Community Treatment Orders: The Service User Speaks
Exploring the Lived Experience of Community Treatment
Orders
Karen Schwartz PhD (corresponding author)
Assistant
Professor Carleton University
School of Social Work
1125 Colonel By Drive
Ottawa,
ON, Canada K1S
5B6
Karen_schwartz@carleton.ca
Ann-Marie O’Brien MSW
Adjunct
Professor Carleton University
School of Social Work
Vanessa Morel
Meredith Armstrong
Courtney Fleming
Patricia Moore
Citation:
Schwartz K, O'Brian AM, Morel V, Armstrong M, Fleming C, and Moore P. (2010). Community Treatment Orders:
The Service User Speaks Exploring the Lived Experience of Community Treatment Orders.
International
Journal of Psychosocial Rehabilitation. Vol
15(1) 39-50
Abstract
This
study uses an exploratory qualitative design to examine the lived
experience of one group of service users on community treatment orders
(CTOs). The study was designed and completed by four graduate
students at Carleton University School of Social Work.
Despite the
unique features of CTO legislation in Ontario, many findings from this
study are remarkably similar to findings of research conducted in other
jurisdictions. What is unique in our findings is the lack of
focus on the actual conditions and provision of the CTO. The issue for
our participants was less about the CTO itself, and more about the
labels, control and discrimination associated with severe mental
illness.
Cette étude utilise un concept qualitatif et exploratoire
pour examiner les expériences vécues d’un groupe qui utilise les
ordonnances de traitement en milieu communautaire (OTMC). Cette
étude a été designée et complétée par 4 étudiants de l’école de service
social de l’université Carleton.
Malgré les nombreux aspects
uniques de la loi gérant les OTMC de l’Ontario, plusieurs résultats de
cette étude sont remarquablement similaires aux résultats découverts
dans de différentes juridictions. L’élément unique de cette
recherche est le manque de focus sur les conditions véritables et
les provisions des OTMC. La problématique encourue par les
participants n’était pas au sujet des OTMC en soi, mais plus tôt au
sujet de l’étiquetage, du contrôle, et de la discrimination associé aux
troubles de santé mentale sévères.
Keywords: Community Treatment Orders, Service User Perspective, Mental Health, Stigma
Introduction:
Prior
to the introduction of Community Treatment Orders (CTOs) in
the Canadian province of Ontario, service users were strongly
opposed to this legislation arguing that it would contribute to the
oppression of an already stigmatized and marginalized segment of
society and violate a person’s fundamental right to choose the kind of
medical treatment in which they wish to participate. A review of
submissions to the Ontario government’s discussion paper on mental
health reform found no consensus between the various stakeholder groups
with the exception being advocacy groups for service users who were
consistently opposed to this legislation (Boudreau & Lambert,
1993). More recently, the Ontario Ministry of Health and Long Term Care
legislated review of CTOs found that : “If there was common
ground among the consumers that we met, it was on the issue of respect
for their dignity and autonomy, the necessity to provide proper
services to them, the need for easy access to rights advice and
advocacy, and most of all, the absolute imperative that their voices be
heard and that they play a meaningful role in the events that affect
their lives” (Dreezer & Dreezer, 2005). There have been no
published studies that explore service users lived experience with
respect to Community Treatment Orders in the Ontario context. This
paper will begin to redress this gap.
What is a Community Treatment Order (CTO)?
Community
Treatment Orders (CTOs) are one form of mandatory outpatient treatment
that requires a person with serious mental illness to adhere to a plan
of treatment or care and supervision while living in the community.
CTOs exist in various forms in most parts of the developed world.
Australia and New Zealand have well established CTO regimes (Brophy
& Ring, 2004). Many American states have statutes for involuntary
outpatient commitment, another form of mandatory outpatient treatment
(Swartz & Swanson, 2004). CTO legislation has recently been
introduced in Scotland (Campbell et al, 2006). Community Treatment
Orders became part of the Ontario Mental Health Legislation in December
2000. The legislation was marketed as ‘Brian’s Law’ in response to the
murder of a popular sportscaster by a man suffering from untreated
schizophrenia. Following this murder, the public demanded that criteria
be established requiring some seriously mentally ill people released
from institutional care to be compelled to receive treatment while they
live in the community. The legislation targets those service
users who have a history of noncompliance with recommended treatment
that results in behaviour which leads to re-hospitalization.
Opponents of the legislation state that the new law violates an
individual’s right to choose whether or not they wished to participate
in treatment. Proponents of this legislation argue that requiring a
person to follow a prescribed form of treatment while living in the
community is less restrictive than being detained in a hospital.
However, “their coercive nature is seen as a threat to the community
mental health sector’s firmly held values of egalitarianism and
partnership” (Everett, 2001, p6). Moreover, the association of this
legislation with an act of violence further stigmatizes an already
marginalized segment of our society (Schwartz & O’Brien, 2009).
CTO
legislation in Ontario is defined in the Mental Health Act (Ontario,
1990). The legislation attempts to balance the collective need for
safety and order, and the individual right to freedom and autonomy. The
legislation is unique in that it is consent based, and physician
directed, not court ordered, as it is in most American states. If
the person being issued a CTO has capacity to make treatment decisions
they must consent to the CTO, otherwise the person making treatment
decisions on their behalf provides the consent. Prior to the CTO being
issued a plan of treatment or care and supervision is developed by the
physician issuing the CTO, the service user, and community based
service providers. All parties must agree to the plan, and the service
user and Substitute Decision Maker (SDM) (if applicable) must receive
independent rights advice prior to the CTO being issued. All parties
named in the CTO must receive written copies of all CTO documentation
pertaining to them, and information on how to request a consent and
capacity board hearing. The Consent and Capacity Board is the mental
health tribunal in Ontario that reviews all matters in the civil mental
health system.
Literature Review: Community Treatment Orders
CTOs
in Ontario have been described as having ‘admirable respect’ for
service user’s autonomy (Dawson, Romans, Gibbs, & Ratter,
2003). However respectful, CTOs do limit service users’ civil rights
and, therefore, their value ought to be measured in terms of relative
benefits to service users (O’Brien, Farrell, & Faulkner, 2009). Ten
years after the introduction of CTO legislation there remains a paucity
of research on its usefulness (O’Brien, & Farrell, 2005; Hunt et al
2007). The most significant limitation of all existing studies of CTOs
in Ontario is that they fail to include service users’ perceptions.
Most
research aimed at exploring the opinions and beliefs of service users
has been conducted in the United States. Swartz, Swanson, Wagner,
Hannon, Burns, Shumway (2003) examined the preferences of four
stakeholder groups: persons in treatment for schizophrenia (n=104),
family members, clinicians, members of the public, concerning
outpatient commitment for persons with schizophrenia. The study
concluded that ‘stakeholders were willing to accept the coerciveness of
outpatient commitment to gain improved outcomes for certain persons
with schizophrenia and related disorders’. (Swartz et al, 2003).
Borum, Swartz, Riley, Swanson, Hiday, Wagner (1999) examined consumer
perceptions of involuntary outpatient commitment. In this study 306
people with severe and persistent mental illness were interviewed to
determine their perceptions of the requirements of the court order and
its effects in improving treatment compliance and community tenure.
Eighty two percent of respondents believed that under PCT people are
more likely to keep their appointments, take medication, stay out of
hospital (Borum et al, 1999). Rain, Steadman, Robbins (2003)
investigated whether mental health inpatients perceptions of coercion
were associated with post discharge treatment adherence. One
hundred and seventeen participants who were eligible for New York’s OPC
were interviewed and their perception of coercion was measured at 1, 5,
and 11 months post discharge. These authors found no correlation
between patients’ perceived coercion and adherence as reported by
service providers. (Rain et al, 2003). Van dorn , Elbogen, Redlich
Swanson, Swartz, Mustillo (2006) explore the link between receipt of
mandated treatment and reasons for avoiding or delaying treatment
reported by persons with severe mental illness. These researchers found
that “efforts to use leverage to improve treatment adherence may in
some cases have the opposite effect by further alienating some
individuals and strengthening the internal barriers that keep them from
participating voluntarily in treatment.” (Van Dorn et al,
2006). Scheid-Cook (1993) conducted an analysis of
participant constructions of outpatient commitment. In general, he
found that clinicians favoured the greater control over clients that an
outpatient commitment provided. The clients in his study, on the other
hand, were cognizant of the greater liberty it afforded them.
Brophy
and Ring (2004) focus on both consumer and service provider
perspectives of the efficacy of CTOs in Victoria, Australia.
These researchers conducted three focus groups attended by 30
psychiatric consumers as well as conducting 18 interviews with service
providers. Three themes emerged from the focus groups: understanding
the purpose of CTOs; strengths and weaknesses of CTOs; knowledge about
the discharge process. Most consumers expressed a general view that
CTOs had a functional purpose, for example expedited access to
inpatient services when required. However, the authors found that
consumers are unsure about legal processes and their legally mandated
rights (Brophy & Ring, 2004).
In New Zealand, Gibbs, Dawson,
Ansley, Mullen (2005) conducted semi structured interviews with 42 of a
possible 84 eligible service users who, in the past two years, had been
subject to a CTO and not readmitted to hospital. Similar to Brophy’s
findings the usefulness of CTOs was generally accepted by most service
users. In contrast to Brophy’s findings that a CTO might be useful in
accessing inpatient services, the New Zealand findings suggest that
CTOs are viewed as being useful in avoiding an inpatient
admission. In the interviews, service users discussed the themes
of “autonomy and dependence, freedom and control, power and
powerlessness, medication and its side effects, and the desire of
patients to achieve stability, meaningful relationships, and a better
quality of life” (Gibbs et al, 2005). Gibbs, Dawson,
Forsyth, Mullen, Tanga (2004) conducted a similar study focusing on
Maori patients. In general, CTOs were seen to enhance the mental
health, wellbeing, and social relationships of Maori patients.
Canvin,
Bartlett, and Pinfold (2002) conducted a qualitative investigation into
service users’ perceptions and experiences of living with supervised
discharge orders (SDO) in London, England. They found that service
users were able to communicate their understanding of why mental health
professionals placed them on the order and how their lives have been
affected. Interestingly, individual service users were found to be
capable of seemingly contradictory responses, simultaneously accepting
and resisting the orders (Canvin et al, 2002).
One study has
been completed in the Canadian province of Saskatchewan. O’Reilly,
Keegan, Corring, Shrikhane, Natarajan (2006) interviewed 11 patients on
a CTO and three patients who had been on a CTO. Most participants
reported experiencing some degree of coercion while on the CTO, but
many believed that the CTO was necessary to provide structure to their
lives. (O’Reilly et al, 2006). “Many of the themes that emerged
from this study were similar to those from non-Canadian jurisdictions
despite the use of different models of CTOs in those jurisdictions”
(O’Reilly et al, 2006).
In summary, studies of
service users’ perceptions of CTOs reveal, at best, ambivalence toward
CTOs and their inherent coercion. Of concern is the somewhat hopeless
resignation service users expressed. Given the unique features of CTO
legislation in Ontario, and the dearth of information of service users’
lived experience, the current study will redress this gap in knowledge.
This exploratory study will discuss service users’ perceptions of the
impact CTOs are having on their lives, and offer suggestions for future
studies.
Methodology
Service
users living with a severe and persistent mental illness, subject
to a community treatment order, and receiving services by the Royal
Ottawa Mental Health Centre (ROMHC) including two ACT teams were
eligible for inclusion (n=51). The availability of student
researchers, as this project was not externally funded, was the primary
factor that required a convenience sampling method to be used. Service
users who presented at the mental health centre for their scheduled
appointment with their treatment team were approached by the CTO
coordinator and asked if they would be willing to discuss their
experience with the students. Of the 51 service users subject to
a CTO, 14 presented for their scheduled appointments during the
students’ availability. Of these 14 people, 6 agreed to be interviewed
by the students. The students discussed the project with prospective
participants and obtained written consent, prior to commencing with the
interview. This research protocol was approved by the University
of Ottawa Institute for Mental Health Research (IMHR), research ethics
board.
Participants were involved in a semi-structured interview,
with two student researchers, which lasted approximately thirty
minutes. Interview questions were developed from a review of the
literature, and included asking the service users’ perceptions on the
impact that the CTO was having on their lives (work, relationships, and
housing); their ideas for improvements, as well as any areas of concern
about CTO’s.
An interview guide approach was used in the
interviews, so that the order and wording of questions were flexible,
allowed to emerge through conversation (Patton, 2003). A
semi-structured face-to-face interview was used to collect data on the
opinions of service users regarding their experiences with CTOs.
Tutty and colleagues (1996) explain that semi-structured interviews,
which use “predetermined questions or key words” as a guide, “are
particularly appropriate when you want to compare information between
and among people while at the same time you wish to more fully
understand each person’s experience” (p.56).
Audio recordings of
the interviews were transcribed and reviewed by pairs of student
researchers. Thematic analysis (Braun & Clarke, 2006) was used in
this exploratory study. Thematic analysis is useful in analyzing
narrative material from in-depth interviews and focus groups (Dudley,
2009). We employed an etic perspective in identifying categories in our
analysis; the categories were identified by the researchers (Rubin
& Babbie, 2008). Researchers organized “the raw data into
conceptual categories” in order to “create themes or concepts” to
analyze the data (Neuman & Kreuger, 2003, p. 436). We looked for
common patterns or themes presented in the transcribed notes of the
interviews. We began with open coding to locate themes and assign
“initial codes or labels in a first attempt to condense the mass of
data into categories” (Neuman & Kreuger, 2003, p. 438). At
least two independently evaluated the themes in order to insure
inter-rater reliability, (Dudley, 2009).
Results
1) Demographics
This
exploratory study included six interviews with six participants.
Participants consisted of five males and one female, whose ages ranged
from their early 20s to mid-50s. Five were interviewed at a mental
health center. One was interview in their home. Length of time on a
community treatment order for participants ranged from four months to
over seven years. None of the participants had capacity to make
treatment decisions and each had substitute decision makers (SDM)
consent to the CTO.
2) Housing
All participants
are currently living in independent housing that they find
satisfactory. Three participants discussed the challenges that
they faced in the past in obtaining and maintaining safe and stable
housing in the past. Being on a CTO did not appear to have an impact on
housing.
“My father kicked me out, my mother kicked me out, and so
between them I was going back and forth. I found an apartment, and then
I had a problem keeping the crack heads out of my house. Then the
hospital, then the group home, then I found a place to stay”
“That’s
how I was in the hospital for like two months. They left me in there
for a month and a half, they told me I had to go to a group home, I
didn’t like that idea. That was recently, like two years ago.”
2) Employment
Two
participants are currently working part-time, and four participants
discussed issues relating to employment, in general. There were
different opinions held by participants with regards to the impact of
their CTO on employment and employability. Some of the participants
experienced difficulty getting time away from work to keep appointments
and others experience difficulty due to the mandate to comply with
medications.
“You know, I can’t drive a forklift, ‘cause my job says I can’t be medicated, you know what I mean?”
“I
have had to modify my work schedule… yeah, you’ve got to juggle back
and forth just have some days off, … keep up with your appointments and
other things”
“I’ve had a couple of jobs that have tried to work
out. Pretty hard to get up in the morning and go to work for me. So
anyway, I have a job now, on the CTO, and I didn’t have one before.”
3) Personal Relationships
Participants
were asked about the impact of their mental health and the CTO on their
relationships with friends and family. This was not an area of
questioning that participants seemed interesting in engaging in, and
most responses were brief and provided minimal detail. From the
responses given, the families of participants viewed their community
treatment orders favorably, and felt that there had been positive
changes in the lives of the participants.
“My mom, she mentioned that maybe they’re just watching over you, my dad says, yeah, they’re just watching over you.”
“They
said when I was 17, 16, I was really sick, and they say I’m doing great
now, and sometimes they give a bit of input like you better be careful
not to get sick again.”
“They listen more, since the CTO.”
4) Reason for CTO
The
participants cited various reasons for their CTO being initiated. The
two major reasons that were discussed were not taking medication, and
not engaging in self-care.
“I was not taking my medication, and I
was living by myself in a rooming house, and I guess that’s about it, I
just didn’t get activities, didn’t care for myself, do the groceries
and stuff”.
“I don’t know why they put me on a CTO. But I think it might have been because I am so alone, so I have the contact”.
5) Information Provided
Many
participants were vague about the amount of information provided by
their service providers, and their understanding of that information.
The few participants who had strong opinions regarding information
provided to them believed service providers did not ensure they had a
clear understanding of the legal processes.
“My rights? I don’t know about my rights…but I was given a folder with information and other changes”
“Yeah,
I understand my rights. It’s a CTO, there’s no real lawyer that’s gonna
help you out, he just explains to you the CTO. The CTO is like law, its
law and uh, you can’t defeat unless you make like another act, or
change the CTO, and then it’s like for 6 months.”
“Did she explain the reasons? Yeah, poorly, you know, with poor explanation, and poor, misinterpreted information.”
6) Understanding of Legal Processes
There
was more variation amongst participants’ responses concerning the legal
aspects of CTOs, particularly the appeal process. Participants who had
been on the CTO for longer periods of time (in excess of two years)
expressed that they understood the appeal process, and had been
involved with the appeal process, but did not have confidence in their
ability to successfully change or end their order.
“Appeal? To go to the review board is kind of risky you know? They don’t see you, they just see the CTO”
“Well
in the beginning I did appeal, I started to appeal but I decided to go
along with the program because the office threatened to take my
driver’s licence away, so I thought I better be cooperative. They took
my driver’s licence away anyways.”
“Have you done an appeal before? Yeah, I’ve done several”
7) Stigma
Participants
discussed the different ways in which the label of mental illness
creates experiences of stigma. These experiences were described as
occurring in the community through labels, scrutiny and isolation, and
in the stigmatizing behaviour and attitudes of their professional
service providers.
Community-based stigma was described by
participants as a feeling that they were feared and isolated within
their communities. Service users discussed the difficulty of feeling
the constant gaze of the community judging their behaviour and deeming
them something to be wary of.
“So it’s like the community is judging you, you know? To see if you’re safe to live in the community I guess”
“Police
involvement, and then the neighbours are watching, then you’re scared,
and you’re medicated. You wake up, and you don’t know where the fuck
you are, and there’s dirty people around, and you’re not in your
clothes. Or you get up, and you just take another medication, you know?”
“I
think the people across the hallway are getting suspicious of me.
People coming in and leaving (ACT team workers), and we go out, you
know? But I don’t say anything.”
Professional stigma was
identified as a sense of de-personalization as a result of the use of
diagnostic language, and paternalistic ideologies when working with
consumers. Historically, the mental health system has been operating
under a hierarchical “expert doctor”-patient relationship, commonly
referred to as the medical model (Campbell, 2006). CTO service users
discussed how this attitude still permeates many of their interactions
with helping professionals. Mental health consumers, in general, often
resist the diagnostic labels placed on them, and resent losing their
identity to the illness within the institutional (i.e. hospital)
settings and when receiving treatment while living in the community.
“I
went, they told me I was schizophrenic, and I said I wasn’t, and there
was a dispute, and from there on I’ve been taking medication.”
“I don’t want somebody calling me schizophrenic.”
“I
went to the doctor to get sleeping pills, and he tells me I’m
schizophrenic, I was like listen mother-fucker, I don’t have
schizophrenia. And he goes, “you know what, I’m gonna pick my nose, and
I’m going to spit on the floor, and I’m going to say you have
schizophrenia “…and he told me I got to agree to disagree.”
8) Negative Feelings Regarding CTOs
Participants
expressed some overall negative opinions about CTOs. Feelings of being
controlled and labeled as mentally ill were dominant themes. Within our
sample, there appears to be a connection between disagreeing with the
diagnosis of mental illness (particularly schizophrenia) and negative
statements regarding the conditions of their CTO, most frequently the
condition of mandatory psychotropic medication.
“Well I think the
psychiatrist who took my driver’s licence away, I think he had too much
power, he didn’t even know me, because he was a new doctor at the
hospital, when I had never been there before, and I had never talked to
him for a long period of time. And he made an instant diagnosis that I
might be a bad driver, and he took my driver’s licence away by sending
a letter to the ministry of transports, saying I was a threat to
society or something, and actually I don’t have any demerit points on
my licence, I’m a good driver and I found that to be really bad.”
“I
think it’s a hassle, I don’t need a contract or law to tell me to take
my medication and come for blood work. I think it’s just; the big thing
I think is coming in for programming every day. I just can’t be
bothered… Now that I’m on a community treatment order I have to follow
and abide by it”
“What gives the CTO the power? It’s the power of
medication to our culture, crime, people, normal people, who are not
alert to you, some guy. And after everything some crazy guy, some cop,
some psychiatrist, some nurse, some shrink, some whatever you’re on
some medication you know, can you cook dinner for yourself, can you?
Are you going to clean yourself, can you? Or you didn’t do the laundry,
and you’re in public, and you stink, cause you don’t have a washing
machine or no car, or no job “
9) Positive Feelings Regarding CTOs
The
positive statements made by participants were usually associated with
positive outcomes associated with the implementation of the CTO. These
outcomes include increased supports, employment, self-perception of
improved mental health, and positive interactions with professional,
family and friends.
“Yeah, yeah. It changed my whole life around. I went from a paranoid freak, to a well groomed individual”
“All
I know is, I come in and see my doctor, and he gives me medication, and
it keeps me healthy. So that’s good, he was doing his job, and I’m
getting my help.”
“Now I’ve got a doctor, I’ve got a social worker,
I’ve got a nurse who gives me medication, I got peer support, a lot of
people. Yeah”
“Well I like to have it (the CTO) it’s kind of nice to have the attention at the end of the day”
Discussion
Service
users frequently discussed concerns regarding a lack of control over
various aspects of their lives. The impact of the CTO on the daily
lives of service users is apparent. Issues such as having their
drivers’ license revoked, being mandated to take medication that has
unpleasant side effects, and frequent appointments at the hospital were
discussed by participants as negatively impacting the amount of control
they hold over their own lives. This is consistent with the literature,
as most studies found that community treatment orders were perceived as
coercive by service users (Brophy, 2004; Gibbs et al, 2004; Gibbs et
al, 2005; O’Reilly et al, 2006; Scheid-Cook, 1993; Cavin et al, 2002;
Dreezer & Dreezer, 2005).
Service users
with negative feelings about their CTOs spoke more often about the
labels placed on them, and the ways in which they felt they were
perceived by the community and their service providers, than about the
actual conditions of the CTO. The stigma associated with having a
severe mental illness is of obvious concern to all participants
interviewed. The term “schizophrenic” was particularly disliked by
service users. This speaks to the need for professionals to provide
space for self-definition. As stated by Campbell in his article about
psychiatric survivors’ perceptions of the mental health system,
“self-definition
is an essential part of changing the lives of people with a mental
illness diagnosis and choosing a self-description is an element in
this. All service user action is concerned directly or indirectly, with
changing the ways we think about ourselves and others think about us.”
(Campbell, 2006, p. 578)
The stigma
experienced by service users from the community was articulated as a
feeling of being under surveillance. The “othering” of individuals with
severe mental illness is well documented in the literature, and it is
implied in the results of this research which suggest that the CTO
further builds on this feeling of being identified as having a mental
illness, in that it legally defines an individual as mentally ill
(Scheyett, 2006). The feelings of stigma felt by service users
from community members were further compounded by the stigmatizing
attitudes that participants perceived in their interactions with their
service providers.
Professionally based stigma manifested
itself in the participant’s narratives through the acts of diagnosis,
coercion, and authority. Service users discussed the inability of
professionals to empower them to participate in the decision making
process, or move away from an ‘expert-patient’ model of care.
Participants, when talking about feelings of being controlled, most
often discussed medical professionals such as family doctors and
psychiatrists. This is probably reflective of the fact the CTOs in
Ontario are issued by physicians, not courts. If a service user is
noncompliant with the order, it is the physician who has the
responsibility to issue at form for psychiatric assessment that
authorizes the police to apprehend the person to bring them to the
physician for assessment. Moreover, if the person appeals their CTO to
the consent and capacity board it is the physician who has the burden
of proof to demonstrate that the requirements for a CTO have been
met. Service users only occasionally mentioned the role of social
work, and this was generally more positive, noting that ACT teams were
often adaptable to the service users’ needs and schedules.
Service
users, when asked about their understanding of their legal options and
the process of CTOs were unclear about the amount of information that
had been given to them by service providers. All service users
stated that the processes had been explained to them, but several
stated that they did not understand their order, the appeal process, or
how the CTO would end. This limited understanding of the CTO suggests
that service providers should review the information, policies and
rights of the service user with them on a regular basis. This is
necessary due to the varying levels of wellness that service users may
experience, along with documented side effects of medication such as
reduced attention span (Dreezer & Dreezer, 2005).
Limitations
This
pilot study was limited due to time constraints and difficulty
accessing participants. All of the participants were deemed incapable
with respect to treatment decisions regarding their mental health. This
group of service users may experience a CTO as more coercive than
service users who are deemed capable of making decision for
themselves. It would have been beneficial to conduct several
interviews over time with each applicant, as this would increase
rapport with the interviewer. It would also provide the opportunity to
revisit certain questions with the participants in order to clarify or
elaborate on their previous answers. The challenges of interviewing
individuals living with severe and persistent mental illness, such as
side effects of medication, or difficulty-focusing attention,
occasionally caused researchers to ask questions that may have
influenced participant’s answers. Due to the difficulty of interviewing
a population living with varying levels of wellness over time, multiple
interviews may better reflect the overall perceptions of participants.
Conclusion
The
findings of this study have been consistent with the published
literature regarding the perceptions of service users of community
treatment orders. Similar themes emerged across the literature in which
participants report feelings of coercion and powerlessness, but also
recognize some positive aspects of CTOs (Brophy, 2004; Gibbs et al,
2004; Gibbs et al, 2005; O’Reilly et al, 2006; Scheid-Cook, 1993; Cavin
et al, 2002; Dreezer & Dreezer, 2005). What is unique in our
findings is the lack of focus on the actual conditions and provision of
the CTO. Our research suggests that the CTO adds to already problematic
feelings of stigma and powerlessness that are associated with living
with a mental illness. The issue for our participants was less about
the CTO itself, and more about the labels, control and discrimination
associated with severe mental illness.
There is limited research
in Ontario on the topic of service users’ experience of CTOs, and no
study to date that has been completed in collaboration with service
users. A participatory action research (PAR) project would be ideal in
conducting anti-oppressive research, and supporting the goal of
empowerment of individuals on community treatment orders (Tew, 2008).
References
Borum, R.,
Swartz, M., Riley, S., Swanson, J., Hiday,
V. A., & Wagner, R. (1999). Consumer perceptions of involuntary outpatient
commitment . Psychiatric Services. 50
(11), 1489-1491.
Boudreau,
F. & Lambert, P. (1993). Compulsory community treatment? Ontario stakeholders’ responses to
helping those who won’t help themselves. Canadian
Journal of community Mental Health, 12 (1), 57-78.
Braun, V. & Clarke, V. (2006). Using thematic analysis
in psychology. Qualitative Research in
Psychology, 3, 77-101.
Brophy,
L. & Ring, D. (2004). The efficacy of involuntary treatment in the
community: Consumer and service provider perspectives. Social Work Approaches in Health and Mental Health, 2, 157-174.
Canvin, K., Bartlett, A., & Pinfold,
V. (2002). A ‘bitterswert pill to swallow’: Learning from mental health service
users’ responses to compulsory community care in england. Health and Social Care in the Community,
10(5), 361-369.
Campbell,
P. (2006). Changing the mental health system: A survivors view. Journal of
Pyschiatric and Mental Health Nursing, 13 (5), 578-580.
Campbell, J.,
Brophy, L., Healy, W., & O’Brien, A-M. (2006). International perspectives
on the use of community treatment orders: Implications for mental health social
work. British Journal of Social Work,
36, 1-18.
Dawson, J., Romans, S.,
Gibbs, A., & Ratter, N. (2003). Ambivalence about community treatment
orders. International Journal of Law and
Psychiatry, 26, 243-255.
Dreezer
& Dreezer Inc. (2005). Report on the Legislated Review of Community
Treatment Orders Required Under Section 33.9 of the Mental Health Act.
Ontario Ministry of Health and Long-Term Care.
Dudley, J.
R. (2009). Social Work Evaluation:
Enhancing What we Do. Chicago, IL: Lyceum Books, Inc.
Everett, B.
(2001). Community treatment orders: Ethical practice in an era of magical
thinking. Canadian Journal of Community
Mental Health, 20(1), 5-20.
Gibbs, A.,
Dawson, J., Ansley, C., & Mullen, R. (2005). How patients in New Zealand view community treatment orders. Journal of Mental Health 14, 357-368.
Gibbs, A., Dawson, J., Forsyth, H., Mullen, R., & Tanga,
T. O. T.(2004). Maori experience of community treatment orders in Otago,
New Zealand. Australian and New Zealand Journal of Psychiatry, 38, 830-835.
Hitlz, D., & Szigeti, A. (2009). A Guide to Consent and Capacity Law in Ontario. Markham, ON: LexisNexis Canada.
Hunt, A., Da Silva, A., Lurie, S., & Goldbloom, D.
(2007). Community
treatment orders in Toronto: The emerging data. The
Canadian Journal of Psychiatry / La Revue canadienne de psychiatrie, 52(10), 647-656.
Neuman, W., & Kreuger, L. (2003). Social Work Research
Methods: Qualitative and Quantitative Applications. Boston,MA: Pearson
Education, Inc.
O'Brien, A. M., & Farrell, S. (2005). Community
treatment orders: Profile of a Canadian experience. Canadian Journal of
Psychiatry, 50, 27–30.
O'Brien, A. M., Farrell, S. & Faulkner S. (2009). Community
treatment orders beyond hospital utilization rates: Examining the association
between CTOs and community engagement and housing. Journal of Community Mental Health, 45, 415-419.
Ontario,
(1990). The Mental Health Act, R.S.O., c.M7. amended by Mental Health
Legislative Reform, 2000.
O'Reilly, R., Keegan, D., Corring, D., Shrikhande, S., &
Natarajan, D. (2006). A qualitative analysis of the use of community treatment
orders in Saskatchewan. International
Journal of Law and Psychiatry, 29(6), 516-524.
Patton, M. (2003) Qualitative
Research and Evaluation Methods (3rd ed). Thousand
Oaks, CA: Sage.
Rain, S., Steadman, H. J.,
& Robbins, P. C. (2003). Perceived coercion and treatment adherence in an outpatient
commitment program. Psychiatric Services,
54(3), 399-401.
Rubin, A. & Babbie, E.R.
(2008). Research Methods for Social Work
(6th Edition). Belmont, CA: Thompson Higher Education.
Scheid-Cook , T. (1993) Controllers and controlled: an
analysis of participant constructions of outpatient commitment . Sociology of Health and Illness, 15(2),
179-198.
Scheyett, A. (2006). Silence and surveillance: Mental
illness, evidence-based practice and Foucaltian lens. Journal of Progressive
Human Services , 17 (1), 71-92.
Schwartz, K & O’Brien,
A-M. (2010). Injustice can happen whether you’re psychotic or not. In S. Hick,
H. Peters, T. Cormer & T. London (Eds.), Structural Social Work in Action: Examples From Practice (pp.
106-120) Toronto, ON:Canadian Scholars’ Press Inc.
Swartz, M.S.,
& Swanson, J.W. (2004). Involuntary outpatient commitment, community
treatment orders, and assisted outpatient treatment: What’s in the data?, Canadian Journal of Psychiatry, 49,
585-591.
Swartz, M. S.,
Swanson, J.W., Wagner, H. R., Hannon, M. J., Burns, B. J., & Shumway, M.
(2003). Assessment of Four
Stakeholder Groups Preferences Concerning Outpatient Commitment for Persons
with Schizophrenia, American Journal of
Psychiatry (160), 1139-1146.
Tew, J.
(2008). Researching in partnership. Qualitative
Social Work, 7(3), 271-287.
Tutty, L., Rothery, M., & Grinnell, R. (1996). Qualitative
research for social workers: Phases, steps, and tasks. Boston, MA: Allyn &
Bacon.
Van
Dorn, R., Elbogen, E., Redlich, A., Swanson, J., Swartz, M., & Mustillo, S.
(2006). The relationship between mandated community treatment and perceived
barriers to care in persons with severe mental illness. International
Journal of Law and Psychiatry, 29
(6), 495-506.
