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 2013.

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

    1. 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,
    2. 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. 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. 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. 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. 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. 7. Typology of CTOs: Societal goals and institutional means Active Acceptance Resistance Passive
    8. 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. 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. 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'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. 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. 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’