How clinicians make decisions about CTOs in ACT: a qualitative study

Abstract

BackgroundThe first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams’ first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting.MethodsSemi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.ResultsThe participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians’ legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.ConclusionsAccording to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients’ need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.

Patients’ experiences with coercive mental health treatment in Flexible Assertive Community Treatment: a qualitative study

“…For some participants, the responsible psychiatrist was not a part of the FACT team, which seemed to reduce their opportunity to be involved in decisions regarding medication. Former research has shown that psychiatrists and specialised psychologists feel more confident in making decisions regarding CTOs within the context of ACT, due to frequent and long-term contact with the person, and shared responsibility with other ACT practitioners [ 50 ]. These findings support the concept of binding cooperation and collocation of different expertise, which is central in the FACT model.…”

Predicting involuntary hospitalization in psychiatry: A machine learning investigation

“…Perceived risk of danger to self or others has been found to be crucial in professionals' decisions on involuntary admissions [58,59]. However, an accurate prediction of serious violence is very complex [60][61][62]. The use of a structured risk assessment during the admission process and the first days of treatment should be fostered [63][64][65].…”

Community treatment orders and care planning: How is engagement and decision‐making enacted?

“…Decision‐making regarding CTO use is based on clinician perceptions of consumers' level of risk, insight and perceived lack of capacity and engagement with services, specifically, medication compliance 26–28 . While CTOs are considered a treatment tool for enhancing consumer stability and safety, they are also used to reduce risk and prevent harm 29,30 . Although recent studies have explored decision‐making regarding reasons for CTO use, explorations of ongoing involvement in decision‐making during all care contacts whilst the person is subject to a CTO have been neglected.…”

“… 26 , 27 , 28 While CTOs are considered a treatment tool for enhancing consumer stability and safety, they are also used to reduce risk and prevent harm. 29 , 30 Although recent studies have explored decision‐making regarding reasons for CTO use, explorations of ongoing involvement in decision‐making during all care contacts whilst the person is subject to a CTO have been neglected.…”