Trust and Community Treatment Orders

Abstract

There are conflicting views about the benefits of community treatment orders (CTOs) for people with mental illness. While there is a significant literature on the coercive nature of CTOs, there is less on the impact that CTOs have upon trust. A recovery-oriented approach requires a trusting therapeutic relationship and the coercion inherent in the CTO process may make it difficult for trust to be built, nurtured, and sustained between workers and patients. Our aim was therefore to examine the role of trust within the CTO experience for mental health workers and patients on CTOs. Methods: We conducted a thematic discourse analysis of 8 in-depth interviews with people who were currently on a CTO and 10 interviews with multi-disciplinary mental health workers in Adelaide, Australia (total N = 18 interviews). The interviews were coded and analyzed with the assistance of a patient representative. The findings reveal the challenges and opportunities for trust within the coercive relationship of a CTO. Findings: We found that patients have diverse experiences of CTOs and that trust or mistrust played an import role in whether or not they found the CTO beneficial.

Suicide rates among patients subject to community treatment orders in England during 2009–2018

“…8,9 However, the coercive nature of supervised community treatment has caused much debate, with critics viewing CTOs as punitive, restricting civil liberties 10 and compromising trust in the patient–psychiatrist relationship. 11 A recent systematic review and meta-analysis found inconsistent evidence that compulsory community treatment improved patient outcomes. 12 It also confirmed findings from the only randomised controlled trial of CTOs in England, the Oxford Community Treatment Order Evaluation Trial (OCTET), that CTOs did not reduce rates of readmission.…”

Risk versus recovery: Care planning with individuals on community treatment orders

“…CTOs were used by some clinicians to engage consumers in treatment, rather than spending the time required to develop trusting relationships (McMillan et al . 2019). At a systems level, a risk focus influences monitoring and reporting procedures, with compliance to risk assessment and management overriding other outcomes relevant to consumers (Szmukler & Rose 2013), such as reported jobs or social contacts.…”

Community treatment orders and care planning: How is engagement and decision‐making enacted?

“…Cath Roper, an Australian consumer academic, highlights that in the context of forced care, a person is ‘judged incompetent, owing to a lack of insight’ and subsequently dismissed as a person without equal status to clinicians. 38 (p. 420) Similarly, McMillan et al 21 found that clinicians did not fully trust consumers to understand their predicament and need for treatment, and thus pathologized any resistance that they expressed about the CTO and treatment.…”

“…Both theories are relevant to care planning for consumers on CTOs. CTOs can create distrust in the health care system and the clinicians and consumers within the system 21,22 . There are significant and valid justifications for consumers to have reduced trust at the interpersonal level (with clinicians) and the systems level (with services).…”

“…CTOs can create distrust in the health care system and the clinicians and consumers within the system. 21 , 22 There are significant and valid justifications for consumers to have reduced trust at the interpersonal level (with clinicians) and the systems level (with services). Such factors include the iatrogenic effects of treatment (medication side effects and coercion), 10 common features that people with a serious mental illness experience (such as paranoia) 4 and trauma experienced before and from care contacts.…”