What Clinicians Say About the Experience of Working With Individuals on Community Treatment Orders

Qualitative systematic review is a method for integrating or comparing the findings from qualitative studies. The accumulated knowledge resulting from this process may lead to the development of a new theory, an overarching narrative, or a wider generalization of previous research. A qualitative systematic review looks for themes or constructs that exist across individual qualitative studies. The goal is not to add studies together but to broaden understanding of a particular phenomenon (8). In chapter 20 of the Cochrane Handbook for Systematic Reviews of Interventions (9), it is noted that a synthesis of the evidence from qualitative research can explore questions such as how people experience illness, why an intervention does or does not work, and for whom and in what circumstances an intervention is likely to be effective?

Ethics approval was not required because there was no direct involvement of individuals. We searched PsycINFO, MEDLINE, EMBASE, and CINAHL and the gray literature. Gray literature refers to publications of reports from government and various nongovernment organizations. For inclusion in the review, research studies had to have used a qualitative method of data collection and analysis. Mixed-method studies that used both quantitative and qualitative methods were included provided the qualitative component met the criteria above. [A complete list of search terms used is included in an online supplement to this article.]

All the generated abstracts were read by one of the authors (CS). If the abstract contained an indication that the study used qualitative methods to examine stakeholder perspectives about CTOs, the article was retrieved and read in full by two of the authors (DC and ROR). A decision about whether inclusion criteria were met was made by consensus. The number of study participants, methods, focus of the inquiry, and country of origin were recorded.

Two authors (DC and ROR) then recorded the themes and subthemes reported in the articles independently by using the constant comparative method to compare and contrast themes and identify themes and the relative prominence of the themes. Several iterations of this comparative analysis were performed until there was consensus on the themes found in the literature and the prominence and strength of one theme relative to another. Saturation was achieved when it became clear that there were no new themes emerging from the results of the studies.

This review of qualitative research shows that clinicians see benefits from CTOs for service users, but they also struggle with the dissonance caused by supporting an imposed treatment regimen while attempting to adhere to the principles of recovery and person-centered care. Clinicians believe that it is necessary to use CTOs in some situations. It is possible that discomfort working with imposed treatment may have led other clinicians to avoid this work and that the voices expressed in the reviewed studies may not reflect those of a wider sample of clinicians.

Clinicians desire to build positive therapeutic relationships with service users because such relationships have been shown to improve health outcomes (30). In a review of the literature on care planning for service users on CTOs, which included quantitative and qualitative research and opinion papers, Dawson and colleagues (31) noted that although clinicians are concerned about the effect of CTOs on the therapeutic relationship, they still believe that CTOs are needed for some service users. But how can clinicians develop positive relationships with service users when treatment is mandatory? Dawson and colleagues reported that clinicians emphasized the need for empathic communication about the purpose of CTOs, the importance of building trust, and the need to encourage service users’ involvement in decision making when possible. Light and colleagues (32) suggested using an approach that focuses on service users’ capabilities and that reconceptualizes their strengths, rather than focusing on their deficits, as most consistent with a recovery approach.

The views and experience of clinicians are given limited importance in a hierarchy of evidence that prioritizes randomized controlled trials (RCTs). However, the lack of clear evidence from RCTs regarding the efficacy of CTOs may reflect the complexity of the intervention (33), which varies markedly in the powers conferred on clinicians and requires the cooperation of multiple participants. Failure of one of these groups to effectively fulfill its commitment to the CTO may make the order ineffective. We saw examples of this in our review, such as the following comment by a psychiatrist in the study by Lawton Smith (22): “The split between ‘inpatient’ and ‘community’ consultants has led to a difference in views on occasions. . . . It is difficult to draw up a care plan for another consultant. . . . This functional split model causes obstacles.”

Clinicians had suggestions about ways to make CTOs more effective. Making procedures for the use of CTOs less burdensome and ensuring that all stakeholders were educated about the powers and responsibilities of various stakeholders and the rights of service users on a CTO were the most frequently heard.

Both psychiatrists and nonmedical clinicians attributed the positive outcomes of CTOs to increased service user adherence to medication prescribed for their mental disorder. This perspective is not unexpected given that a medication requirement is almost universal in CTO schemes (34,35) and that psychiatrists in the United Kingdom rated promoting compliance with medication as second only to ensuring contact with mental health professionals as a reason to place a person on a CTO (7).

It was notable, however, that some clinicians believed that CTOs are excessively focused on medication compliance. The contrasting views of clinicians regarding the importance of medication requirements may reflect different concepts of the “treatment plan.” In many jurisdictions, service users are required to follow a formal treatment plan that is part of the CTO. This treatment plan usually specifies only the mandatory elements of treatment, and psychiatrists prefer to mandate only elements of treatment that are absolutely necessary (36).

Perhaps the pertinent question is how often individuals who are placed on CTOs are offered other services that may support recovery? Some jurisdictions place a clause in the CTO legislation that the services necessary to support the CTO must be available in the community. This requirement is usually interpreted as “services necessary to support the mandatory components of the CTO.” For some cases, the conditions of the CTO could, at a bare minimum, be supported by a psychiatrist who would monitor the person’s condition, prescribe medication, and complete the assessments and paperwork required by the CTO. More typically, service users require a case manager or an assertive community treatment team, and a minority of service users may require an appropriately supervised residential setting. Lack of services in rural areas and a more pervasive lack of suitable supported housing were noted in several studies as limiting the effectiveness of CTOs.

Maximizing opportunity for recovery usually necessitates more than simply ensuring that the person takes medication and stays symptom free. Many individuals on CTOs could benefit from skills training designed to promote independence or to secure competitive employment. Others could benefit from attendance at a clubhouse or other social outlet or from addiction services tailored to their needs. The principle of reciprocity dictates that when the state takes away a right, it must provide a benefit (37). Such a benefit must be more than just reducing system utilization, which is often more of a benefit for the system than for the service user. Some critics suggest that prioritizing service users on CTOs for scarce services, such as assertive community treatment, could result in inappropriate placement on CTOs, a concern shared by some clinicians (20). However, a well-functioning review board system should be able to obviate this risk. One of the authors (ROR) works in a system in which the commitments of clinicians are written into the CTO treatment plans. These commitments often include such things as taking the service user to medical appointments or teaching activities of daily living. This type of reciprocity may reduce concerns that CTOs are “all about medication.”

Variation of CTO statutes across jurisdictions results in differences in the powers and the administrative details of the orders. Our review found that even within a single jurisdiction, clinicians reported variations in how the powers of the legislation were being interpreted (21), especially concerns that suitable service users were not being placed on CTOs and, conversely, that services users were being maintained on CTOs for longer than necessary.

In a previous report, we noted that families of persons on CTOs complained about the burdensome legal and administrative process of initiating and maintaining a CTO (11). This review found that clinicians shared these concerns (18,21,27,28). One contribution to the bureaucratic burden is the requirements of CTO renewal. The frequency of renewal has been identified as an important issue (6). In Saskatchewan, the original legislation required renewal every three months. In a study conducted in that province with clinicians and other stakeholders, the three-month renewal requirement was noted as unnecessary and burdensome to case managers and psychiatrists (18). Partly as a result of these findings, the Saskatchewan government lengthened the duration of CTOs to six months (38). Other jurisdictions authorize the use of a CTO for a much longer period. For example, in Quebec a court may renew a CTO for up to three years (39). A compromise would be for a first CTO to last six months, with renewals lasting up to 12 months.

Qualitative research has confirmed many findings from quantitative research about clinicians’ views on CTOs. Although quantitative studies indicate that most clinicians believe that CTOs are both ethical and necessary, qualitative studies show that clinicians actually tend to have ambivalent views about CTOs and that clinicians struggle to balance perceived benefits with ethical and philosophical concerns. Clinicians have many suggestions about how CTO legislation could be improved and how CTOs could be implemented in ways that ameliorate the potential negative effects for service users. One source of tension for clinicians is the potential detrimental effects on the therapeutic relationship, and this is an area where a focused qualitative inquiry of clinicians’ and service users’ views would likely add to our knowledge and improve practice.