This document summarizes Hannah Jobling's research on Community Treatment Orders (CTOs) in England and Wales. The research uses ethnographic methods to understand how CTOs are implemented in practice and their implications. It develops a typology of CTOs based on service user engagement (active, passive, resistant) and goals (acceptance, resistance). Case studies illustrate different experiences, influenced by context and relationships. The research aims to understand CTO outcomes based on how individuals interpret and respond to interventions, given their personal experiences and beliefs. It concludes CTO success and failure cannot be simply judged and outcomes should be viewed broadly, beyond effectiveness.

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’