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BMC Health Services Research
Published in: BMC Health Services Research 1/2018

Open Access 01-12-2018 | Research article

Responsibilities with conflicting priorities: a qualitative study of ACT providers’ experiences with community treatment orders

Authors: Hanne Kilen Stuen, Anne Landheim, Jorun Rugkåsa, Rolf Wynn

Published in: BMC Health Services Research | Issue 1/2018

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Abstract

Background

Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients’ autonomy and the clinicians’ responsibility to act in the patients’ best interest are resolved in practice. The aim of this study was to explore the service providers’ experiences with CTOs within an ACT setting.

Methods

The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.

Results

The main theme ‘responsibility with conflicting priorities’ emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model’s comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers’ commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients’ everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.

Conclusions

Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.
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Literature
1.
Rugkåsa J. Effectiveness of community treatment orders: the international evidence. Can J Psychiatr. 2016;61:15–24.CrossRef
2.
3.
Sjöström S, Zetterberg L, Markström U. Why community compulsion became the solution—reforming mental health law in Sweden. Int J Law Psychiatry. 2011;34:419–28.CrossRefPubMed
4.
5.
Løvsletten M, Haug E, Granerud A, Nordby K, Smaaberg T. Prevalence and management of patients with outpatient commitment in the mental health services. Nord J Psychiatry. 2016;70:401–6.CrossRefPubMed
6.
Bremnes R, Pedersen PB, Hellevik V, Urfjell B, Solberg A, Engeset Vedvik MA. Bruk av tvang i psykisk helsevern for voksne i 2014 [use of coercion in the mental health services for adults in 2014]. In: Norwegian. Oslo: Norwegian Directorate of Health; 2016.
7.
Wynn R. Coercion in psychiatric care: clinical, legal, and ethical controversies. Int J Psychiatry Clin Pract. 2006;10:247–51.CrossRefPubMed
8.
Wynn R, Myklebust LH, Bratlid T. Psychologists and coercion: decisions regarding involuntary psychiatric admission and treatment in a group of Norwegian psychologists. Nord J Psychiatry. 2007;61:433–7.CrossRefPubMed
9.
Røtvold K, Wynn R. Involuntary psychiatric admission: how the patients are detected and the general practitioners’ expectations for hospitalization. An interview-based study Int J Ment Health Syst. 2016;10:20.CrossRefPubMed
10.
Wynn R, Myklebust LH, Bratlid T. Attitudes to coercion among health-care workers and the general public in Norway. J Psychiatr Intens Care. 2006;2:31–7.CrossRef
11.
Wynn R. Restraint and seclusion in a Norwegian university psychiatric hospital. Tromsø: University Hospital of North Norway; 2004.
12.
13.
Wynn R, Kvalvik AM, Hynnekleiv T. Attitudes to coercion at two Norwegian psychiatric units. Nord J Psychiatry. 2011;65:133–7.CrossRefPubMed
14.
Canvin K, Rugkåsa J, Sinclair J, Burns T. Patient, psychiatrist and family carer experiences of community treatment orders: qualitative study. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1873–82.CrossRefPubMed
15.
O'Reilly RL, Keegan DL, Corring D, Shrikhande S, Natarajan D. A qualitative analysis of the use of community treatment orders in Saskatchewan. Int J Law Psychiatry. 2006;29:516–4.CrossRefPubMed
16.
Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers. BMC Psychiatry. 2016;16:82.CrossRefPubMedPubMedCentral
17.
Newton-Howes G, Banks D. The subjective experience of community treatment orders: patients’ views and clinical correlations. Int J Soc Psychiatry. 2014;60:474–81.CrossRefPubMed
18.
Stensrud B, Høyer G, Granerud A, Landheim AS. “Life on hold”: a qualitative study of patient experiences with outpatient commitment in two Norwegian counties. Issues Mental Health Nurs. 2015;36:209–16.CrossRef
19.
Riley H, Høyer G, Lorem GF. When coercion moves into your home’–a qualitative study of patient experiences with outpatient commitment in Norway. Health Soc Care Community. 2014;22:506–14.CrossRefPubMed
20.
Coyle D, Macpherson R, Foy C, Molodynski A, Biju M, Hayes J. Compulsion in the community: mental health professionals’ views and experiences of CTOs. Psychiatrist. 2013;37:315–21.CrossRef
21.
DeRidder R, Molodynski A, Manning C, McCusker P, Rugkåsa J. Community treatment orders in the UK 5 years on: a repeat national survey of psychiatrists. BJPsych Bull. 2016;40:119–23.CrossRefPubMedPubMedCentral
22.
Riley H, Lorem GF, Høyer G. Community treatment orders–what are the views of decision makers? J Ment Health. 2018;27:97–102.
23.
Stensrud B, Høyer G, Beston G, Granerud A, Landheim AS. “Care or control?”: a qualitative study of staff experiences with outpatient commitment orders. Social Psychiatry Psychiatr Epidemiol. 2016;51:747–55.CrossRef
24.
Dawson J, Mullen R. Insight and use of community treatment orders. J Ment Health. 2008;17:269–80.CrossRef
25.
Burns T, Rugkåsa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet. 2013;381:1627–33.CrossRefPubMed
26.
Kisely SR, Campbell LA, O'Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev. 2017;3:CD004408.PubMed
27.
Steadman HJ, Gounis K, Dennis D, Hopper K, Roche B, Swartz M, et al. Assessing the New York City involuntary outpatient commitment pilot program. Psychiatr Serv. 2001;52:330–6.CrossRefPubMed
28.
Swartz MS, Swanson JW, Hiday VA, Wagner HR, Burns BJ, Borum R. A randomized controlled trial of outpatient commitment in North Carolina. Psychiatr Serv. 2001;52:325–9.CrossRefPubMed
29.
Phelan J, Sinkewicz M, Castille D, Huz S, Link B. Effectiveness and outcomes of assisted outpatient treatment in New York state. Psychiatr Serv. 2010;61:137–43.CrossRefPubMed
30.
Swanson JW, Swartz MS, Elbogen EB, Wagner HR, Burns BJ. Effects of involuntary outpatient commitment on subjective quality of life in persons with severe mental illness. Behavioral Sci Law. 2003;21:473–91.CrossRef
31.
Swartz M, Wilder C, Swanson J, Van Dorn R, Robbins PC, Steadman H. Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatr Serv. 2010;61:976–81.CrossRefPubMed
32.
Van Dorn RA, Swanson JW, Swartz MS, Wilder CM, Moser LL, Gilbert AR. Continuing medication and hospitalization outcomes after assisted outpatient treatment in New York. Psychiatr Serv. 2010;61:982–7.CrossRefPubMed
33.
Rawala M, Gupta S. Use of community treatment orders in an inner-London assertive outreach service. Psychiatr Bull. 2014;38:13–8.CrossRef
34.
Swanson JW, Van Dorn RA, Swartz MS, Robbins PC, Steadman HJ, McGuire TG, et al. The cost of assisted outpatient treatment: can it save states money? Am J Psychiatry. 2013;170:1423–32.CrossRefPubMed
35.
Burns T. Assisted outpatient treatment services and the influence of compulsory treatment. Am J Psychiatry. 2014;171:228.CrossRefPubMed
36.
Huus G, Storm-Olsen B, Herheim Å. Mennesker med alvorlige psykiske lidelser og behov for særlig tilrettelagte tilbud [People with serious mental disorders and the need for specialized services]. In: Norwegian. Oslo: Directorate of Health; 2008.
37.
Bond GR, Drake RE, Mueser KT, Latimer E. Assertive community treatment for people with severe mental illness. Disease Managem Health Outcomes. 2001;9:141–59.CrossRef
38.
Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. Cochrane Database Syst Rev. 2010;10:CD007906.
39.
Dixon LB, Goldman HH. Forty years of progress in community mental health: the role of evidence-based practices. Austral NZ J Psychiatry. 2003;37:668–73.CrossRef
40.
Monroe-DeVita M, Teague GB, Moser LL. The TMACT: a new tool for measuring fidelity to assertive community treatment. J Am Psychiatr Nurs Assoc. 2011;17:17–29.CrossRef
41.
Clausen H, Landheim A, Odden S, Heiervang KS, Stuen HK, Killaspy H, et al. Associations between quality of life and functioning in an assertive community treatment population. Psychiatr Serv. 2015;66:1249–52.CrossRefPubMed
42.
Landheim A, Ruud T, Odden S, Clausen H, Heiervang KS, Stuen HK, et al. Utprøving ACT-team i Norge – Hva viser resultatene? Oslo: Norwegian Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders; 2014.
43.
Patton MQ. Qualitative evaluation and research methods. London: Sage Publications; 1990.
44.
Stuen HK, Rugkåsa J, Landheim A, Wynn R. Increased influence and collaboration: a qualitative study of patients’ experiences of community treatment orders within an assertive community treatment setting. BMC Health Serv Res. 2015;15:409.CrossRefPubMedPubMedCentral
45.
Charmaz K. Constructing grounded theory. London: Sage Publications; 2014.
46.
47.
Angell B. Clinician attitudes, experiences, and use of coercion. In: Molydynski A, Rugkåsa J, Burns T, editors. Coercion in community mental health care: international perspectives. Oxford: Oxford University Press; 2016.
48.
Appelbaum PS, Le Melle S. Techniques used by assertive community treatment (ACT) teams to encourage adherence: patient and staff perceptions. Community Ment Health J. 2008;44:459–64.CrossRefPubMed
49.
George M, Manuel JI, Gandy-Guedes ME, McCray S, Negatu D. “Sometimes what they think is helpful is not really helpful”: understanding engagement in the program of assertive community treatment (PACT). Community Ment Health J. 2016;52:882–90.CrossRefPubMed
50.
Kidd SA, George L, O'Connell M, Sylvestre J, Kirkpatrick H, Browne G. Recovery-oriented service provision and clinical outcomes in assertive community treatment. Psychiatric Rehabil J. 2011;34:194.CrossRef
51.
Barrett B, Young MS, Teague GB, Winarski JT, Moore KA, Ochshorn E. Recovery orientation of treatment, consumer empowerment, and satisfaction with services: a mediational model. Psychiatric Rehabil J. 2010;34:153.CrossRef
52.
Neale MS, Rosenheck RA. Therapeutic limit setting in an assertive community treatment program. Psychiatr Serv. 2000;51:499–505.CrossRefPubMed
53.
Manuel JI, Appelbaum PS, Le Melle SM, Mancini AD, Huz S, Stellato CB, et al. Use of intervention strategies by assertive community treatment teams to promote patients’ engagement. Psychiatr Serv. 2013;64:579–85.CrossRefPubMed
54.
Moser LL, Bond GR. Scope of agency control: assertive community treatment teams’ supervision of consumers. Psychiatr Serv. 2009;60:922–8.CrossRefPubMed
55.
Angell B. Measuring strategies used by mental health providers to encourage medication adherence. J Behav Health Serv Res. 2006;33:53–72.CrossRefPubMed
56.
Killaspy H, Johnson S, Pierce B, et al. Successful engagement: a mixed methods study of the approaches of assertive community treatment and community mental health teams in the REACT trial. Soc Psychiatry Psychiatr Epidemiol. 2009;44:532–40.CrossRefPubMed
57.
Davidson G, Campell J. An Exanination of the use of coercion by assertive outreach teams and community mental health teams in Northern Ireland. Br J Soc Work. 2007;37:537–55.CrossRef
58.
Lofthus AM, Westerlund H, Bjørgen D, Lindstrøm JC, Lauveng A, Clausen H, et al. Are users satisfied with assertive community treatment in spite of personal restrictions? Community Ment Health J. 2016;52:891–7.CrossRefPubMed
59.
Gomory T. The origins of coercion in assertive community treatment: a review of early publications from the special treatment unit of Mendota state hospital. Ethical Human Sci Serv. 2002;4:3–16.
60.
Spindel P, Nugent J. Polar opposites: empowerment philosophy and assertive community treatment (ACT). Ethical Human Sci Serv. 2000;2:93–100.
61.
Lerbæk B, Aagaard J, Andersen MB, Buus N. Moral decision-making among assertive community treatment (ACT) case managers: a focus group study. Issues Mental Health Nurs. 2015;36:659–68.CrossRef
62.
Aggett P, Goldberg D. Pervasive alienation: on seeing the invisible, meeting the inaccessible and engaging ‘lost to contact’clients with major mental illness. J Interprofessional Care. 2005;19:83–92.CrossRef
63.
Corrigan PW. Empowerment and serious mental illness: treatment partnerships and community opportunities. Psychiatric Quart. 2002;73:217–28.CrossRef
64.
65.
Tew J, Ramon S, Slade M, Bird V, Melton J, Le Boutillier C. Social factors and recovery from mental health difficulties: a review of the evidence. Br J Soc Work. 2012;42:443–60.CrossRef
66.
Pridham KM, Bertson A, Simpson AI, Law SF, Sterigiopoulos V, Makhost A. Perception of coercion among patients with a psychiatric community treatment order: a literature review. Psychiatr Serv. 2016;67:16–28.CrossRefPubMed
67.
Tam C, Law S. Best practices: a systematic approach to management of patients who refuse medications in an assertive community treatment team setting. Psychiatr Serv. 2007;58:457.CrossRefPubMed
68.
Segal S, Preston N, Kisely S, Xiao J. Conditional release in Western Australia: effect on hospital length of stay. Psychiatr Serv. 2009;60:94–9.CrossRefPubMed
69.
Røtvold K, Wynn R. Involuntary psychiatric admission: characteristics of the referring doctors and the doctors’ experiences of being pressured. Nord J Psychiatry. 2015;69:373–9.CrossRefPubMed
70.
Bagby RM, Atkinson L. The effects of legislative reform on civil commitment admission rates: a critical analysis. Behav Sci Law. 1988;6:45–61.CrossRef
71.
Cleveland S, Mulvey EP, Appelbaum PS, Lidz CW. Do dangerousness-oriented commitment laws restrict hospitalization of patients who need treatment? A test Hosp Community Psychiatry. 1989;40:266–71.PubMed
72.
Appelbaum PS. Almost a revolution: an international perspective on the law of involuntary commitment. J Am Acad Psychiatry Law. 1997;25:135–47.PubMed
73.
Myklebust LH, Sørgaard K, Wynn R. Local psychiatric beds appear to decrease the use of involuntary admission: a case-registry study. BMC Health Serv Res. 2014;14:64.CrossRefPubMedPubMedCentral
74.
Morrissey JP. Perceived coercion, outpatient commitment, and reinvestment in community mental health programs. Psychiatr Serv. 2016;67:1.CrossRefPubMed
75.
Aakerholt A. ACT-håndbok [ACT-handbook]. Norwegian National Advisory Unit on concurrent substance abuse and mental health disorder. Brummundal: Sykehuset Innlandet HF; 2013.
Metadata
Title
Responsibilities with conflicting priorities: a qualitative study of ACT providers’ experiences with community treatment orders
Authors
Hanne Kilen Stuen
Anne Landheim
Jorun Rugkåsa
Rolf Wynn
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Health Services Research / Issue 1/2018
Electronic ISSN: 1472-6963
DOI
https://doi.org/10.1186/s12913-018-3097-7

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