Making sense of a Community Treatment Orders: Service-users’ Experience.

Community Treatment Orders (CTOs) are now an increasingly common feature of mental health treatment in England and Wales. However, the use of CTOs remains contentious raising ethical questions about increased coercion and infringement of autonomy. Although compulsory community treatment is used in many countries, there is a lack of supportive evidence.  The research is often characterised by conflicting results and methodological limitations, which make it difficult to draw conclusions about the effectiveness of CTO use. The qualitative studies that have been undertaken reveal wide variations in service-user experience and understanding.  As a consequence professionals have called for studies that seek to make sense of CTOs from a service-user perspective. This Interpretative Phenomenological Analysis (IPA) recruited ten active CTO service-users from an Assertive Outreach Team caseload.  The aim of this explorative study was to make sense of service-users making sense of CTOs. Objectives focussed on investigating the participant’s story and examining the meaning, understanding and purpose of the CTO together with the felt impact on their daily life.  Each participant agreed to undertake one or two semi-structured interviews (18 interviews in all) with photo-journals and diaries used to support the narrative and help elicit responses.

From the IPA data set, themes and clusters were generated and organised into three typologies under the headings of Resisting ‘Therapeutics’; Renegotiating Recovery; and Relinquishing Responsibility. The findings indicated that CTO service-users confronted therapeutic intent; were conflicted about their recovery potential; and used the CTO to evade accountability. The grouped responses and typologies were compared with extant theory and literature. Links were established between the clusters and the wider concepts of social control and the suppression of deviance; social integration and the reinforcement of norms; as well as social independence and the promotion of recovery.  Implications for policy and practice were considered where the core recovery principles of choice, hope, freedom and autonomy are in opposition to the established societal focus on risk. The limitations of the medicalisation of deviance are also discussed where treatment, risk management and mental health law are resisted by participants. This resistance is predicted by psychological reactance theory which suggests using motivational interviewing to explore ambivalence and a subsequent transition towards a social model that controls deviancy and promotes conformity through stronger societal bonds.

A conceptual model was developed and recommended as a guide to CTO interventions. The transition from compulsory ‘therapeutic’ medical treatment towards a more acceptable form of social control in recovery is proposed using social bonding theory. The model promotes the use of the three elements of the theory – attachment; commitment/involvement; and belief – which can be developed and enhanced to maintain healthy social behaviour. Using the model as an intervention guide may reduce the frequency and duration of CTO use as well as offering an alternative approach to the use of compulsory community treatment. Finally, limitations of the study are considered and a conclusion drawn where the legally sanctioned power of medicine can be combined – and potentially replaced – with a social power influencing conformity. The proposed conceptual model incorporates the recovery approach, legislative treatment and the social bond for a potentially more effective and acceptable form of community treatment.