This research explores good practice with people on CTOs - via a case study of one area mental health service in Victoria. The emancipatory values of Social Work were used to guide the investigation, thereby ensuring the involvement of consumers and their families or carers. Critical Social Work theory provided an important theoretical base for the research, and both critical theory and pragmatism supported the methodology. A mixed methods approach was undertaken. This included a cluster analysis of 164 people on CTOs. Three clusters emerged from the exploratory cluster analysis. These clusters, labelled ‘connected’, ‘young males’ and ‘chaotic’ are discussed in relation to their particular characteristics. The results from the cluster analysis were used to inform the recruitment of four people on CTOs who were the central focus of case studies that represented the different clusters. Semi-structured group interviews were also undertaken to enhance the triangulation of data collection and analysis. This resulted in 29 semi-structured interviews with multiple informants, including consumers, family/carers, case managers, doctors, Mental Health Review Board members and senior managers. The data analysis was guided by a general inductive approach that was supported by the use of NVivo 7. / Five principles, and the processes required to enable them, emerged from the qualitative data: 1) use and develop direct practice skills, 2) take a human rights perspective, 3) focus on goals and desired outcomes, 4) aim for quality of service delivery, and, 5) enhance and enable the role of key stakeholders. These principles are discussed and then applied to the case studies in order to consider their potential relevance to practice within a diverse community of CTO recipients. The application of the principles identified two further findings: 1) that the principles are interdependent, and 2) the relevance of the principles varies depending on the characteristics of the consumer. The two most important findings to emerge from this thesis are that: 1) people on CTOs, their family/carers, and service providers are a diverse community of people who have a range of problems, needs and preferences in relation to either being on a CTO or supporting someone on a CTO; and 2) the implementation of CTOs is influenced by social and structural issues that need to be considered in developing any recognition or understanding about what represents good practice. Recommendations relating to each of the principles are made, along with identification of future research questions. A particular focus is whether application of the principles will enable improvements in practice on a range of measures, including reducing the use of CTOs, and the experience of coercion by consumers.

ABSTRACT Assertive Community Treatment (ACT) is considered the primary service-delivery vehicle for integrating individuals with severe mental illness into the community. Research on the model suggests that it has been helpful in aiding service users to achieve basic levels of integration including stabilized housing and maintaining financial and social security (Bond, Drake, Mueser & Latimer, 2001; Mueser, Bond, & Drake, 2001). However, critics of the model emphasize its limited success in enabling higher-order aspects of integration such as mainstream employment, recreation and socialization (Estroff, 1981; Gomory, 1998, 2001, 2002a, 2002b). These are fundamental criticisms given the significant investment in the model by policy makers. The rationale for the failure to promote higher-order integration typically rests on two central assumptions: a) service users are incapable of realizing full integration; and b) practitioners lack the training, skills, and philosophical base required to foster full integration. By focusing on the personal and professional characteristics of practitioners and service users, these views serve to obscure organizing structures operating at organizational, systemic, and social levels that encourage common ways of thinking about and carrying out community integration practice. The concern of this thesis is to explicate the impact of these organizing structures on the everyday practices engaged in by individual practitioners. In particular this thesis focuses on how practice becomes shaped by external structures that overrule both personal and professional values and intentions. The current study used the method of institutional ethnography to examine the impact of organizing structures of ACT in shaping how community integration practice is conceptualized, carried out, and accounted for on an everyday basis. The study findings are threefold. First, they suggest that organizing structures foster goals associated with protection as opposed to empowerment. Second, they reveal that organizing structures advance an individual-level focus over a social-level focus, prohibiting the community capacity building and environmental change necessary for fostering social autonomy and empowerment. Third, they show that organizing structures encourage practices discordant with integration, resulting in contradictory and therefore inconsistent attempts to facilitate higher-order aspects of integration. The power of these organizing structures is such that the personal and professional intentions of providers to facilitate broad community integration are consistently overruled within the context of everyday practice. The results of this study highlight the powerful role played by organizing structures in shaping community integration practice and provide an important theoretical model for planning, implementing, and evaluating models of service delivery for individuals with severe mental illness. / Thesis (Ph.D, Rehabilitation Science) -- Queen's University, 2007-09-27 15:10:26.391

In British Columbia, approximately 11,750 adults with severe addictions and/or mental illness are homeless. People who live with mental illness or the ill social or physical effect of substance use represent a sub population of people who experience homelessness. Many factors have contributed to poverty and homelessness among people who are mentally ill and to the neglect of their physical and mental health needs. A key factor has been the policy decision to de-institutionalize mental health services in British Columbia from the hospital to the community setting. Individuals living with mental illness were discharged from the hospital into the community, where housing is expensive and individuals have limited opportunities to earn an adequate income. Moreover, the community setting lacked the infrastructure to support and promote the health of severely mentally ill individuals. In the studied region, Assertive Community Treatment (ACT) teams have been established to work with individuals to break the cycle of homelessness, mental illness, and addiction as well as to support the improvement and maintenance of the mental and physical health of these individuals living in the community. Among the criteria for care by these regional teams is chronic homelessness caused by the barriers of mental health and addiction. In this grounded theory study, I explore how four regional ACT teams support their clients to maintain housing. In addition to examining the successes and challenges experienced by ACT team members, I consider the strengths of the team as they attempt to provide a supportive infrastructure that enables clients to maintain housing. Data were collected from four ACT teams in the region. The data collection involved two focus group discussions, three observational sessions with team members in the field, twelve one-on-one interviews, and a review of documents and reports. Data collection and analysis occurred concurrently, and guided further interviews. Through systematic analysis a theory was constructed form the data. In this study, I explore and analyze the issues that team members encounter and how they resolve them. I also take into account the beneficial outcomes of their complex work to produce a grounded theory explaining how ACT teams assist clients in maintaining housing. The knowledge gained during this study can be used to inform practice guidelines and policy development for the ACT teams. This study also contributes to the evolving body of knowledge that may strengthen provincial initiatives to break the cycle of homelessness. This work also contributes to current discussions on how to provide optimal housing support to individuals with severe mental illness and/or addiction issues. / Graduate / 0569 / 0573 / 0347 / shonalalonde@gmail.com

Compulsory interventions are widely used in general adult psychiatry for the treatment and care of patients with severe mental illness. While involuntary hospitalisation is established in practice around the world, the use of compulsory interventions outside of hospital – so called community treatment orders (CTOs) – is a more recent development. Three randomised controlled trials of CTO effectiveness have been conducted to date finding no benefits for patients in terms of reduced relapse and readmission to hospital. However, these trials have been relatively short (11-12 months) and focused almost exclusively on CTO effects on clinical functioning and service use. Little attention has been given to patients' social outcomes and broader welfare despite their recognised importance. A sub-sample (n = 121) from the Oxford Community Treatment Order Evaluation Trial (OCTET) were interviewed 48-months after randomisation to assess whether the duration of the CTO intervention was associated with more or less favourable social outcomes at follow-up. Social outcomes were assessed using three main concepts: social networks (Study 1), social inclusion (Study 2), and capabilities (Study 3). No significant associations between the duration of the CTO intervention and social outcomes at follow-up were found. The association between involuntary hospitalisation and social outcomes was also tested but no significant associations were found. Because the field of social outcome measurement is relatively undeveloped, a further aim was to contribute to the validation and testing of two recently developed instruments: the Social and Community Opportunities Profile (SCOPE) (Study 4) and the Oxford Capability Questionnaire for Mental Health (OxCAP-MH) (Study 5). The SCOPE performed well overall as a measure of social inclusion but questions were raised about its feasibility (length) and the reliability of one of its sub-scales. The OxCAP-MH demonstrated good psychometric properties (reliability and validity) and represents a promising new multi-dimensional patient-reported outcome measure for use in mental health research.

No description available.

<p>Idag riktas allt mer fokus i samhällsdebatten och i politiken på personer med</p><p>allvarlig psykisk sjukdom. Man debatterar dels hur samhället skall kunna tillhandahålla en</p><p>högkvalitativ vård och ett bra omhändertagande, men också ur ett samhällsekonomiskt</p><p>perspektiv. Den psykiatriska slutenvårdens kostnader är höga och debatten handlar ofta om</p><p>hur dessa kostnader skall kunna reduceras.</p><p>Denna studie vill titta närmare på om metoden Case management enligt</p><p>Assertive Community Treatment (ACT) kan bidra till att den psykiatriska</p><p>slutenvårdskonsumtionen minskar för personer med allvarlig psykisk sjukdom. För att</p><p>granska detta har intervjuer med fyra brukare använts där frågeställningen var fokuserad på</p><p>deras subjektiva upplevelser av att erhålla Case management enligt ACT under en period av</p><p>tre år. Vidare granskades skattningar enligt Kvalitetsstjärnan som utförts under en tre års</p><p>period. Därefter inhämtades statistik från databas avseende respondenternas konsumtion av</p><p>psykiatrisk slutenvård under tre år. Dessutom har artiklar i ämnet Case management kontra</p><p>psykiatrisk slutenvård granskats.</p><p>Resultaten av intervjuerna visade att respondenterna upplevt att Case</p><p>management enligt ACT hade varit viktigt för dem för att undvika psykiatrisk slutenvård.</p><p>Kvalitetsstjärnans resultat visade på en ökad livskvalitet, minskade besvär och detta i</p><p>kombination med en minskad konsumtion av psykiatrisk slutenvård. Vidare visade statistiken</p><p>från respondenternas psykiatriska slutenvårdskonsumtion att antalet inläggningar minskade</p><p>och antalet dagar som inläggningarna varade minskade också. Den dokumentation som</p><p>granskats i vetenskapliga artiklar visar att Case management enligt ACT är den metod som</p><p>bäst medverkar till att den psykiatriska slutenvårdskonsumtionen minskar.</p><p>Slutsatsen är att genom arbetssättet Case management enligt ACT tillsammans</p><p>med en hög programtrohet och validerade mätmetoder såsom Kvalitetsstjärnan kan den</p><p>psykiatrisk slutenvårdskonsumtion för personer med allvarlig psykisk sjukdom minska.</p><p>Nyckelord: Case management, Assertive Community Treatment, ACT,</p><p>Kvalitetsstjärnan, psykiatrisk slutenvårdskonsumtion.</p>

Idag riktas allt mer fokus i samhällsdebatten och i politiken på personer med allvarlig psykisk sjukdom. Man debatterar dels hur samhället skall kunna tillhandahålla en högkvalitativ vård och ett bra omhändertagande, men också ur ett samhällsekonomiskt perspektiv. Den psykiatriska slutenvårdens kostnader är höga och debatten handlar ofta om hur dessa kostnader skall kunna reduceras. Denna studie vill titta närmare på om metoden Case management enligt Assertive Community Treatment (ACT) kan bidra till att den psykiatriska slutenvårdskonsumtionen minskar för personer med allvarlig psykisk sjukdom. För att granska detta har intervjuer med fyra brukare använts där frågeställningen var fokuserad på deras subjektiva upplevelser av att erhålla Case management enligt ACT under en period av tre år. Vidare granskades skattningar enligt Kvalitetsstjärnan som utförts under en tre års period. Därefter inhämtades statistik från databas avseende respondenternas konsumtion av psykiatrisk slutenvård under tre år. Dessutom har artiklar i ämnet Case management kontra psykiatrisk slutenvård granskats. Resultaten av intervjuerna visade att respondenterna upplevt att Case management enligt ACT hade varit viktigt för dem för att undvika psykiatrisk slutenvård. Kvalitetsstjärnans resultat visade på en ökad livskvalitet, minskade besvär och detta i kombination med en minskad konsumtion av psykiatrisk slutenvård. Vidare visade statistiken från respondenternas psykiatriska slutenvårdskonsumtion att antalet inläggningar minskade och antalet dagar som inläggningarna varade minskade också. Den dokumentation som granskats i vetenskapliga artiklar visar att Case management enligt ACT är den metod som bäst medverkar till att den psykiatriska slutenvårdskonsumtionen minskar. Slutsatsen är att genom arbetssättet Case management enligt ACT tillsammans med en hög programtrohet och validerade mätmetoder såsom Kvalitetsstjärnan kan den psykiatrisk slutenvårdskonsumtion för personer med allvarlig psykisk sjukdom minska. Nyckelord: Case management, Assertive Community Treatment, ACT, Kvalitetsstjärnan, psykiatrisk slutenvårdskonsumtion.

Since de-institutionalization, numerous community based treatment modalities have been implemented to provide treatment for individuals diagnosed as seriously and persistently mentally ill. CTOs are a recent addition to the community mental health care system designed to provide outpatient mental health services to seriously mentally ill clients and using legal mechanisms to enforce a contractual obligation to participate in those services. Although there is a growing body of literature on CTOs and other mandated outpatient treatment programs for people diagnosed with mental illnesses, the research predominantly focuses on the perspectives of service providers and family members. Little attention has been given to how clients view the experience of receiving the treatment and no attention has been given to the experience of clients who are of ethno-racial minority background. As Ontario is a racially and ethnically diverse environment in which many people of minority backgrounds are placed on CTOs. This study, utilizing a phenomenological methodology, interviewed twenty-four participants of ethno-racial minority background who are either on CTOs or have been on a CTO in the past. The focus of the study was to explore the views and lived experience of the participants regarding the treatment. The outcome of the study showed that the participants did not experience the treatment as racially motivated but felt it was necessary and beneficial. The participants discussed the impact of power in the treatment process. Implications of the study were that it would enhance the mental health literature by providing an understanding of serious mental illness among individuals of ethno-racial minority background. The study would provide insight for policy makers and practitioners on providing effective support for the marginalized.

Since de-institutionalization, numerous community based treatment modalities have been implemented to provide treatment for individuals diagnosed as seriously and persistently mentally ill. CTOs are a recent addition to the community mental health care system designed to provide outpatient mental health services to seriously mentally ill clients and using legal mechanisms to enforce a contractual obligation to participate in those services. Although there is a growing body of literature on CTOs and other mandated outpatient treatment programs for people diagnosed with mental illnesses, the research predominantly focuses on the perspectives of service providers and family members. Little attention has been given to how clients view the experience of receiving the treatment and no attention has been given to the experience of clients who are of ethno-racial minority background. As Ontario is a racially and ethnically diverse environment in which many people of minority backgrounds are placed on CTOs. This study, utilizing a phenomenological methodology, interviewed twenty-four participants of ethno-racial minority background who are either on CTOs or have been on a CTO in the past. The focus of the study was to explore the views and lived experience of the participants regarding the treatment. The outcome of the study showed that the participants did not experience the treatment as racially motivated but felt it was necessary and beneficial. The participants discussed the impact of power in the treatment process. Implications of the study were that it would enhance the mental health literature by providing an understanding of serious mental illness among individuals of ethno-racial minority background. The study would provide insight for policy makers and practitioners on providing effective support for the marginalized.

The present study examined the subjective experiences of individuals living in the community with a severe or persistent mental illness receiving services from the Sunnybrook Program of Assertive Community Treatment (SunPACT). The researcher employed McCracken’s (1998) Long Interview Method to interview a sample of 8 clients from SunPACT. The aim of this research was to explore client perspectives on their experiences of SunPACT and their perception of its impact on their quality of life. The findings from this study overlapped with the literature, as well providing new and vital information in the implementation and monitoring of quality of care of an ACT model. This research demonstrated that clients experience the effects of their treatment differently, and therefore, understanding client feedback is imperative to understanding how to maximize treatment benefits and provide effective services. Specific details about their experiences are outlined. Implications for social work practice are discussed.