenous/Māori led studies. This is a significant finding, and the report calls for those affected the most to lead future research on the subject and to have their voices heard in the upcoming reform of the Mental Health Act.
The report is a useful starting point for anyone wanting to understand the concerns about compulsory treatment from the perspective of tāngata whaiora and engage in the development of a new transformational mental health law as an ally. It discusses the high rates of compulsory treatment in Aotearoa, the extreme disparities in its use, and the lack of evidence about the effectiveness of community treatment orders. It also includes insights into what some lived experience groups think about compulsory treatment from the submissions they made to the government public consultation in 2022 on the new mental health law.
... Therefore, the adverse societal reactions of communities towards mentally unwell individuals are pervasive. This worsens the person living with mental health problems' condition and limits the scope of their social integration [40]. It also relapses the self-stigma of the mentally distressed individuals which is assimilated with the social stereotypes and causes loss of self-esteem and deterioration of self-efficacy. ...
This paper investigates the social perception and stigmatization of individuals living with mental health problems and their caregivers in Khulna, Bangladesh.
... Therefore, the adverse societal reactions of communities towards mentally unwell individuals are pervasive. This worsens the person living with mental health problems' condition and limits the scope of their social integration [40]. It also relapses the self-stigma of the mentally distressed individuals which is assimilated with the social stereotypes and causes loss of self-esteem and deterioration of self-efficacy. ...
Background
Worldwide, mental health issues constitute a substantial threat to people’s social, economic, and mental well-being and contribute significantly to many fatalities each year. In Bangladesh, people with mental health issues typically delay contacting health professionals because they prefer traditional or religious healers. Moreover, the situation is exacerbated by a lack of awareness, social stigma, and negative perception of sufferers of mental health issues on the part of families and the community. Therefore, this paper investigates the social perception and stigmatization of individuals living with mental health problems and their caregivers in Khulna, Bangladesh.
Methods
Data were collected from university students with concurring mental health issues as well as their closest caregivers, who had in-depth knowledge of the problem and a willingness to take care of the individuals with mental health issues. Following the criteria for data collection, eight individuals living with mental health problems and five caregivers were purposively selected for this research. A semi-structured in-depth interview guide was used for the confidential data collection process, which took place in November and December 2021, and each interview lasted 40–50 min on average.
Results
This study used thematic analysis to present the results; the findings showed that: individuals afflicted with mental health problems sought both medical and spiritual support to recover. Those with mental health issues who received positive family support recovered relatively faster than those who did not. However, negative social perception and stigmatization were the key impediments for individuals suffering from mental health problems and their families, as they found it difficult to discuss their issues with relatives and communities when attempting to access support or seek remedies. Moreover, the commonality of social stigmas, such as labeling mental health problems as equal to ‘madness,’ hindered disclosure to family members, peers, and the community.
Conclusion and recommendations
In Bangladesh, the majority of individuals living with mental health problems are stigmatized and do not receive emotional support. Hence, we suggest nationwide community-based awareness-building programs to promote more positive perceptions of the fight against mental health disorders. Furthermore, counseling and awareness-building programs for effective discouragement of non-scientific remedies such as spiritual healing, as well as diagnosis and medication at the primary stage of sickness, are recommended for early detection and better medical assistance.
... 8,11 However, some studies have reported preference among patients for CCT if the alternative is admission to hospital, 12 and carers also support use of CCT. 13,14 The benefits of CCT might also result from community services being obliged to provide care instead of any direct effect on patient behaviour. 15 The ethics and effectiveness of CCT continue to be debated, with previous systematic reviews finding that CCT is of uncertain benefit. ...
Background
Compulsory community treatment (CCT) aims to reduce hospital readmissions among people with mental illness. However, research examining the usefulness of CCT is inconclusive. We aimed to assess the effectiveness of CCT in reducing readmission and length of stay in hospital and increasing community service use and treatment adherence.
Methods
For this systematic review and meta-analysis, we searched three databases (PsycINFO, MEDLINE and Embase) for quantitative studies on CCT published in English between Jan 1, 1806, and Jan 4, 2018. We included both randomised and non-randomised designs that compared CCT with no CCT, and pre-post designs that compared patients before and after CCT. Studies were eligible if they had been peer-reviewed, if 50% or more of patients had severe mental illness, and if CCT was the intervention. Trials in which CCT was used in response to a criminal offence were excluded. We extracted data on study characteristics and length of follow-up, patient-level data on diagnosis, age, sex, race, and admission history, and outcomes of interest (readmission to hospital, inpatient bed-days, community service use, and treatment adherence) for meta-analysis, for which we extracted summary estimates. We used a random-effects model to compare disparate outcome measures and convert effect size statistics into standardised mean differences. This systematic review is registered with PROSPERO, number CRD42018086232.
Findings
Of 1931 studies identified, 41 (2%) met inclusion criteria and had sufficient data for analysis. Before and after CCT comparisons showed significant large effects on readmission to hospital (standardised mean difference 0·80, 95% CI 0·53–1·08; I²=94·74), use of community services (0·83, 0·46–1·21; I²=87·26), and treatment adherence (2·12, 1·69–2·55; I²=0), and a medium effect on inpatient bed-days (0·66, 0·46–0·85; I²=94·12). Contemporaneous controlled comparison studies (randomised and non-randomised) showed no significant effect on readmission, inpatient bed-days, or treatment adherence, but a moderate effect on use of community services (0·38, 0·19–0·58; I²=96·92). A high degree of variability in study quality was found, with observational study ratings ranging from three to nine. Bias most frequently centred on poor comparability between CCT and control participants.
Interpretation
We found no consistent evidence that CCT reduces readmission or length of inpatient stay, although it might have some benefit in enforcing use of outpatient treatment or increasing service provision, or both. Future research should focus on why some people do not engage with treatment offered and on enhancing quality of the community care available. Shortcomings of this study include high levels of variability between studies and variation in study quality.
Funding
National Institute for Health Research.
... Family members interviewed also showed high levels of support for the regime (Mullen et al, 2006b) and even many patients under CTOs were found, to our surprise, either to be ambivalent about their own compulsory community care or to be mildly supportive of their treatment under the regime, often because of their strong desire to avoid further institutional care (Gibbs et al, 2005). ...
Many legal mechanisms can be used to authorise compulsory community mental healthcare: leave or conditional discharge for compulsory in-patients; adult guardianship (or incapacity) legislation; treatment as a condition of a community-based criminal sentence, like probation, or of parole from imprisonment; or a full-fledged community treatment order (CTO) scheme. It is the specific mix of mechanisms employed in a particular jurisdiction that will characterise how that legal system manages the delivery of compulsory (or quasi-consensual) community psychiatric care.
... 7 Clinicians prefer to have CTOs available as an option 8,9 and many believe CTOs have the desired effects. 10,11 Family members often find CTOs necessary or helpful 12 but are concerned that the order is insufficient to help patients lead better lives, and that other community services must also be offered. 13,14 Patients reportedly hold mixed views. ...
Objective: Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness.
Method: The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies.
Results: The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion.
Conclusion: There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs.
... Concerns have been raised about the political drivers for community treatment orders (CTOs) and whether these relate to cost saving through further de-institutionalisation (Galappathie 2008). However, it is argued that CTOs are justifiable ethically on the grounds of helping 'revolving door patients' to stay out of hospital and to progress to recovery with the help of the stabilising effects of medication (Torrey & Zdanowicz 2001, Cornwell & Deeney 2003, Mullen et al. 2006, Dale 2010, Gibbs 2010. CTOs can also be justified on the basis of fulfilling the 'least restrictive' care option. ...
The introduction of supervised community treatment, delivered through community treatment orders (CTOs) in England and Wales, contrasts with the policy of personalisation, which aims to provide service users autonomy and choice over services. This article draws upon findings from a primarily qualitative study which included 72 semi-structured interviews (conducted between January and December 2012) with practitioners, service users and nearest relatives situated within a particular NHS Trust. The article also refers to a follow-on study in which 30 Approved Mental Health Practitioners were interviewed. The studies aimed to develop a better understanding of how compulsory powers are being used in the community, within a policy context that emphasises personalisation and person-centred care in service delivery. Findings from the interview data (which were analysed thematically) suggest that service users were often inadequately informed about the CTO and their legal rights. Furthermore, they tended to be offered little, or no, opportunity to make choices and have involvement in the making of the CTO and setting of conditions. Retrospectively, however, restrictions were often felt beneficial to recovery, and service users reported greater involvement in decisions at review stage. Areas of good practice are identified through which person-centred care can be better incorporated into the making of CTOs.
© 2015 John Wiley & Sons Ltd.
... The ambivalence arose from an acknowledgement that while CTOs are coercive and constrain autonomy and agency, they may also be beneficial -a perception of CTOs that has been described in other contexts. 16,[22][23][24]37,39 This ambivalence does not describe a simple dichotomy between paternalism and autonomy 40 ; but an experience characterised by intense practical, moral, existential and legal complexity and uncertainty. ...
Objective: To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers. Method: We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies.
Results: The lived experiences were characterised by ‘access’ concerns, ‘isolation’, ‘loss and trauma’, ‘resistance and resignation’ and ‘vulnerability and distress’. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes. Conclusions: The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.
... Overall, these studies suggest that clinicians prefer to work in systems where CTOs are available [14], that views among psychiatrists often get more positive over time [7] and that many believe CTOs to have positive clinical outcomes [15,16]. In general, family members find CTOs necessary or helpful but consider the community services offered to be inadequate [17,18]. Patients reportedly hold ambivalent views, some finding aspects of the order helpful, while also restricting their lives in ways experienced as problematic [19][20][21]. ...
Community Treatment Orders (CTOs) require outpatients to adhere to treatment and permit rapid hospitalisation when necessary. They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence. In this article, we appraise the current literature on CTOs from the viewpoint of Evidence-Based Medicine and discuss the way forward for using and researching CTOs.
Non-randomised outcome studies show conflicting results, but their lack of standardisation of methods and measures makes it difficult to draw conclusions. In contrast, all three randomised controlled trials (RCTs) conducted concur in their findings that CTOs do not impact on hospital outcomes. No systematic review or meta-analysis has identified any clear clinical advantage to CTOs.
The evidence-base does not support the use of CTOs in their current form. Involuntary clinical interventions must conform to the highest standard of evidence-based care. To enable clinicians to take an evidence-based approach and to settle remaining uncertainties about the current evidence, high-quality RCTs should be designed and undertaken, using standardised outcome measures.
... This result must be considered in light of the finding that the number of detained patients in England has increased year on year since the introduction of CTOs A study that looked at the preferences of four stakeholder groups (patients being treated for schizophrenia, family members, clinicians and members of the public) concerning CTOs for individuals with schizophrenia concluded that the stakeholders were willing to accept the use of outpatient commitment to gain improved outcomes for people with schizophrenia (Swartz et al. 2003). The opinions of family members were specifically sought in one qualitative study in which they reported improvements for the service user and better family relationships in relation to the use of CTOs (Mullen et al. 2006). Of 124 individuals under a CTO in Scotland, 60% reported that they believed that the CTO had been beneficial for them, with only 15% reporting that they found it to be of no benefit (Mental Welfare Commission, 2011). ...
The use of community treatment orders (CTOs) remains controversial despite their widespread use in a number of
different countries. The focus of a CTO should be on individuals with severe and enduring mental disorders, typically
requiring adherence with recommended outpatient treatment in the community and requiring that they allow access to
members of the clinical team for the purpose of assessment. There is no current provision for CTOs under Irish mental
health legislation, although patients who are involuntarily detained under the MHA 2001 (Ireland) can be granted
approved leave from hospital. This provision allows for the patient to be managed in the community setting, though,
while technically on leave, they remain as inpatients detained under the MHA 2001 (Ireland). This article describes the
use of CTOs and considerations relating to their implementation. There is discussion of the ethical grounds and evidence
base for their use. Ethical considerations such as balancing autonomy against health needs and the utilisation of capacity
principles need to be weighed by clinicians considering the use of CTOs. Though qualitative research provides some
support for the use of CTOs, there remains a clear lack of robust evidence based findings to support their use in terms of
hospitalisation rates, duration of illness remission and improved social functioning.
... Their family members viewed the orders as necessary to control the chaos caused by the individuals' limited insight. In New Zealand, Mullen et al (2006a) found in qualitative interviews with relatives that (although they were aware of the ethical dilemmas) they reported benefits for the service user and themselves, and better family relationships and relations with the clinical team. An international study by Lawton-Smith (2005) showed marked variation in the use of CTOs, from 2 to 60 per 100 000 population in eight jurisdictions across the USA, Australia, New Zealand and Canada. ...
This article describes the background to the introduction of supervised community treatment (SCT) in the 2007 amendments to the Mental Health Act 1983 for England and Wales. The evidence base for the use of SCT in the UK and in other countries to date is considered, and guidance from the literature regarding the decision to impose it is reviewed. Early local experience of SCT is described, in part through a number of fictitious vignettes. Finally, we present a set of guidelines which may be used by clinicians when considering SCT.
... We only included papers in a certain time frame and from a given range of countries. Thus, a wide range of results that might be important to report are not considered in this review, especially from developed countries, e.g., from Australia (Chee, Ng, & Kua, 2005;Hahm & Cho, 2005;Jorm, Christensen, & Griffiths, 2005;Kim et al., 2006;Mahendran et al., 2005;Mahendran, Subramaniam, Cai, & Chan, 2006;Oshima & Kuno, 2006;Song, Chang, Shih, Lin, & Yang, 2005) or New Zealand (Kumar, Tse, Fernando, & Wong, 2006;Mullen, Gibbs, & Dawson, 2006). Moreover, many countries are not covered by this review as no data are available. ...
There is a wide range of literature on stigmatization and discrimination of people with mental illness. Most studies, however, derive from Western countries. This review aims at summarizing results from developing countries in Asia published between 1996-2006.
Medline search focusing on English-speaking literature.
Comparable to Western countries, there is a widespread tendency to stigmatize and discriminate people with mental illness in Asia. People with mental illness are considered as dangerous and aggressive which in turn increases the social distance. The role of supernatural, religious and magical approaches to mental illness is prevailing. The pathway to care is often shaped by scepticism towards mental health services and the treatments offered. Stigma experienced from family members is pervasive. Moreover, social disapproval and devaluation of families with mentally ill individuals are an important concern. This holds true particularly with regards to marriage, marital separation and divorce. Psychic symptoms, unlike somatic symptoms, are construed as socially disadvantageous. Thus, somatisation of psychiatric disorders is widespread in Asia. The most urgent problem of mental health care in Asia is the lack of personal and financial resources. Thus, mental health professionals are mostly located in urban areas. This increases the barriers to seek help and contributes to the stigmatization of the mentally ill. The attitude of mental health professionals towards people with mental illness is often stigmatizing.
This review revealed that the stigmatization of people with mental illness is widespread in Asia. The features of stigmatization-beliefs about causes of and attitudes towards mental illness, consequences for help-seeking-have more commonalities than differences to Western countries.
Background: Worldwide, mental health issues constitute a substantial threat to the social, economic, and mental wellbeing of people and contribute significantly to many fatalities each year. In Bangladesh, people with mental health issues typically delay contacting health professionals because they rely on traditional or religious healers. Moreover, the situation is exacerbated by a lack of awareness, social stigma and negative perception from families and the community towards sufferers of mental health issues. Therefore, this paper investigates the social perception and stigmatisation of mental health patients and their caregivers in Khulna city of Bangladesh.
Methods: Data were collected from university students who had concurring mental health issues and from their closest caregivers who had in-depth knowledge and willingness to take care for the patients. Following the criteria for data collection, eight (8) mental health patients and five (5) caregivers were purposively selected for this research. An unstructured in-depth interview guide was used for the confidential data collection process between November to December 2021, and each interview lasted for, on average, 40-50 minutes.
Results: This study used thematic analysis to present the results, and the findings showed that: mental health patients seek both medical and spiritual support to recover. Mental health patients with positive family support improved quicker than those with the opposite. However, negative social perception and stigmatisation are the key impediments for mental health patients and their families to discuss their issues with relatives and communities to get support or to seek remedies. Moreover, the commonality of social stigmas, such as labelling mental health problems equal to ‘madness’, hinders disclosure to family members, peers, and the community.
Conclusion and recommendations: In Bangladesh, the majority of mental health patients are stigmatized without receiving emotional support. Hence, we suggest nationwide community-based awareness-building programs to promote positive perceptions against mental-health disorders. Besides, counselling and awareness-building programs for effective prevention against non-scientific remedies, such as spiritual healing; and diagnosis at the primary stage of sickness and medication, are recommended for early detection and better medical assistance.
Involuntary treatment orders (ITOs) represent coercive leverage for treatment adherence against the will of individuals incapable of providing consent. ITOs have failed to demonstrate benefits in quantitative studies, but little attention has been paid the growing body of qualitative evidence on ITOs. The current study is an interpretative meta-synthesis designed to integrate qualitative evidence and enhance our understanding of stakeholders’ perspectives (service users, relatives, professionals, psychiatrists) of ITOs in the context of mental health care. Forty-four studies met the following inclusion criteria, peer-reviewed empirical qualitative studies, and focus on perspectives and experiences of ITOs in a mental health context. Themes resulting from the analysis are: an ITO as leverage to manage compliance and risk; legal concerns; learning to play the game; building a therapeutic relationship in a coercive context; positive and negative impacts of ITOs; family involvement; and discharge. Based on these themes, an exploratory model of ITOs is proposed.
Qualitative studies provide a different kind of understanding of the effectiveness of community treatment orders (CTOs) by exploring the perspectives of stakeholders. This article documents a systematic review of 12 qualitative studies that explored the views of families of individuals on a CTO. Relevant databases and grey literature were searched. Themes were identified: the benefits of CTOs outweigh the disadvantages, CTOs increased their involvement in care, and families were dissatisfied with aspects of the CTO process. Recommendations include how to maximize the benefits of CTOs, reduce administrative burdens and employ strategies to increase involvement of families in the care of their loved ones.
Background: Coercion comprises formal coercion or compulsion [treatment under a section of the Mental Health Act (MHA)] and informal coercion (a range of treatment pressures, including leverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.
Design: The programme comprised three studies, with associated substudies: Oxford Community
Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial
comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during
treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative
study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.
Participants: Participants in the OCTET Study were 336 patients with psychosis diagnoses, currently
admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.
Outcomes: The OCTET Trial primary outcome was psychiatric readmission. Other outcomes included
measures of hospitalisation, a range of clinical and social measures, and a newly developed measure
of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the
primary outcome was the level of disengagement during the 36 months.
Results: Community treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for
professionals about how to exercise leverage.
Conclusions: Community Treatment Orders do not deliver clinical or social functioning benefits for
patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal
coercion is widespread and takes different forms.
Trial registration: Current Controlled Trials ISRCTN73110773.
Funding: The National Institute for Health Research Programme Grants for Applied Research programme.
IntroductionLimitations of mental health services researchComponents of mental health services for schizophreniaMultidisciplinary community teamsSpecialized teamsSpecialist teams or specialist functions?Controversies and ethics in schizophrenia careConclusions
References
Our aim was to determine the views and experiences of carers of people with severe mental illness in regard to Community Treatment Orders (CTOs).
Questionnaires were posted using the mailing lists of two well-established carer support organisations in Victoria. The questionnaires included information about the person with a mental illness, the carer and their experience of care (ECI) and knowledge of recovery (RKI).
In total, 278 questionnaires were sent and 63 returned, of which 62 provided valid data. Those who responded were predominantly female (90%) and older (mean age 63 years), and were the carer of a person with a severe and recurrent mental illness. Some 60% had experience of caring for a person on a CTO. Most felt the CTO had been of benefit, and in 89% the person relapsed and needed further treatment when the CTO was stopped.
Mental health legislation is shifting to bring a greater focus on rights, individual choice and autonomy in line with recovery-oriented care. This study describes the impact of severe mental illness and decisions in relation to CTOs on carers.
© The Royal Australian and New Zealand College of Psychiatrists 2015.
The shift from hospital-based care to community-based programs for people with serious and persistent mental illnesses has led to the creation of numerous treatment programs, including the recent implementation of community treatment orders (CTOs). This form of mandated outpatient commitment is controversial because it is widely acknowledged to be a coercive intervention. Yet, there is little discussion about why this intervention is considered coercive and whether coercion is acceptable in the context of emerging commitments to recovery for people with serious and persistent mental illnesses. Moreover, there is a need to evaluate whether CTOs advance or undermine the interests of people who are diagnosed with mental illness. This paper seeks to contribute to a discussion of these issues by exploring coercion and its role in community mental health care, and how it may co-exist with recovery in the implementation of community treatment orders.
Legislation that permit compulsion in the community exist in many countries despite limited evidence for how they work.' 57 In most industrialised, Western countries, there has been a gradual change over the last few decades towards delivering mental health care in the community and not in hospital settings. In addition to an increased concern with cost-effectiveness in service delivery, advances in psychopharmacology and pressures from user organisations have contributed to this deinstitutionalisation (Crossley, 2004; Williams, 2009). As a consequence, the threshold for hospitalisation is higher and a larger proportion of people with severe and enduring mental illness are being treated in the community (Molodynski, Rugkåsa & Burns, 2010). This presents new challenges to service providers regarding those patients who refuse treatment, but whose lives are being adversely affected as a result of their mental illness. At a policy level, the response to these challenges has in many cases been to introduce legislation that allows for compulsory community treatment. This makes it a legal requirement for a patient to adhere to their treatment plan, and allows for swift recall to hospital should he or she fail to do so. In this article I will review different fea-tures of compulsion in the community. First I describe different legal regimes and current use. Second, I present the (some-what limited) research on the effectiveness of community compulsion and how it is experienced. Third, I compare the public discourses that surrounded the introduc-tion of these legal regimes in various ju-risdictions. Finally, I conclude that further evidence is needed to fully understand the effects of community compulsion and to design better services for patients. Different legal regimes for community compulsion
An interview-based study of 42 people with serious mental illness was undertaken in New Zealand during the early 2000s. Of the 42 people, 10 were women. The women were either currently on a Community Treatment Order or had been recently discharged from a long period of being on a Community Treatment Order. Analysis of the original interview data revealed how these women experienced both benefits and limitations under conditions of compulsory community treatment. The women's key workers, clinicians, and nominated family members were also interviewed. The findings indicate that women considered the overall advantages of Community Treatment Orders to outweigh the disadvantages. Advantages included: greater access to treatment and respite care in hospital; and an increased sense of safety and reassurance for women and their families. Disadvantages included: some restrictions, such as where women resided; feelings of stigma; and having to comply with treatment with the threat of being returned to hospital if they did not. Overall, Community Treatment Orders made a significant impact on the lives of the 10 women but they also allowed the women to remain out of hospital long enough to rebuild their lives and maintain their close relationships.
The use of involuntary outpatient commitment (IOC) is a significant international issue. Variations can be found in Australia, New Zealand, Scotland, Ontario (Canada), Switzerland, and the United States. Its use varies considerably by country and in the United States, between states. In Florida, the IOC statute has been used sparingly. This paper first presents information about the first fifty IOC cases in Florida including a description of the pre- and post-IOC order emergency commitments and state hospital admissions of these individuals. It then provides results from a survey of mental health professionals about their experience with and opinions about IOC. The majority of the individuals with IOC orders had at least one emergency commitment in the two years pre-IOC order (n = 46; range 1–7) and in the two years post-IOC order (n = 41; range 1–13). While 41 individuals experienced 68 total emergency commitments in the 180 days prior to the IOC order, 18 individuals had 24 emergency commitments in the 180 days after the order. Eleven had at least one state hospital admission pre-IOC order, with eight having such an admission post-IOC order. Results from the survey suggest that a number of issues have reduced the use of IOC, including difficulties in applying the statute, inadequate clinical resources, and skepticism regarding the practical effect of an IOC order on positive clinical outcomes. The implications of these results for policy development are discussed.
Background: Judgments about insight and compulsory treatment are routine, though contentious, aspects of psychiatric practice. But how should judgments about patients' insight inform involuntary treatment decisions? Aims: To explore the role played by judgments about patients' insight in reasoning concerning the use of community treatment orders (CTOs) in New Zealand. Method: Interviews were conducted with 42 patients treated on CTOs, their clinicians, and carers, concerning reasons for involuntary outpatient care. Their comments concerning patients' insight were analysed to investigate how they used the concept in reasoning about involuntary care. Results: Lack of insight was viewed as an important indicator for compulsory outpatient treatment, due to the perceived link with treatment compliance. There was also a common perception that outpatients could progressively gain insight during sustained treatment on a CTO. Obtaining good insight was not necessarily viewed as an indicator for discharge from a CTO, however, if the patient posed continuing risks of harm, or had a rapid or severe relapse profile. Conclusion: The patient's potential for treatment compliance appeared to be the primary focus of involuntary treatment decisions. Improved insight acted as one important indicator that such compliance would occur.
Schizophrenia has been at the centre of psychiatry’s development. The severity of schizophrenia’s disabilities, in both its
acute and more long-term phases, ensures its dominance in service planning. Self-neglect, apathy and disability derived from
negative symptoms and cognitive dysfunction require social care and support as a central part of services. For practical purposes
this means that the history and configuration of psychiatric services are broadly equivalent to the history and configuration
of schizophrenia services.
There is ongoing debate in the UK as to the place of coercion and compulsion in community mental health care. Recent changes in service provision and amendments to the Mental Health Act in England and Wales have increased the scope for compulsion in the community. This has intensified the debate revealing fault lines in the psychiatric and legal professions. Despite powerful arguments from all sides there is little empirical evidence to inform this debate at a clinical or a theoretical level. This review utilizes evidence from articles in peer reviewed journals. Papers were identified from electronic databases, the authors' databases of relevant literature and personal correspondence with experts in the field. The evidence base is relatively small but is expanding. It has been demonstrated that informal coercion is common in USA mental health services and can be experienced negatively by patients. There is evidence that powers of compulsion in community mental health care are used frequently when available and their availability is generally seen as positive by clinicians when practice becomes embedded. The evidence for the effectiveness of compulsion in community mental health care is patchy and conflicting, with randomized or other trials failing to show significant benefits overall even if secondary analyses may suggest positive outcomes in some subgroups. There are widespread regional and international differences in the use of community compulsion. Research examining treatment pressures (or 'leverage') and the subjective patient experience of them appears to be expanding and is increasing our awareness and understanding of these complex issues. There is an urgent need for evidence regarding the usefulness and acceptability of compulsion in the community now that powers have been made available. Trials of the effectiveness of compulsion are needed as is qualitative work examining the experiences of those involved in the use of such orders. These are needed to help clinicians utilize the powers available to them in an informed and judicious fashion and to ensure adequate training.
Involuntary outpatient commitment (IOC) has been in use in various countries for a number of years and has recently been implemented (in the form of supervised community treatment) in England and Wales. Several studies indicate that IOC reduces relapse and readmission rates and decreases length of stay on inpatient units in patients diagnosed with schizophrenia. The aim of the present study was to examine whether the use of IOC in the Australian context, in the form of community treatment orders (CTOs), may be associated with a reduction in problem behaviours and improved social functioning.
A naturalistic retrospective mirror image study of case notes, with each case serving as its own control, was used. Behavioural and social outcomes were examined: episodes of aggression and suicidal and self-harming behaviour, episodes of homelessness, frequency of contact with family members and overall quality of relationship between family and patient, and employment status.
Ninety-four sets of case notes were identified as meeting the criteria for inclusion. The number of episodes of aggression was found to be halved from the year before the CTO to the subsequent year (p<0.0001). Significant reductions in the number of episodes of homelessness were experienced by patients (p<0.05) when the pre-CTO year was compared with the CTO year.
A CTO may contribute to improved outcomes related to patient quality of life. This may be seen to mitigate concerns about infringement of civil rights.
Clinicians who treat patients using Community Treatment Orders (CTOs) face many potential dilemmas in their relations with involuntary outpatients and the exercise of their powers. We compare the dilemmas identified in the literature with those reported by responsible clinicians in New Zealand (NZ). These clinicians experienced a number of well-known dilemmas, such as determining the right moment for a person's discharge from a CTO, but they seemed less troubled by some other difficulties than might be expected, usually because they considered involuntary outpatient treatment the best option for the patient or the best way to manage the risks involved. Further dilemmas were identified by the NZ clinicians that have not been widely discussed, concerning the proper scope of clinical authority over patients under CTOs and the decision to revoke involuntary outpatient status. In conclusion, some suggestions are made as to how clinicians might best manage the dilemmas involved.
This article discusses the major tension points in the legislation that authorises involuntary outpatient treatment for mental disorder in six British Commonwealth jurisdictions. Particular attention is paid to the role of competence (or capacity) principles in the ruling legal criteria, to the precise powers of community treatment conferred, and to the potential impact of the legislation on clinicians' liability concerns. It is argued that the conferral on clinicians of a power to administer 'forced medication' in community settings is not required to promote active use of involuntary outpatient care, and that such a power should not be provided. The article concludes with discussion of the reasons why community treatment orders are used more frequently in some jurisdictions than others.
According to the philosopher Charles Taylor (1989), the moral origins of our viewpoints remain largely implicit until some challenge pushes them into the foreground. Coercion in involuntary hospitalization has been treated as a moral construct (Wertheimer, 1993), and preliminary research suggests that patients experience it as such (Bennett et al., 1993). Today, converging notions of person-centered care, individual rights, and the centrality of agency and personhood are shifting public debate in the United States from a focus on coercion in traditional, inpatient settings to evaluating its presence in community care. Opponents of coercive practices propose empowering alternatives, while proponents question whether psychiatric treatment is even possible without a sanctioned system of coercion (Gellner, cited in Group for the Advancement of Psychiatry, 1994). Research on the imposition of mental health interventions in community settings will not provide answers to the ethical questions raised. However, it can problematize coercion as a moral construct while examining its effect as a treatment strategy.
On the evening of 23 February 2000 at the Maudsley Hospital in London the motion ‘This house believes that compulsory community treatment is not justified’ was debated in front of an audience of mental health professionals, carers, service users and other members of the general public. Peter Campbell, a mental health system survivor, and Dr Frank Holloway, consultant psychiatrist at the South London and Maudsley Trust, supported the motion. Cliff Prior, Chief Executive of the National Schizophrenia Fellowship (NSF), and Professor Tom Burns, professor of community psychiatry at St George's Hospital Medical School, opposed it.
An outline of a general inductive approach for qualitative data analysis is described and details provided about the assumptions and procedures used. The purposes for using an inductive approach are to (1) to condense extensive and varied raw text data into a brief, summary format; (2) to establish clear links between the research objectives and the summary findings derived from the raw data and (3) to develop of model or theory about the underlying structure of experiences or processes which are evident in the raw data. The inductive approach reflects frequently reported patterns used in qualitative data analysis. Most inductive studies report a model that has between three and eight main categories in the findings. The general inductive approach provides a convenient and efficient way of analysing qualitative data for many research purposes. The outcomes of analysis may be indistinguishable from those derived from a grounded theory approach. Many researchers are likely to find using a general inductive approach more straightforward than some of the other traditional approaches to qualitative data analysis. A general inductive approach for qualitative data analysis David R. Thomas, School of Population Health, University of Auckland, August 2003 2 A general inductive approach for qualitative data analysis There is a wide range of literature that documents the underlying assumptions and procedures associated with analysing qualitative data. Many of these are associated with specific approaches or traditions such as grounded theory (Strauss & Corbin, 1990), phenomenology (e.g., van Manen, 1990), discourse analysis (e.g., Potter & Wetherall, 1994) and narrative analysis (e.g., Leiblich, 1998). However some analytic approaches are "generic" and are not labelled within one of the specific traditions of qualitative research (e.g., Ezzy, 2002; Pope, Ziebland, & Mays, 2000; Silverman, 2000). In working with researchers who adopt what has been described as a "critical realist" epistemology (Miles & Huberman, 1994) the author has found that many researchers unfamiliar with any of the traditional approaches to qualitative analysis, wish to have a straightforward set of procedures to follow without having to learn the technical language or "jargon" associated with many of the traditional approaches. Often they find existing literature on qualitative data analysis too technical to understand and use. The present paper has evolved from the need to provide researchers analysing qualitative data with a brief, non-technical set of data analysis procedures. A considerable number of authors reporting analyses of qualitative data in journal articles (where space for methodological detail is often restricted) describe a strategy that can be labelled as a "general inductive approach." This strategy is evident in much qualitative data analysis (Bryman & Burgess, 1994; Dey, 1993), often without an explicit label being given to the analysis strategy. The purpose of the present paper is to describe the key features evident in the general inductive approach and outline a set of procedures that can be used for the analysis of qualitative data. The inductive approach is a systematic procedure for analysing qualitative data where the analysis is guided by specific objectives.
This paper examines, in terms of a complex loss, the experiences of people who have a family member who suffers from serious mental illness. Whilst partnership between professionals and family carers is clearly being encouraged and is doubtless laudable in the whole area of health and social care, there seem to be serious obstacles to successful collaboration between families and professionals involved in serious mental illness. Part of the reason for this is that the emotional experiences of relatives are not well understood. This paper uses interview material from a larger qualitative study of an ethnically diverse sample to argue that the families of people with serious mental health problems need to be understood as having experienced a complex loss. The loss is complicated by (i) the continuing presence of the person who is felt to have been lost; (ii) feelings of anger (and subsequent guilt); and (iii) feelings of shame. Professionals who work with families need to be aware of the uncomfortable feelings that they are often struggling with. Professionals are in a good position to provide support in allowing those feelings to be acknowledged and to take their place in the dialogue that families need to have if they are to move on from the frustrations of the chronic grief that others have observed (MacGregor, 1994; Wasow, 1995). Published (author's copy) Peer Reviewed
Sixty-four patients were interviewed about changes to leave of absence brought about by the Mental Health (Patients in the Community) Act 1995 in the context of their views about services and medication. Few patients were clear about the change in the law,which suggests that more has to be done to inform patients of their rights and legal status. A number of patients reported difficulty in negotiating preferred medication with their psychiatrists and felt compelled to take medication that resulted in debilitating side-effects. A third of patients eligible to be interviewed agreed to an interview and ethical and practical difficulties in accessing patients for this type of research are discussed.
The authors examined the relationship between violent acts and threats by persons with serious mental illness, the size and composition of their social networks, and characteristics of the social support they received.
A group of 169 respondents with serious mental illness and 59 of their significant others were interviewed using structured and semi-structured protocols to elicit data on demographic characteristics, clinical characteristics, characteristics of respondents' social networks and of the social support they received, and perceptions of threat within the social network. Data on acts and threats of violence by respondents over an 18-month period were collected from self-reports by respondents and significant others and from hospital and court records.
Fifty-six respondents either threatened violence or committed a violent act during the study period. Respondents with a diagnosis of schizophrenia were more likely to commit violent acts but were not more likely to threaten violence than were respondents with other diagnoses. Respondents in larger networks, those with networks composed primarily of relatives, and those who lived with unrelated persons were more likely to threaten violence. Financial dependence on family was associated with more violent threats and acts. Respondents who perceived hostility from others were more likely to engage in violent threats and acts, and those with confused thinking were less likely to act or threaten violence. More than half of the targets of violence were respondents' relatives, particularly mothers living with a respondent. Respondents who were violent perceived their significant others as threatening but did not perceive themselves as being threatening in return.
The interpersonal and social contexts of respondents and their perceptions of these contexts are important considerations in assessing risk for violence by persons with mental illness. Mothers who live with an adult offspring with schizophrenia may be at increased risk for being a target of violence. Violence by persons with psychiatric disorders may be linked to their perceptions and experience of being threatened by others.
The study evaluated the effectiveness of a three-year outpatient commitment pilot program established in 1994 at Bellevue Hospital in New York City.
A total of 142 participants were randomly assigned; 78 received court-ordered treatment, which included enhanced services, and 64 received the enhanced-service package only. Between 57 and 68 percent of the subjects completed interviews at one, five, and 11 months after hospital discharge. Outcome measures included rehospitalization, arrest, quality of life, symptomatology, treatment noncompliance, and perceived level of coercion.
On all major outcome measures, no statistically significant differences were found between the two groups. No subject was arrested for a violent crime. Eighteen percent of the court-ordered group and 16 percent of the control group were arrested at least once. The percentage rehospitalized during follow-up was about the same for both groups-51 percent and 42 percent, respectively. The groups did not differ significantly in the total number of days hospitalized during the follow-up period. Participants' perceptions of their quality of life and level of coercion were about the same. From the community service providers' perspective, patients in the two groups were similarly adherent to their required treatments.
All results must be qualified by the fact that no pick-up order procedures for noncompliant subjects in the court-ordered group were implemented during the study, which compromised the differences between the conditions for the two groups, and that persons with a history of violence were excluded from the program.
A randomized controlled trial of outpatient commitment was conducted in North Carolina to provide empirical data on involuntary outpatient commitment and to evaluate its effectiveness in improving outcomes among persons with severe mental illnesses.
A total of 331 involuntarily hospitalized patients awaiting discharge under outpatient commitment were randomly assigned to be released or to undergo outpatient commitment. Each received case management services and outpatient treatment. Participants in both groups were monitored for one year. After the initial 90-day outpatient commitment order, a patient could receive a renewable 180-day extension. Patients in the control group were immune from outpatient commitment for one year. Information was obtained from self-reports and reports of several informants as well as from outpatient treatment, hospital, and arrest records.
In most bivariate analyses, outcomes for the outpatient commitment group and the control group did not differ significantly when the duration of outpatient commitment was not taken into account. However, patients who underwent sustained outpatient commitment and who received relatively intensive outpatient treatment had fewer hospital admissions and fewer days in the hospital, were more likely to adhere to community treatment, and were less likely to be violent or to be victimized. Extended outpatient commitment was also associated with fewer arrests of participants with a combined history of multiple rehospitalizations and previous arrests. The intervention was particularly effective among individuals with psychotic disorders.
Outpatient commitment can improve treatment outcomes when the court order is sustained and combined with relatively intensive community treatment. A court order alone cannot substitute for effective treatment in improving outcomes.
Study findings indicating that involuntary outpatient commitment can improve treatment outcomes among persons with severe mental illness remain controversial. Opponents of outpatient commitment argue that its coerciveness is unacceptable even given its arguable benefits. However, it is unclear to what extent the public debate surrounding outpatient commitment represents the preferences of persons with a stake in the benefit or harm resulting from outpatient commitment. This study examines and compares views of outpatient commitment among four stakeholder groups: 1) persons in treatment for schizophrenia and related disorders, 2) family members of persons with these disorders, 3) clinicians treating persons with these disorders, and 4) members of the general public.
Subjects from the Piedmont region of North Carolina who were members of the four stakeholder groups were presented with short vignettes that depicted potential outcomes that were associated alternatively with outpatient commitment and with voluntary treatment. Subjects rated each vignette according to how positively or negatively they viewed the overall situation for the individual described. Multivariate regression techniques were used to estimate preference weights for each stakeholder group.
With some exceptions, each group gave the highest preference to avoiding involuntary hospitalization, followed by avoiding interpersonal violence and maintaining good interpersonal relationships. No group gave appreciable importance to outpatient commitment, which suggests that avoiding its coerciveness is a lesser concern compared to other outcomes.
The findings suggest that these stakeholders are willing to accept the coerciveness of outpatient commitment to gain improved outcomes for certain persons with schizophrenia and related disorders.
A variety of tools are being used as leverage to improve adherence to psychiatric treatment in the community. This study is the first to obtain data on the frequency with which these tools are used in the public mental health system. Patients' lifetime experience of four specific forms of leverage-money (representative payee or money handler), housing, criminal justice, and outpatient commitment-was assessed. Logistic regression was used to examine associations between clinical and demographic characteristics and receipt of different types of leverage.
Ninety-minute interviews were conducted with approximately 200 adult outpatients at each of five sites in five states in different regions of the United States.
The percentage of patients who experienced at least one form of leverage varied from 44 to 59 percent across sites. A fairly consistent picture emerged in which leverage was used significantly more frequently for younger patients and those with more severe, disabling, and longer lasting psychopathology; a pattern of multiple hospital readmissions; and intensive outpatient service use. Use of money as leverage ranged from 7 to 19 percent of patients; outpatient commitment, 12 to 20 percent; criminal sanction, 15 to 30 percent; and housing, 23 to 40 percent.
Debates on current policy emphasize only one form of leverage, outpatient commitment, which is much too narrow a focus. Attempts to leverage treatment adherence are ubiquitous in serving traditional public-sector patients. Research on the outcomes associated with the use of leverage is critical to understanding the effectiveness of the psychiatric treatment system.
Stigma affects not only people with mental illnesses, but their families as well. Understanding how stigma affects family members in terms of both their psychological response to the ill person and their contacts with psychiatric services will improve interactions with the family.
To investigate factors of psychological significance related to stigma of the relatives.
In a Swedish multi-centre study, 162 relatives of patients in acute psychiatric wards following both voluntary and compulsory admissions were interviewed concerning psychological factors related to stigma.
A majority of relatives experienced psychological factors of stigma by association. Eighteen per cent of the relatives had at times thought that the patient would be better off dead, and 10% had experienced suicidal thoughts. Stigma by association was greater in relatives experiencing mental health problems of their own, and was unaffected by patient background characteristics.
Interventions are needed to reduce the negative effects of psychological factors related to stigma by association in relatives of people with mental illness.
Using New York's "Kendra's Law" as an illustrative vehicle, this article addresses the principal criticisms lodged by opponents of preventive outpatient commitment. The authors argue that preventive outpatient commitment is a useful adjunct to conditional release or placement in the least restrictive alternative that has neither produced revolutionary change in psychiatric commitment standards nor will be used inappropriately to assert governmental control over mentally ill citizens. The authors contend additionally that preventive outpatient commitment does not violate federal constitutional norms or represent bad policy making. The authors acknowledge, however, that the coercion inherent in outpatient commitment schemes may produce certain undesirable side effects. Thus, they explore an alternative approach currently in development in Australia that promotes community-based treatment for chronically mentally ill persons without judicial intervention.
Issues of concern regarding coercion of psychiatric patients, which were once relevant only to psychiatric hospitalization, are now applicable to the community arena as well. The need to understand coercive treatment strategies used in community settings for handling those with severe mental disorders is pressing, as the consequences of the competing values between preserving individual autonomy and protecting vulnerable individuals are far more visible in a growing population of mentally ill people living in the community. For example, homeless mentally ill persons on the streets of virtually every large urban area raise the issue of whether these individuals have an inherent right to remain in this situation or whether they should be forced into hospitals, homeless shelters, or other structured housing arrangements. These types of dilemmas that are being confronted today make the use of coercive strategies to force compliance with outpatient treatment quite attractive to some (Mulvey, Geller, & Roth, 1987). Coerced treatment includes mandated attendance at day programs, counseling, and acceptance of neuroleptic medication enforced by a threat of institutional controls. The situations that necessitate coercing patients into receiving needed treatment are not going to go away; therefore, coercive strategies will persist and “can no longer be ignored” (Steinwachs et al., 1992, p. 649).
Since the passing of the Mental Health Act (1986), Victoria, Australia, has implemented Community Treatment Orders (CTOs) as an alternative to involuntary inpatient admission for patients who are assessed as unable to be treated less restrictively but in an effort to avoid frequent hospital admissions. It is estimated that currently 3,000 people are annually placed on CTOs in this Australian state. The following article will review existing international and national literature on the subject of forms of involuntary treatment in the community before reporting on the findings of a research project that focused on gaining both consumer and service provider perspectives on the efficacy of CTOs. The research method was largely qualitative, involving three focus groups attended by 30 consumers, as well as 18 individual interviews with service providers. The aim of the project was to offer a voice to both consumers and service providers about their experiences and views of current practice and policy implementation in an area that can have a profound effect on the rights of consumers. Findings suggest that CTOs involve complex decision-making that tests professionals' ability to make judgements about legal and clinical processes. Consumers were generally dissatisfied with many aspects of the use of CTOs and both groups tended to view CTOs as stigmatising and disempowering. There were a variety of views expressed about the process of admission, discharge, and community supports. The article concludes by discussing the findings in the context of existing national and international literature and makes a number of recommendations about law reform, and service provision.
Background: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge. Method: A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process. Treatment recommendations: This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no special Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.
As part of a survey of 260 Oregon family members with mentally ill relatives, respondents were asked about their experiences with civil commitment and their opinions about proposed modifications in the commitment statutes. Family members typically described their mentally ill relative as a schizophrenic man in his thirties who had had six psychiatric hospitalizations and was currently being treated with medications at a community mental health center. Three-fourths of the relatives had been committed. A majority (57 percent) of the respondents were in favor of mandatory outpatient treatment and medication after involuntary hospitalization but were not enthusiastic about outpatient commitment without hospitalization. Family members also wanted more education about mental illness, more information about the commitment process, and assignment of a professional to help in the commitment process.
Research shows a higher risk of relapse among schizophrenics in high "expressed emotion" families. In this paper, the measure called "expressed emotion" is conceptualized as an indicator of family attempts to socially control the schizophrenic person's behavior in a particular way. This social control conceptualization is supported by a review of the type of information in the measure. Hypotheses following from this view are examined to assess the construct validity of the measure conceptualized as a type of social control. First, attempts at control are hypothesized to be ways anxious and fearful families try to cope. Second, the family's recognition of the schizophrenic's problem as mental illness is hypothesized to reduce the fearful and anxious family's likelihood of an intense interpersonal social control coping response. This type of social control of involuntary illness behaviors would be abandoned as unjust and unlikely to be effective. Data from the pioneering 1972 study by Brown, Birley, and Wing (Br. J. Psychiatry 121:241-258) provide support for these hypotheses and thus provide support for this social control conceptualization.
The aim of this study was to develop a practical, comprehensive, and valid self-report measure of the experience of caring for a relative with a serious mental illness. The notion of caregiver "burden' was rejected; instead caregiving was conceptualised within a 'stress-appraisal-coping' framework. A 66-item version of the Experience of Caregiving Inventory (ECI) was derived from analyses of responses from 626 caregivers, and then tested on an independent sample of 63 relatives of patients with schizophrenia recently in acute care. The extent to which the ECI complied with the stress-coping model was tested, especially the degree to which it, in association with coping, predicted psychological morbidity in carers. Ten sub-scales with good internal consistency resulted from our analyses, eight negative (difficult behaviours; negative symptoms; stigma; problems with services; effects on the family; the need to provide backup; dependency; loss) and two positive (rewarding personal experiences; good aspects of the relationship with the patient). The ECI, in conjunction with coping style, predicted a large proportion of the variance in the General Health Questionnaire (GHQ). We concluded that the ECI taps salient dimensions of caregiving distinct from, although linked with, coping and psychological morbidity. It has potential as a useful outcome measure for interventions aimed at promoting caregiver well-being.
Many experimental trials of community mental health interventions fail to develop testable conceptual models of the specific mechanisms and pathways by which relevant outcomes may occur, thus falling short of usefully interpreting what happens inside the experimental "black box." This paper describes a conceptual model of involuntary outpatient commitment (OPC) for persons with severe and persistent mental disorders. The model represents an attempt to "unpack" the effects of OPC by incorporating several interacting variables at various stages. According to this model, court-mandated outpatient treatment may improve long-term outcomes both directly and indirectly in several ways: by stimulating case management efforts, mobilizing supportive resources, improving individual compliance with treatment in the community, reducing clients' psychiatric symptoms and dangerous behavior, improving clients' social functioning, and finally by reducing the chance of illness relapse and rehospitalization. A randomized clinical trial of OPC is underway in North Carolina that will test the direct and indirect effects suggested by this model, using longitudinal data from the multiple perspectives of mental health clients, family members, and case managers.
Families' difficulties in getting treatment for highly disruptive, assaultive, or suicidal family members are compounded by patients' resistance, their resentment if relative seek forced interventions, and systemic and legal barriers to timely care. Consumer services and outreach may be a route to voluntary treatment.
In the light of recent legislation, this paper reviews the implementation of the Community Treatment Order (CTO) in terms of clinical efficacy and ethical issues involved in its use. The debate surrounding the introduction of CTOs in other countries is explored.
A Medline search was conducted and references of recent articles followed up, with attention to Australian, New Zealand and international trends. A review of relevant legislation and government reports was conducted.
There has been limited debate in the Australian and New Zealand literature concerning the operation of CTOs. Despite their increasing and widespread use, there is a paucity of research on the efficacy of CTOs. Concerns about their negative effects on civil liberties have been stressed in the United Kingdom and American literature.
If the continued use of CTO is to be justified, both clinically and from the civil liberties perspective, controlled research needs to be carried out to identify whether CTOs are more effective than comprehensive assertive community outreach programs in reducing relapse rates and hospitalisation, and increasing compliance. Clinical guidelines concerning who is most likely to respond to such orders need to be developed. Alternatives to the CTO are explored, and future directions in research are outlined.
Little is known about the coercive pressures brought to bear on psychiatric patients in the hospitalization process. Significant methodological hurdles stand in the way of this research. Most notably, reliable and valid methods of ascertaining and quantifying perceptions of coercion have not been developed. This report summarizes the findings of an exploratory study designed to gather data needed to refine the conceptualization and measurement of coercion. Multiple perspectives on admission incidents for forty-three patients (26% of whom were involuntarily hospitalized) were obtained. Patients were administered research interviews and completed a self-administered inventory shortly after the admission decision. The admitting clinician and a family member involved in the admission were administered parallel interviews. In addition, focus groups comprised of outpatients, former patients, family members, and clinical staff were conducted to uncover the terminology and description of coercion commonly used. The implications of these preliminary quantitative and qualitative findings for future research are discussed.
Coercion during psychiatric admissions has been a topic of debate for many years. Although there has been considerable research on patients' perceptions of coercion, there has been no work on who places pressures on patients to be admitted.
This article integrates interview data from interviews with patients, admitting staff and family and friends to describe the pressures brought to bear on patients to be admitted.
Health-care professionals appear to be the most important source of pressures on patients, and to have the most impact on patients' perceptions of coercion. However, there are differences in type of pressure, and the pressures used by family and friends appear to have the most longstanding impact.
Legal and clinical efforts to reduce the level of coercive pressures on patients need to recognize the importance of mental-health professionals, including especially those who are not legally mandated to participate in the admission process.
Policy makers have recently begun to reconsider involuntary outpatient commitment as a means of enhancing public safety and providing mental health services to people deemed to be noncompliant with treatment. The authors review the therapeutic claims for outpatient commitment and take the position that there is insufficient evidence that it is effective. They offer arguments that outpatient commitment may not improve public safety and may not be more effective than voluntary services. The authors further point out that outpatient commitment may undermine the delivery of voluntary services and may drive consumers away from the mental health system. The authors conclude that outpatient commitment programs are vulnerable to legal challenge because they may depart from established constitutional standards for involuntary treatment.
The authors describe studies showing the effectiveness of involuntary outpatient commitment in improving treatment compliance, reducing hospital readmission, and reducing episodes of violence among persons with severe psychiatric illnesses. They point out that because of its role in enhancing compliance with treatment, outpatient commitment can be regarded as a form of assisted treatment, such as assertive case management, representative payeeship, and mental health courts. The authors argue that such assisted treatment is necessary for persons with severe psychiatric illnesses who are noncompliant with their medication regimens because many lack awareness of their illnesses because of biologically based cognitive deficits. They recommend outpatient commitment for any individual with a severe psychiatric disorder who has impaired awareness of his or her illness and is at risk of becoming homeless, incarcerated, or violent or of committing suicide, and they provide case examples. The authors conclude by addressing eight of the most common objections to outpatient commitment by mental health professionals and civil liberties groups that oppose outpatient commitment.
To assess the uses of Community Treatment Orders (CommTOs) in New Zealand.
A retrospective study of patients' records held by the regional administrator of mental health legislation and a survey of psychiatrists attending a conference in Dunedin.
Males under Community Treatment Orders (CommTOs) outnumbered females 6:4; a high proportion were considered to have a major psychotic disorder; and one fifth remained under a CommTO for more than a year without inpatient care. Among the psychiatrists, there was a high level of agreement that, when used appropriately, the benefits of CommTOs outweigh their coercive impact on the patients; the most strongly supported indicator for use was the promotion of compliance with medication. The rate of use of CommTOs in Otago is remarkably similar to the rate in Victoria, Australia.
Records suggest that a significant proportion of patients under CommTOs are not soon readmitted; and many clinicians in New Zealand consider CommTOs to be a useful strategy for managing the community care of long-term patients with schizophrenia and major affective disorders.
Clinicians working in community mental health must currently attempt to reconcile competing practice perspectives: on the one hand consumer-driven approaches, and on the other hand a move to more paternalistic practices, advocated by family support groups, and reflected in assertive treatment programs and legislative initiatives such as community treatment orders. This article reviews these different perspectives, and offers some comments on practice guidelines for those working in this clinically and politically complex environment.
Recent evidence suggests that involuntary outpatient commitment (OPC), when appropriately applied, can improve adherence with psychiatric treatment, decrease hospital recidivism and arrests, and lower the risk of violent behavior in persons with severe mental illness. Presumably these are benefits that improve quality of life (QOL); however, insofar as OPC involves legal coercion, the undesirable aspects of OPC could also exert a negative effect on quality of life, thus offsetting clinical benefits.
Involuntarily hospitalized subjects, awaiting discharge under outpatient commitment, were randomly assigned to be released or continue under outpatient commitment in the community after hospital discharge, and were followed for one year. Quality of life was measured at baseline and 12 months follow‐up. Treatment characteristics and clinical outcomes were also measured.
Subjects who underwent longer periods of outpatient commitment had significantly greater quality of life as measured at the end of the 1 year study. Multivariable analysis showed that the effect of OPC on QOL was mediated by greater treatment adherence and lower symptom scores. However, perceived coercion moderated the effect of OPC on QOL.
Involuntary outpatient commitment, when sustained over time, indirectly exerts a positive effect on subjective quality of life for persons with SMI, at least in part by improving treatment adherence and lowering symptomatology. Copyright © 2003 John Wiley & Sons, Ltd.
To determine New Zealand mental health clinicians' views about community treatment orders, indications for their use, their benefits, problems and impact on patients and therapeutic relationships.
A national survey of New Zealand psychiatrists and a regional survey of non-psychiatric community mental health professionals for comparison.
The great majority of NZ psychiatrists prefer to work with community treatment orders as an option. They consider they are used properly in most cases, can enhance patients' priority for care, provide a structure for treatment, support continuing contact and produce a period of stability for patients during which other therapeutic changes can occur. They consider these orders can harm therapeutic relationships, especially in the short term, but when used appropriately their overall benefits outweigh their coercive impact. The other mental health professionals surveyed have similar views. A minority of clinicians do not support their use.
The precise impact of community treatment orders on patients' quality of life remains an open question. Until that matter is more clearly resolved, New Zealand law should continue to authorise compulsory outpatient care, provided it is carefully targeted and adequate community services are available.
To consider the impact of community treatment orders (CommTOs) on Maori patients and their whanau (extended family) and the associated views of mental health professionals.
As a distinct aspect of a larger study of CommTOs, eight Maori patients under compulsory community care were interviewed and, where possible, members of their whanau. Associated interviews were held with their psychiatrists, key workers and other carers: 39 interviews in total.
Both benefits and drawbacks of CommTOs for Maori were identified by patients and whanau. CommTOs were considered helpful in increasing patient safety and whanau security and in promoting access to services. They were favoured over hospital care, forensic care and homelessness. The drawbacks included the sense of external control imposed on both Maori patients and staff, particularly concerning medication and restrictions on choices.
This was a small study of a limited number of Maori patients under CommTOs. Their views may not be fully representative. There was a general consensus among those interviewed that the timely use of CommTOs can enhance the mental wellbeing and social relationships of Maori patients. Continuing efforts are needed by health professionals to communicate effectively with whanau and to understand the conflicts experienced by Maori in reconciling their traditional beliefs with the medical model of mental illness.
This study examines factors that contribute to the subjective strain experienced by caregivers of persons with severe mental illness and addresses potential improvement in caregiver strain associated with involuntary outpatient commitment. Subjects from a population of involuntarily hospitalized people awaiting discharge under outpatient commitment were randomly assigned to be released or continue under outpatient commitment after hospital discharge. A nonrandomized group with a recent history of serious violence was also studied under outpatient commitment. Randomized control and outpatient commitment groups did not differ significantly in caregiver strain. However, analyses of all subjects, including the nonrandomized violent group, showed that among subjects who underwent sustained periods of outpatient commitment, caregivers reported significantly decreased subjective strain compared with caregivers of those who underwent only brief outpatient commitment or none. Improved treatment adherence also reduced caregiver strain independently of the effect of sustained outpatient commitment.
Department of Community and Family Studies
- Anita Gibbs
Anita Gibbs, Department of Community and Family Studies, University of Otago, New Zealand.
Coercion and social control: a framework for research on aggressive strategies in community mental health
- A M Lovell
LOVELL, A.M. (1996) Coercion and social control: a framework for research on aggressive strategies in community mental health. In Coercion and Aggressive Community Treatment: A New Frontier in Mental Health
Law (eds D.L. Dennis and J. Monahan). New York: Plenum Press.
Community treatment orders: international comparisons. Otago University Print, Dunedin (available at Otago CTO study website
- J Dawson
DAWSON, J. (2005) Community treatment orders: international comparisons. Otago University Print,
Dunedin (available at Otago CTO study website http://www.otago.ac.nz/law/otagoCTO/index.html)
Stigma by association
- Ö Stman
- M Kjellin
Ö STMAN, M. & KJELLIN, L. (2002) Stigma by association. British Journal of Psychiatry, 181, 494-498.
Is involuntary treatment ever justified?
- V Bindman
PINFOLD, V. & BINDMAN, J. (2001) Is involuntary treatment ever justified? Psychiatric Bulletin, 25, 268270.