Responsibilities with conflicting priorities: a qualitative study of ACT providers’ experiences with community treatment orders

Abstract

BackgroundPatients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.MethodsThe study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.ResultsThe main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.ConclusionsMany of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3097-7) contains supplementary material, which is available to authorized users.

RAISe‐ing awareness: Person‐centred care in coercive mental health care environments—A scoping review and framework development

“…The papers reviewed spoke about communication and emphasized approach as a way to promote PCC. Communication which was person centred was viewed as direct or clear (Dawson, Lawn, Simpson, & Muir-Cochrane, 2016;Stuen, Landheim, Rugkasa, & Wynn, 2018), empathic (Courtney & Moulding, 2014) and consistent (Barnao, Ward, & Casey, 2015). Another way communication was used as a form of PCC was by asking for service user feedback and input in treatment plans or assessments (Dawson et al, 2016;Proctor, 2005;Stuen et al, 2018).…”

“…Although service users found coercive care to be prescriptive and rigid, some also acknowledged that there were times where such control was necessary (Seed et al, 2016). This was similar for compulsory community treatments, as some service providers felt such mechanisms were necessary to support overall goals for recovery (Stuen et al, 2018). Geller (2012), suggests that directly acknowledging and addressing the imbalance of power in coercive care environments between providers and users is one way to increase perceived choice.…”

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

“…Our data show that the ACT providers perceived that the multidisciplinary nature of their work allowed for frequent patient contact, coordinated support, relationship building and more flexible treatment options. As a specific component of clinical care, the ACT model’s focus on everyday activities and improving patients’ lives was seen as pivotal to improve patients’ well-being and to gradually help patients work toward greater independence and self-sufficiency [ 30 ]. Further, the ACT team’s long-term treatment perspective and the ways in which the teams often managed to gradually involve patients in treatment decisions and joint crisis planning were considered as important in reducing the use of coercion [ 39 ].…”

“…The ACT model has a strong focus on promoting patients’ autonomy and recovery [ 28 , 29 ], and, as we have shown previously, the enactment of CTOs typically involves competing priorities and role tensions [ 30 ]. Some studies show that assertive outreach teams reported using less intrusive approaches than other community mental health services [ 31 , 32 ].…”

Cooperation in the mental health treatment of patients with outpatient commitment

“…9 A study that interviewed health professionals highlighted the dilemma of combining the role of the therapist with a control function, even if they saw that OC provided a secure framework for treatment. 10 Another study of relatives of patients with OC decisions referred to the positive experience of OC providing safety and ensuring functioning in daily life. 11 The mental health service in Norway is organized on two main levels: a specialist health service and a primary care level in the municipality.…”