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.

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.

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.

Community treatment orders (CTOs), which allow for involuntary psychiatric treatment of individuals who meet particular legal criteria while they are living in the community, have been in effect in Ontario since 2001. Some similar form of mandated community-based psychiatric treatment exists in every Canadian province and in many other jurisdictions around the world. In the wake of deinstitutionalization, CTOs filled a gap in mental health care, allowing for the treatment of people with serious and persistent mental illness (SPMI) who were otherwise unable or unwilling to access care; however, CTOs brought their own host of legal, ethical and practice dilemmas, as well as mixed results in research about their effectiveness. This doctoral research examines the way CTO policy is situated within a larger historical, social, legal and discursive system; the way it is deployed, operationalized and negotiated in day-to-day practice; and the layered effects that this has on the multiple actors involved. This study gives voice to a small and vulnerable subset of the population who, in addition to experiencing mental illness, have layered experiences of stigmatization and low socio-economic status. The purpose of this study was to explore the cultural context, beliefs and values underlying the CTO and perpetuated by the CTO, as it was used in community mental health care in Ontario, through an examination of its impact on identity of people living with SPMI. The study was guided by a theoretical framework that brought together the work of Michel Foucault on governmentality and Elizabeth Grosz on body image in order to critically examine the issue of identity from both the outside in (how identity is constructed) and the inside out (how that constructed identity is experienced). It used a critical ethnographic methodology. Data collection included in-depth interviews with persons with SPMI (N=7), family members (N=5) and clinicians (N=10), observations of health care practices for people with CTOs, and analysis of documents used during the CTO process. Data was analyzed using critical discourse analysis. This study revealed insights in the into social context of CTOs, that is, the complex social landscape in which CTOs operate; the social practice of CTOs, that is, the many steps and many actors involved in the CTO process; and the social impact of CTOs, that is the effect of CTO processes on both the constructed and the experienced identity of the patient, family member and clinician. The constructed identity of the patient included perceptions of the patient as risky, defective, and in need of surveillance; the experience of this identity was characterized by feelings of being criminalized, disconnected, muted, traumatized and gaslit. The constructed identity of the family members included an idealization of families as responsible and available, and instrumentalization of the family role. This identity experience was characterized as a dissonance between roles, a witnessing of the absurd, and as putting a strain on other elements of life/identity. The constructed identity of the clinician in relation to CTOs included the role of enforcer, fall-guy, paternalistic provider, and the patient’s adversary. The experience of this identity was characterized by frustration, powerlessness, distress, and an acceptance of dissonance. CTOs, while facilitating access to some treatments and services, also act to construct identities for patients that further limit their full integration into communities as valued members. An examination of the constituent parts of the CTO highlights areas in which CTO processes could be changed; research participants conveyed areas in which they thought the CTO could be improved, including changes to methods of police intervention, better collection and use of administrative data, systemic change, the use of specific approaches to care, changes to the timings of renewals, and changes to the Consent and Capacity Board hearings. The discussion highlights ways in which a re-examination of the context in which CTOs are used can lead to the consideration of political and therapeutic means to reduce both the circumstances that lead to mental and emotional distress and to improve our responses to mental and emotional distress when these are experienced by members of our communities.

Bakgrund: En stor revision av lagstiftningen för tvångsvård skedde 2008 då lagen om öppen psykiatrisk tvångsvård [ÖPT] tillkom. En av intentionerna med lagstiftningen var att användandet av tvångsåtgärder skulle minska, och patienter som får vård i ÖPT vistas i regel i sitt hem. Det finns dock bestämmelser att förhålla sig till för den som får öppen tvångsvård, vårdformen är tämligen omfattande och påverkar nästan alla aspekter av en individs vardag. Studier om vilka erfarenheter och upplevelser patienterna faktiskt har av att vårdas i ÖPT är dock sällsynta. Syfte: Att beskriva patienters erfarenheter av att vårdas i öppen psykiatrisk tvångsvård Metod: Åtta patienter som vårdas i öppen psykiatrisk tvångsvård har ingått som deltagare i studien. Det är en kvalitativ semistrukturerad intervjustudie, intervjuerna var individuella och analyserades med en manifest metod för att synliggöra patienternas egna ord om sina erfarenheter. Resultat: Resultatet beskrevs genom temat: Begränsningar och möjligheter, och visade att flertalet områden i deltagarnas liv berördes. Resultatet kunde sammanfattas i fem huvudkategorier: Att känna sig begränsad i sin vardag; Att känna vanmakt av att inte bli trodd och inte kunna påverka; Att känna sig utanför och inte förstå sina rättigheter; Att känna sig involverad av att bli sedd och hörd samt Att vårdens innehåll är viktigare än formen. Slutsats: Att vårdas i ÖPT innebär att känna sig begränsad, men slutsatsen är att denna erfarenhet till viss del kan hänga samman med otillräcklig medvetenhet hos patienter om vad ÖPT och dess villkor innebär. Vården misslyckas i vissa fall att tillgodose patienters behov av och rätt till information, och det finns uppenbara brister i att involvera både patienter liksom anhöriga i utformandet av vården, samt hur vården tar hänsyn till patienters lagliga rättigheter. Vården kan också bli bättre på att ge patienter personligt anpassad information samt tro på patientens önskan att medverka. Att patienter bjuds in till diskussion och medverkan kan öka möjligheter till förståelse och acceptans för vårdbehovet, att ges utrymme att få uttrycka sin åsikt samt ha möjlighet att påverka stärker också autonomi. Det är även betydelsefullt för patienterna att finnas i ett sammanhang, omvårdnadspersonal behöver därför tillvarata de erfarenheter som beskrivs som främjade och arbeta motiverande. Det finns positiva konsekvenser av vårdformen, såsom ökat stöd som ett resultat av tvingande samverkan. Men vi drar slutsatsen av att finns betydande brister, varför det är ett angeläget område i behov av översyn gällande hur patienters lagliga rättigheter tillgodoses.