Abstract
BackgroundPatients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.MethodsThe study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.ResultsThe main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.ConclusionsMany of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.
Highlights
Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment
Results from three RCTs and meta-analyses on the effectiveness of CTOs show no clear difference in service use, social functioning, mental state or quality of life compared to standard care [1, 25,26,27,28]
Some studies show that CTOs, combined with assertive community treatment (ACT) or intensive case management, were associated with positive outcomes such as decreased hospitalization, increased medication possession, reduced violence, and even increased subjective quality of life [29,30,31,32,33,34,35]
Summary
Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. Despite a lack of clear evidence of effectiveness, more than 75 jurisdictions worldwide have implemented community treatment orders (CTOs), which is a legal mechanism to secure the treatment adherence of patients with severe mental illness living in the community [1]. In Norway, the involuntary admission rates and the CTO rates are relatively high compared to other western countries and reducing the use of coercion has for many years been a central policy goal [4]. While we lack reliable knowledge about the extent of CTOs, it is estimated that more than one of three patients are placed under CTOs following involuntary hospital admissions [6]
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