An Ethical Balancing Act? How context and causal mechanism influence Community Treatment Order outcomes

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Hannah Jobling. 'An Ethical Balancing Act: How Context and Causal Mechanisms Influence Community Treatment Order Outcomes', 33rd International Conference on Law and Mental Health, Amsterdam, July …

Hannah Jobling. 'An Ethical Balancing Act: How Context and Causal Mechanisms Influence Community Treatment Order Outcomes', 33rd International Conference on Law and Mental Health, Amsterdam, July 2013.

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  • Reverse coercion

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  • 1. An Ethical Balancing Act? How context and causal mechanism influence Community Treatment Order outcomes Hannah Jobling, University of York, Social Policy and Social Work Department, hannah.jobling@york.ac.uk
  • 2. Overview • Community Treatment Orders (CTOs) in England and Wales • Research scope and methodological approach • CTOs in practice: The creation of a typology • How we can reach an understanding of who CTOs work for in what circumstances (context), why (mechanisms) • How CTO outcomes can be reframed
  • 3. CTOs: Background • Introduced in England and Wales under the Mental Health Act 2007, became ‘live’ in late 2008. • Allow for conditions to be imposed on how mental health service users live in the community • Provide a mechanism for detention and treatment enforcement if conditions are not met, or health & safety concerns • CTOs “enforce community treatment outside (and independently) of the hospital, contain specific mechanisms for enforcement and/or revocation and are authorised by statute” (Churchill et al, 2007, 20)
  • 4. CTOs: Background • Three drivers highlighted in policy and research literature: • Revolving door (resources) • Risk management • Rehabilitation and recovery • CTOs probably the most controversial aspect of new Act: • On one hand – help to engage service users, reduce rates of hospitalisation, improve clinical outcomes and promote stability • On the other – extend compulsion, result in unnecessary coercion, loss of rights and neglect of alternative options
  • 5. An Ethnography of CTOs • Considerable scope for finding out how CTOs are practiced and what that might mean • A CTO ethnography: • Enables “the particular context of social actors and groups and the social matrices of their thoughts and behaviour” (Swanson, 2010, 185) to be accounted for • Connects stakeholder experiences to CTO-related events as they occur • Allows for CTOs to be viewed as a process, unfolding over time, mediated by contextual factors • Illuminates what CTO practice looks and feels like – joins abstract political concerns with concrete ethical dilemmas
  • 6. The Study • Aim: To find out in what ways CTOs are being implemented and with what implications for the practice and experiences of service users and practitioners. • Case study design: Two Trusts > One AOT in each Trust > 18 CTO cases across the field sites • Fieldwork took place over 8 months and tracked the progress of the 18 cases: • Interviews (some repeat) with 18 service users and 20 practitioners • Observation of key meetings, daily practice and informal interactions • Content analysis of case files • Additional research activities: • Key informant interviews with 16 practitioners • Content analysis of Trust policy
  • 7. Typology of CTOs: Societal goals and institutional means Active Acceptance Resistance Passive
  • 8. Case study: Active acceptance • James • Active acceptance something to be worked at from ‘I felt that part of my Community initial discharge Treatment Order and part of my injections were in • Taking ownership - “It belong to me”conflict because I • didn’t feel in control of my injections. I • Taking control was being told you’ve got to have them. It ? • Questions over dischargefelt like the responsibility had been taken out of my hands. It was in the Key Factors: hands of the nurses here and the • Negotiation of medication doctors here and I thought, well, that’s not fair because my CTO says I’ve got to • Collaborative work – ‘mutuality of accounts’ to be in charge be responsible; I’ve got • Making sense of the CTO –and then, when Ipurpose the developing went up to medical centre and they started doing • On-going explanation and it, I settled down aof legal development bit better.’ consciousness
  • 9. Case study: Active Resistance • ‘She’s not a risk to others or really to herself, but it’s a really tight-knit community where she lives and Sheila everyone knows her. She’d only just built up trust again there and • Bioethical balancing act now…So I think it’s about • Reinforcement of barriers to supporting her in the community care and support – ‘she’s not on my side’ really’ • No hope of discharge by either Sheila or her care coordinator • Key factors: • Active resistance either through use of legal mechanisms or avoidance • Repeat recalls – reinforcing cycles of resistance • ‘Surface’ work • Making sense of the CTO – previous difficult experiences
  • 10. Ambivalence • Michael • CTO ‘double think’ • Perspective on the CTO and sense of self • Risk and ‘dangerousness’ prominent in self-narrative – “But I don't get the injections because of the psychosis...it's required by law that I take injections now because my mental health affects other people not just myself” • Vs. hopes for the future and ‘becoming normal’ - “I'm quite happy with the way it is but I do find it a bit of a burden because I do want to go to university to study and they said under the CTO I'd still need a CPN to visit me and give me injections” • Plus perspective on services – “The CTO makes me feel stronger and more important in the eyes of the doctors” • Key Factors: • Shifting of position • Difficulties in reaching shared understandings • Greyness of how CTO mechanisms work • Discharge and ‘getting under the surface’ •
  • 11. Context and causal mechanisms • Context affects the way individuals respond to the programme concept, which in turn influences the ways they interact with programme intervention strategies. • Context • Refers both to the characteristics of those individuals made subject to a policy programme, the institutional and micro-social factors that mediate their experiences and the responses of practitioners to CTOs in general and their actions. • Complex interactions between personal values and beliefs, and past and present experiences of services, medication and relationships with professionals. • Mechanisms • Refers to the “process of how individuals interpret and act upon the intervention strategies” (Pawson and Tilley, 2004, 6). • Recall as an intervention paradox
  • 12. Concluding Thoughts: What does this mean for CTO outcomes? • Multiple intended and unintended consequences of relationship between mechanisms and context. • Judging ‘success’ or ‘failure’ • Viewing ‘outcomes’ more broadly • Moving beyond ‘effectiveness = ethically sound’