Hannah Jobling, University of York, Social Policy and Social Work Department, hjls500@york.ac.uk

1. An Ethical Balancing Act? How context and causal mechanism influence Community Treatment Order outcomes Hannah Jobling, University of York, Social Policy and Social Work Department, hjls500@york.ac.uk

2. Overview • Community Treatment Orders (CTOs) in England and Wales • Research scope and methodological approach • CTOs in practice: The creation of a typology • How we can reach an understanding of who CTOs work for in what circumstances (context), why (mechanisms) • How CTO outcomes can be reframed

3. CTOs: Background • Enacted in around 70 jurisdictions worldwide, including USA, Canada, Australia, New Zealand • Introduced in England and Wales under the Mental Health Act 2007, became ‘live’ in late 2008. • Allow for conditions to be imposed on how mental health service users live in the community • Provide a mechanism for detention and treatment enforcement if conditions are not met, or health & safety concerns • CTOs “enforce community treatment outside (and independently) of the hospital, contain specific mechanisms for enforcement and/or revocation and are authorised by statute” (Churchill et al, 2007, 20)

4. CTOs: Background • Three drivers highlighted in policy and research literature: • Revolving door (resources) • Risk management • Rehabilitation and recovery • CTOs probably the most controversial aspect of new Act: • On one hand – help to engage service users, reduce rates of hospitalisation, improve clinical outcomes and promote stability • On the other – extend compulsion, result in unnecessary coercion, loss of rights and neglect of alternative options

5. An Ethnography of CTOs • Considerable scope for finding out how CTOs are practiced and what that might mean • A CTO ethnography: • Enables “the particular context of social actors and groups and the social matrices of their thoughts and behaviour” (Swanson, 2010, 185) to be accounted for • Connects stakeholder experiences to CTO-related events as they occur • Allows for CTOs to be viewed as a process, unfolding over time, mediated by contextual factors • Illuminates what CTO practice looks and feels like – joins abstract political concerns with concrete ethical dilemmas

6. The Study • Aim: To find out in what ways CTOs are being implemented and with what implications for the practice and experiences of service users and practitioners. • Case study design: Two Trusts > One AOT in each Trust > 18 CTO cases across the field sites • Fieldwork took place over 8 months and tracked the progress of the 18 cases: • Interviews (some repeat) with 18 service users and 20 practitioners • Observation of key meetings, daily practice and informal interactions • Content analysis of case files • Additional research activities: • Key informant interviews with 16 practitioners • Content analysis of Trust policy

7. Typology of CTOs: Societal goals and institutional means Ambivalence Subversion

8. Case study: Active acceptance ‘I felt that part of my Community Treatment Order and part of my injections were in conflict because I didn’t feel in control of my injections. I was being told you’ve got to have them. It felt like the responsibility had been taken out of my hands. It was in the hands of the nurses here and the doctors here and I thought, well, that’s not fair because my CTO says I’ve got to be responsible; I’ve got to be in charge and then, when I went up to the medical centre and they started doing it, I settled down a bit better.’ • James • Active acceptance something to be worked at from initial discharge • Taking ownership - “It belong to me” • Key factors: • Negotiation of medication • Collaborative work – ‘mutuality of accounts’ • Making sense of the CTO – developing purpose • On-going explanation and development of legal consciousness • Taking control

9. ‘She’s not a risk to others or really to herself, but it’s a really tight-knit community where she lives and everyone knows her. She’d only just built up trust again there and now…So I think it’s about supporting her in the community really’ Case study: Active Resistance • Sheila • Reinforcement of barriers to care and support – ‘she’s not on my side’ • No hope of discharge by either Sheila or her care coordinator • Key factors: • Active resistance either through use of legal mechanisms or avoidance • Repeat recalls – reinforcing cycles of resistance • ‘Surface’ work • Making sense of the CTO – previous difficult experiences • Bioethical balancing act

10. Context and causal mechanisms • Context affects the way individuals respond to the programme concept, which in turn influences the ways they interact with programme intervention strategies. • Context • Refers both to the characteristics of those individuals made subject to a policy programme and the institutional and micro-social factors that mediate their experiences. • Complex interactions between personal values and beliefs, and past and present experiences of services, medication and relationships with professionals. • Mechanisms • Refers to the “process of how individuals interpret and act upon the intervention strategies” (Pawson and Tilley, 2004, 6). • Recall as an intervention paradox

11. What does this mean for CTO outcomes? • Multiple intended and unintended consequences of relationship between mechanisms and context. • Judging ‘success’ or ‘failure’ • Viewing ‘outcomes’ more broadly • Moving beyond ‘effectiveness = ethically sound’