Controllers and controlled: an analysis of participant constructions of outpatient commitment

Abstract

This paper utilises qualitative data to examine outpatient commitment from two points of view: clinicians (the controllers) and clients (the controlled). Outpatient commitment is a legal mechanism whereby 'mentally ill' individuals are courtordered to report to their community mental health centre for treatment. In this paper I provide the reader with an understanding of how outpatient commitment works by allowing clinicians and clients to describe the meaning outpatient commitment has for them. While the experience of outpatient commitment varies, and supports the contention that there are multiple definitions of reality, it is clear that in general clinicians favoured the greater control over clients' outpatient commitment provided and clients were cognisant of the greater liberty it afforded them. This has important theoretical implications for research into medicalisation and social control, in that providers and clients interpret medical dominance and ideology differentially. Consequently I analyse the interpretations of controllers and controlled from those sociological perspectives relevant to the issues of ideology, power, and social control. I conclude by calling for further investigation of those agents who seek to engage in 'heretical discourse' (Bourdieu 1991) which challenge dominant medical constmctions.

Reconceptualizing the Case Management Relationship in Intensive Treatment: A Study of Staff Perceptions and Experiences

“…These negative interactions are in some cases inevitable since clients and clinicians often disagree about treatment goals (Gibbons, Bedard, & Mack, 2005;Rosenheck & Lam, 1997) and because case management involves social control functions in addition to therapeutic and supportive ones (Kanter, 1988;Pescosolido, Wright, & Sullivan, 1995;Thornicroft, 2000). Several studies, for example, show that case managers regulate treatment adherence through the use of social influence or limit-setting strategies (Angell, 2006;Angell, Mahoney, & Martinez, 2006;Neale & Rosenheck, 2000), particularly in situations in which they are enforcing a court mandate for involuntary treatment (Draine & Solomon, 2001;Scheid-Cook, 1993). Unlike psychotherapists, case managers may perceive that the mental health system assigns them full responsibility for the safety and wellbeing of their clients, which translates into pressure to ensure that clients follow treatment recommendations Scheid, 2004).…”

Measuring Strategies Used by Mental Health Providers to Encourage Medication Adherence

“…16 Whether or not formal mechanisms, such as courtordered treatment or representative payeeships, are in effect for a given client, the actual responsibility for exerting pressure on clients to adhere often falls upon mental health providers. 17 Mental health workers and probation and parole officers who work with clients on civil or forensic commitment orders, for example, issue warnings to nonadherent clients and invoke sanctions when clients fail to comply with treatment orders. 17,18 Under representative payeeship agreements, clinicians may exert a similar type of power by withholding clients' spending money if they fail to participate in treatment appointments or take medications faithfully.…”

“…17 Mental health workers and probation and parole officers who work with clients on civil or forensic commitment orders, for example, issue warnings to nonadherent clients and invoke sanctions when clients fail to comply with treatment orders. 17,18 Under representative payeeship agreements, clinicians may exert a similar type of power by withholding clients' spending money if they fail to participate in treatment appointments or take medications faithfully. 19 A growing body of evidence suggests that such mechanisms contribute to improved medication adherence rates.…”

Coping with Compulsion: Women's Views of Being on a Community Treatment Order

“…Their experiences are similar in many ways to those of all male and female populations on CTOs with both positive and negative experiences (Churchill et al, 2007;Gibbs et al, 2005;Scheid-Cook, 1993). The 10 women highlight the ambivalences faced by patients on CTOs and the way in which they become ''volunteers for compulsion'' (Dawson et al, 2003).…”

“…They wanted to be ''independent'' from the mental health system but they couldn't get by without the regular input of social work and mental health professionals. They felt ''controlled'' but they also said they had ''more freedom'' than they would have had by being hospitalised (Scheid-Cook, 1993). The women were reflective enough to try and make sense of their CTO experiences, and to try and make the best of the limited choices and options they faced.…”