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de Waardt DA, van Melle AL, Widdershoven GAM, Bramer WM, van der Heijden FMMA, Rugkåsa J, Mulder CL. Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders' opinions. Front Psychiatry 2022; 13:1011961. [PMID: 36405930 PMCID: PMC9669570 DOI: 10.3389/fpsyt.2022.1011961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Multiple studies have examined the effects of compulsory community treatment (CCT), amongst them there were three randomized controlled trials (RCT). Overall, they do not find that CCT affects clinical outcomes or reduces the number or duration of hospital admissions more than voluntary care does. Despite these negative findings, in many countries CCT is still used. One of the reasons may be that stakeholders favor a mental health system including CCT. AIM This integrative review investigated the opinions of stakeholders (patients, significant others, mental health workers, and policy makers) about the use of CCT. METHODS We performed an integrative review; to include all qualitative and quantitative manuscripts on the views of patients, significant others, clinicians and policy makers regarding the use of CCT, we searched MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science Core Collection, Cochrane CENTRAL Register of Controlled Trials (via Wiley), and Google Scholar. RESULTS We found 142 studies investigating the opinion of stakeholders (patients, significant others, and mental health workers) of which 55 were included. Of these 55 studies, 29 included opinions of patients, 14 included significant others, and 31 included mental health care workers. We found no studies that included policy makers. The majority in two of the three stakeholder groups (relatives and mental health workers) seemed to support a system that used CCT. Patients were more hesitant, but they generally preferred CCT over admission. All stakeholder groups expressed ambivalence. Their opinions did not differ clearly between those who did and did not have experience with CCT. Advantages mentioned most regarded accessibility of care and a way to remain in contact with patients, especially during times of crisis or deterioration. The most mentioned disadvantage by all stakeholder groups was that CCT restricted autonomy and was coercive. Other disadvantages mentioned were that CCT was stigmatizing and that it focused too much on medication. CONCLUSION Stakeholders had mixed opinions regarding CCT. While a majority seemed to support the use of CCT, they also had concerns, especially regarding the restrictions CCT imposed on patients' freedom and autonomy, stigmatization, and the focus on medication.
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Affiliation(s)
| | | | - Guy Antoine Marie Widdershoven
- Department of Ethics, Law, and Humanities, Amsterdam University Medical Centers (Location VUmc), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | | | - Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway.,Centre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
| | - Cornelis Lambert Mulder
- Parnassia Psychiatric Institute, Rotterdam, Netherlands.,Department of Psychiatry, Epidemiological and Social Psychiatric Research institute (ESPRi), Erasmus MC, Erasmus University Medical Center, Rotterdam, Netherlands
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2
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Macgregor A. Meaningful participation or tokenism for individuals on community based compulsory treatment orders? Views and experiences of the mental health tribunal in Scotland. J Ment Health 2020; 31:158-165. [PMID: 32955380 DOI: 10.1080/09638237.2020.1818708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The Mental Health (Care and Treatment) (Scotland) Act 2003 was considered as world leading when it was enacted due to its rights-based approach. Changes were made to encourage participation and enhance autonomy, including the Mental Health Tribunal for Scotland (the tribunal) replacing the Sheriff Court in making decisions about compulsory treatment. AIMS To explore the views of individuals on community based compulsory treatment orders (CCTOs) and independent advocates to assess whether participation in the tribunal is perceived as meaningful in practice. METHOD A qualitative research design was adopted and semi-structured interviews were undertaken with 19 people with experience of being on a CCTO and eight mental health advocates in Scotland. The data were thematically analysed and explored using ethics of care principles. RESULTS Individuals faced barriers to participation, including mental distress, medication, and inaccessible communication, and both the tribunal process and outcome were important in shaping perceptions of fairness. A perceived unsuccessful outcome was found to undermine an ostensibly participatory process, and unequal power dynamics resulted in feelings of powerlessness. CONCLUSIONS The findings suggest that participation is often experienced as tokenistic in practice and that cultural change is required if people are to be meaningfully involved in tribunal proceedings.
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Affiliation(s)
- Aisha Macgregor
- Strathclyde Centre for Disability Research, School of Social and Political Sciences, University of Glasgow, Glasgow, UK
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3
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Weller P, Alvarez-Vasquez S, Dale M, Hill N, Johnson B, Martin J, Maylea C, Thomas S. The need for independent advocacy for people subject to mental health community treatment orders. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 66:101452. [PMID: 31706387 DOI: 10.1016/j.ijlp.2019.101452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 04/08/2019] [Accepted: 05/22/2019] [Indexed: 06/10/2023]
Abstract
Independent mental health advocacy (IMHA) has been proposed as a way of maintaining peoples' rights in involuntary settings, but little is known about the challenges and opportunities associated with the provision of independent mental health advocacy to those on compulsory treatment orders in the community. In Victoria, Australia, an IMHA service is available to people who are at risk of or subject to compulsory treatment, including those who are subject to Community Treatment Orders. The IMHA service is based on the independent advocacy model developed in the United Kingdom. This paper details the benefits and challenges of providing independent non-legal advocacy to those in the community, drawing on a 15-month independent co-produced evaluation of the IMHA service. With limited publicly available sector level data, the evaluation employed qualitative approaches. Issues raised include the need to better target limited resources in the most effective way and the problem of ensuring timely and adequate access. While advocacy was well received by consumers, tensions specific to the community setting were influenced by the attitudes of clinicians to need, risk and recovery as opposed to a coherent understanding of consumer preference and choice.
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Affiliation(s)
- Penelope Weller
- RMIT University, Building 13, City Campus, Melbourne, Australia.
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4
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Corring D, O'Reilly R, Sommerdyk C, Russell E. The lived experience of community treatment orders (CTOs) from three perspectives: A constant comparative analysis of the results of three systematic reviews of published qualitative research. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 66:101453. [PMID: 31706379 DOI: 10.1016/j.ijlp.2019.101453] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 04/10/2019] [Accepted: 05/22/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Deborah Corring
- Department of Psychiatry, Western University, London, Ontario, Canada.
| | - Richard O'Reilly
- Department of Psychiatry, Western University, London, Ontario, Canada; Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
| | | | - Elizabeth Russell
- Parkwood Institute, St. Joseph's Health Care London, London, Ontario, Canada
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5
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Jager F, Perron A. The social utility of community treatment orders: Applying Girard's mimetic theory to community-based mandated mental health care. Nurs Philos 2019; 21:e12280. [PMID: 31441197 DOI: 10.1111/nup.12280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 11/27/2022]
Abstract
Serious mental illness (SMI) has long posed a dilemma to society. The use of community treatment orders (CTOs), a legal means by which to deliver mandated psychiatric treatment to individuals while they live in the community, is a contemporary technique for managing SMI. CTOs (or a similar legal mechanism) are used in every province in Canada and in many jurisdictions around the world in the care and management of clients with severe and persistent mental illness (most frequently schizophrenia) who have a history of treatment non-compliance and subsequent relapse. Although there is ongoing controversy around CTOs, their use continues to be on the rise. René Girard's mimetic theory, in which he posits the social utility of the scapegoat mechanism, may shed some light on how established cultural patterns contribute to contemporary responses to SMI: how culture depends on the reproduction of certain narratives, and how these act to shape the identity of those involved. The CTO specifically can be seen to act as a scapegoating mechanism, wherein, by singling out and controlling individuals who appear to threaten social order, social order is restored. This paper reviews Girard's theory, looks at how it has been applied to SMI, and then considers how it may illuminate the social role of the CTO. This examination may provide mental health nurses with insight into the constructed identities of their patients, as well as the role of mental health care within broader cultural narratives.
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Affiliation(s)
- Fiona Jager
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Amélie Perron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
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6
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Brophy L, Kokanovic R, Flore J, McSherry B, Herrman H. Community Treatment Orders and Supported Decision-Making. Front Psychiatry 2019; 10:414. [PMID: 31244699 PMCID: PMC6580382 DOI: 10.3389/fpsyt.2019.00414] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/24/2019] [Indexed: 11/26/2022] Open
Abstract
This paper presents findings from an interdisciplinary project undertaken in Victoria, Australia, investigating the barriers and facilitators to supported decision-making (SDM) for people living with diagnoses including schizophrenia, psychosis, bipolar disorder, and severe depression; family members supporting them; and mental health practitioners, including psychiatrists. We considered how SDM can be used to align Australian laws and practice with international human rights obligations. The project examined the experiences, views, and preferences of consumers of mental health services, including people with experiences of being on Community Treatment Orders (CTOs), in relation to enabling SDM in mental health service delivery. It also examined the perspectives of informal family members or carers and mental health practitioners. Victoria currently has high rates of use of CTOs, and the emphasis on SDM in the Mental Health Act, 2014, is proposed as one method for reducing coercion within the mental health system and working towards more recovery-oriented practice. Our findings cautiously suggest that SDM may contribute to reducing the use of CTOs, encouraging less use of coercive practices, and improving the experience of people who are subject to these orders, through greater respect for their views and preferences. Nonetheless, the participants in our study expressed an often ambivalent stance towards CTOs. In particular, the emphasis on medication as the primary treatment option and the limited communication about distressing side effects, alongside lack of choice of medication, was a primary source of concern. Fears, particularly among staff, about the risk of harm to self and others, and stigma attached to complex mental health conditions experienced by consumers and their families, represent important overarching concerns in the implementation of CTOs. Supporting the decision-making of people on CTOs, respecting their views and preferences about treatment, and moving towards reducing the use of CTOs require system-wide transformation and a significant shift in values and practice across mental health service delivery.
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Affiliation(s)
- Lisa Brophy
- School of Allied Health, Human Services and Sport, La Trobe University.,Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.,Mind Australia, Heidelberg, VIC, Australia
| | - Renata Kokanovic
- Social and Global Studies Centre, RMIT University, Melbourne, VIC, Australia
| | - Jacinthe Flore
- Social and Global Studies Centre, RMIT University, Melbourne, VIC, Australia
| | - Bernadette McSherry
- Melbourne Social Equity Institute and Melbourne Law School, The University of Melbourne, Parkville, VIC, Australia
| | - Helen Herrman
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia.,Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia
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Cleary M, Raeburn T, West S, Escott P, Lopez V. Two approaches, one goal: How mental health registered nurses' perceive their role and the role of peer support workers in facilitating consumer decision-making. Int J Ment Health Nurs 2018; 27:1212-1218. [PMID: 29770544 DOI: 10.1111/inm.12473] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2018] [Indexed: 01/16/2023]
Abstract
Recovery-oriented principles underpin modern-day mental health care and are enhanced by consumer participation in decision-making. Understanding how consumer participation can be maximized is central to promoting recovery-oriented care. This study explored the key strategies used by mental health registered nurses and perceived by nurses to be used by peer support workers in facilitating consumer decision-making to determine similarities, differences, and possible tensions. A qualitative descriptive approach using semi-structured interviews was conducted with nine nurses employed in mental health care. Thematic analysis was conducted using open coding. Frequency of views expressed and prevalence of these amongst participants were noted to determine the most common strategies and challenges. Registered nurses use strategies aimed at empowerment, self-management, and managing expectations to facilitate decision-making but are challenged by entrenched coercion within the system. These same nurses view peer support workers as using their lived experience to build rapport, role model, and advocate for consumers. Tensions arise in how the peer support workers' lived experience should be used and how this impacts on professional and therapeutic boundaries. Nurses expressed support for the role of peer support workers and viewed their inclusion in facilitating consumer decision-making positively. Their own role is perceived as being caught between modern-day service principles of empowerment and long-standing practices based on coercion.
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Affiliation(s)
- Michelle Cleary
- School of Health Sciences, University of Tasmania, Sydney, New South Wales, Australia
| | - Toby Raeburn
- Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia
| | - Sancia West
- School of Health Sciences, University of Tasmania, Sydney, New South Wales, Australia
| | - Phil Escott
- School of Health Sciences, University of Tasmania, Sydney, New South Wales, Australia.,Sydney Local Health District Mental Health Service, Sydney, New South Wales, Australia
| | - Violeta Lopez
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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8
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Brophy LM, Roper CE, Hamilton BE, Tellez JJ, McSherry BM. Consumers' and their supporters' perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings. AUST HEALTH REV 2018; 40:599-604. [PMID: 26934498 DOI: 10.1071/ah15128] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 01/09/2016] [Indexed: 11/23/2022]
Abstract
Objective This paper examines the perspectives of consumers and their supporters regarding the use of seclusion and restraint in mental health settings. Methods Five focus groups for consumers and five focus groups for supporters were conducted in four Australian cities and in one rural location. The 66 participants were asked about strategies to reduce or eliminate the use of seclusion and restraint in mental health settings. Results All participants supported the reduction of the use of seclusion and restraint. Barriers to reducing these practices related to the environment, the effects of drug and alcohol issues, lack of a human rights focus and poor recognition of trauma, stigma and discrimination. Strategies for reducing or eliminating seclusion and restraint included workforce development, environmental and cultural changes. Conclusions Participants clearly identified that the status quo needs to change and conveyed urgency for action. Participants suggested that the involvement of supporters and a range of consumer roles are integral to reducing the use of seclusion and restraint. The findings support the current policy emphasis of working towards the elimination of these practices. What is known about the topic? Mental health policies across many jurisdictions support the reduction and elimination of restraint and seclusion. Evidence suggests those subjected to restraint and seclusion largely experience a range of harmful consequences. No studies focus on the views of supporters of consumers regarding the reduction and elimination of seclusion and restraint, whereas the views of consumers appear in a minority of international studies. What does this paper add? The research enabled an opportunity to hear from people who have been personally affected by and/or have lived experience of these coercive practices. Participants identified local reforms that can uphold the human rights of consumers. They suggested practices to increase accountability, peer support and family involvement, areas that have not been analysed in depth in any of the seclusion and restraint literature. What are the implications for practitioners? This paper will give healthcare services a deeper insight into how to reduce or eliminate restraint or seclusion from the perspective of those with lived experience.
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Affiliation(s)
- Lisa M Brophy
- Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, 4/207 Bouverie Street, Carlton, Vic. 3010, Australia. Email
| | - Catherine E Roper
- Centre for Psychiatric Nursing, School of Health Sciences, The University of Melbourne, Level 6 Alan Gilbert Building, 161 Barry Street, Carlton, Vic. 3053, Australia. Email
| | - Bridget E Hamilton
- Department of Nursing, School of Health Sciences, The University of Melbourne, Level 6 Alan Gilbert Building, 161 Barry Street, Carlton, Vic. 3053, Australia. Email
| | - Juan José Tellez
- Melbourne Social Equity Institute, The University of Melbourne, 201 Grattan Street, Carlton, Vic. 3053, Australia
| | - Bernadette M McSherry
- Melbourne Social Equity Institute, The University of Melbourne, 201 Grattan Street, Carlton, Vic. 3053, Australia
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9
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Olasoji M, Maude P, McCauley K. Not sick enough: Experiences of carers of people with mental illness negotiating care for their relatives with mental health services. J Psychiatr Ment Health Nurs 2017; 24:403-411. [PMID: 28499065 DOI: 10.1111/jpm.12399] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: Existing literature provides insight into the general experience of carers of people with a mental illness. Previous studies have found that carers experience a range of emotions when looking after their relatives with a mental illness. However, experiences of carers as they engage with the healthcare system is largely absent from the literature. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper identified the experiences of carers when their relatives are experiencing a crisis or acutely unwell. Carers found themselves in the middle between mental health services and their relatives. Strategies employed by carers to ensure their relatives receive adequate care were identified from this study. This paper identified how carers needed to become more assertive in order to receive adequate care for their relatives, and this finding has implications for any future carer education. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The participants identified the need to work more collaboratively with carers of people with a mental illness as they seek treatment for their relatives in order to achieve better health outcomes for the patients. Improved health service engagement of carers was seen by participants to assist them to better care for their relative. The study also found that there needs to be a clearer definition as to what constitutes mental health crisis and how carers are able to intervene during this period. Services could provide clear information concerning crisis services and in particular triage. ABSTRACT Aim The literature reporting experiences of relatives of people with mental illness regarding their interactions with mental health services identifies many commonalities. However, the actual experience of carers engaging the services and understanding healthcare systems remains a gap in the literature. The aim of this study was to explore the experiences of carers (of people with a severe mental illness) in a major area mental health service in Victoria Australia as they fulfil their caring role while negotiating support for their relative. A carer is defined as a family member or significant other who is the primary individual who provides informal care for a person with severe mental illness and may or may not be in receipt of income supplement for such a role. Specifically this study has a focus on the experience of the carer when negotiating care needs or admission with a mental health service. Method A qualitative descriptive approach was used with five focus groups as a means of data collection. Ethical approval for the study was obtained from both the hospital and universities ethics committees. Results Key themes identified using thematic analysis are presented in the words of the carers and include: "Juggling" between services; We became assertive and If only they would listen. Often carers were advocating for their relative and needing to negotiate between services (police and crisis assessment teams) to gain any form of assessment or intervention. Carers often spent a great deal of time on the phone to services only to be told that their relative was "not sick enough" to access care or that no response would occur without another service also being involved. Discussion Our research highlights the importance of working collaboratively with informal carers and acknowledging their valuable contribution to the care of their relatives with a severe mental illness. It is very important that adequate support is given to carers especially during the period when their relatives are experiencing a crisis. An understanding of their experiences ensures a more family focused approach towards care. The study findings should enable the healthcare team to focus attention on the issues which are most pertinent to carers. Nurses are advocates not only for the patient but also for their families. Relevance statement Carers supporting a person who experiences mental illness can often find themselves in difficult and emotionally challenging situations such as at times of crisis and admission to mental health services. The fourth and latest Australian National Mental Health Plan (2009-2014) acknowledged these concerns and highlighted the need to recognize the role of carers in promoting well-being and recovery of the relative with a mental illness. The plan acknowledges that families are often best placed to recognize signs of relapse in their family members with a mental illness and discharge planning should include the involvement of family members (Commonwealth of Australia, ). To achieve best care outcomes for consumers, mental health nurses need to recognize the role of the carer and collaborate in care planning.
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Affiliation(s)
- M Olasoji
- School of Nursing and Midwifery Monash University, Clayton, Vic, Australia
| | - P Maude
- School of Health Sciences RMIT University, Bundoora, Vic, Australia.,School of Health Sciences, University of Tasmania, Tas, Australia
| | - K McCauley
- School of Nursing, Massey University, Wellington, New Zealand
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10
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Corring D, O'Reilly R, Sommerdyk C. A systematic review of the views and experiences of subjects of community treatment orders. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2017; 52:74-80. [PMID: 28325533 DOI: 10.1016/j.ijlp.2017.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 01/17/2017] [Accepted: 03/02/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE CTOS have been the subject of many qualitative and quantitative research studies. Both research approaches add value to our understanding of CTOs. Qualitative studies provide an understanding of CTOs and the experience of being on a CTO that quantitative studies cannot provide. Many qualitative studies that have examined the views of subjects of CTOs have been published. However, authors of these studies continue to note that views and experiences of the subjects of these orders are not well known. This paper provides the results of a systematic review of qualitative studies focused on understanding the experiences of individuals who have been the subjects of CTOs. METHOD Relevant databases and grey literature were searched. To be included, a study had to have used a qualitative methodology for data collection and analysis, and focus on examining stakeholder perspectives on the lived experience of CTOs. RESULTS After a rigorous review of the abstracts, we identified 22 papers that met the criteria. These papers were analysed in detail in order to examine the existence of common themes. The 22 papers represented the views of 581 participants from 7 countries around the world. Ten themes were found to be common among the research findings of the 22 papers. Three themes in particular were highlighted: feelings of coercion and control, medication seen as the main reason for a CTO and that the perception of CTOs as a safety net. Findings also highlight the ambivalence that subjects of CTOs experience, the importance of the therapeutic relationship for successful engagement of the subject of the CTO and the complex role of coercion. RECOMMENDATIONS We have made a number of recommendations about how clinicians might use the views of the subjects of CTOs achieve a more positive experience of a CTO.
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Affiliation(s)
- Deborah Corring
- Department of Psychiatry, Faculty of Medicine and Dentistry, Clinical Skills Building, Rm. 3700, Western University, London, ON, Canada.
| | - Richard O'Reilly
- Department of Psychiatry, Faculty of Medicine and Dentistry, Clinical Skills Building, Rm. 3700, Western University, London, ON, Canada
| | - Christina Sommerdyk
- Department of Psychiatry, Faculty of Medicine and Dentistry, Clinical Skills Building, Rm. 3700, Western University, London, ON, Canada
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11
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Stomski N, Morrison P, Whitely M, Brennan P. Advocacy processes in mental health: a qualitative study. QUALITATIVE RESEARCH IN PSYCHOLOGY 2017. [DOI: 10.1080/14780887.2017.1282567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Norman Stomski
- Murdoch University, School of Health Professions, Murdoch, Australia
| | - Paul Morrison
- Murdoch University, School of Health Professions, Murdoch, Australia
| | | | - Pip Brennan
- Health Consumers Council, East Perth, Australia
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12
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Light EM, Robertson MD, Boyce P, Carney T, Rosen A, Cleary M, Hunt GE, O'Connor N, Ryan CJ, Kerridge IH. How shortcomings in the mental health system affect the use of involuntary community treatment orders. AUST HEALTH REV 2017; 41:351-356. [DOI: 10.1071/ah16074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/03/2016] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs). Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n = 5), carers (n = 6), clinicians (n = 15) and members of the Mental Health Review Tribunal of NSW (n = 12). Data were analysed using established qualitative methodologies. Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services. Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation. What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood. What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs. What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.
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Burns T, Rugkåsa J, Yeeles K, Catty J. Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04210] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BackgroundCoercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.DesignThe programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.ParticipantsParticipants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.OutcomesThe OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.ResultsCommunity treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.ConclusionsCommunity Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.Trial registrationCurrent Controlled Trials ISRCTN73110773.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Tom Burns
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jorun Rugkåsa
- Department of Psychiatry, University of Oxford, Oxford, UK
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Ksenija Yeeles
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Jocelyn Catty
- Department of Psychiatry, University of Oxford, Oxford, UK
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Dawson S, Lawn S, Simpson A, Muir-Cochrane E. Care planning for consumers on community treatment orders: an integrative literature review. BMC Psychiatry 2016; 16:394. [PMID: 27832769 PMCID: PMC5105250 DOI: 10.1186/s12888-016-1107-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders' perspectives and experiences of care planning for consumers' on CTOs. METHODS An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management. RESULTS Forty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions. CONCLUSIONS Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the 'control and care' dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.
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Affiliation(s)
- Suzanne Dawson
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia.
| | - Sharon Lawn
- School of Medicine, Flinders University, Adelaide, Australia
| | - Alan Simpson
- School of Health Sciences, Nursing, City University London, London, UK
| | - Eimear Muir-Cochrane
- School of Nursing & Midwifery, Flinders University, GPO Box 2100, Adelaide, 5001, Australia
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15
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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. [PMID: 27030136 PMCID: PMC4815077 DOI: 10.1186/s12888-016-0791-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community Treatment Orders (CTOs) are often complex because of the ethical tensions created by an intervention that aims at promoting the patient's good through an inherently coercive process. There is limited research that examines the complexity of CTOs and how patients on CTOs and workers administering CTOs make sense of their experiences. METHODS The study involved in-depth interviews with 8 patients on CTOs and 10 community mental health workers in South Australia, to explore how they constructed their experiences of CTOs. Critical discourse analysis (CDA) was used to analyse the data, supported by NVIVO software. RESULTS Analysis of the interviews revealed that patients and workers experienced the CTO process as multi-dimensional, including some positive as well as more negative constructions. The positive metaphor of CTOs as a safety net is described, followed by a more detailed description of the metaphors of power and control as the dominant themes, with five sub-themes of the CTO as control, wake-up, punishment, surveillance, and tranquiliser. DISCUSSION Metaphors are a way that mental health patients and mental health workers articulate the nature of CTOs. The language used to construct these metaphors was quite different, with patients overwhelmingly experiencing and perceiving CTOs as coercive (that is, punishing, controlling and scrutinizing), whereas workers tended to perceive them as necessary, beneficial and supportive, despite their coerciveness. CONCLUSIONS By acknowledging the role of metaphors in these patients' lives, workers could enhance opportunities to engage these patients in more meaningful dialogue about their personal experiences as an alternative to practice predominantly focused on risk. Such a dialogue could enhance workers' reflection on their work and promote recovery-based practice. More understanding of how to promote autonomy, capacity and supported decision-making, and how to address the impacts of coercion within care, is needed.
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Affiliation(s)
- Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Room 4 T306 Margaret Tobin Centre, PO Box 2100, Adelaide, South Australia, 5001, Australia.
| | - Toni Delany
- Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, South Australia, Australia
| | | | - Ann Smith
- C/o Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia
| | - John McMillan
- The Bioethics Centre, University of Otago, Dunedin, New Zealand
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16
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Brophy LM, Roper CE, Hamilton BE, Tellez JJ, McSherry BM. Consumers and Carer perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups. Int J Ment Health Syst 2016; 10:6. [PMID: 26855669 PMCID: PMC4744440 DOI: 10.1186/s13033-016-0038-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 01/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Seclusion and restraint are interventions currently permitted for use in mental health services to control or manage a person's behaviour. In Australia, serious concerns about the use of such seclusion and restraint have been raised at least since 1993. Consumers and their supporters have also expressed strong views about the harm of these practices. This paper presents the results of ten focus group discussions with people with lived experience of mental health issues and also carers, family members and support persons in relation to the use of seclusion and restraint. METHODS The 30 consumers and 36 supporters participating in the focus groups convened in four Australian cities and one regional centre discussed their understandings of the use of seclusion and restraint and its impact on the people involved. Participants also presented their observations about poor practice and what contributes to it as well as providing ideas and recommendations regarding strategies to reduce or eliminate seclusion and restraint. Focus group discussions were recorded and transcribed, then analysed using the NVivo 10 qualitative data analysis software with a general inductive approach used to analyse data. This analysis enabled consideration of the responses to key questions in the focus groups as well as the identification of emerging themes. RESULTS Six themes emerged from the analysis, these being: human rights, trauma, control, isolation, dehumanisation and 'othering', and anti-recovery. Examples of poor practice identified by focus groups included the use of excessive force, lack of empathy/paternalistic attitudes, lack of communication and interaction and a lack of alternative strategies to the use of seclusion and restraint. There was a confluence of factors identified by participants as contributing to poor practice, with the main factors being organisational culture, the physical environment, under-resourced mental health services and fear and stigma. CONCLUSIONS Focus group participants in the main viewed seclusion and restraint practices in mental health settings as unnecessarily overused, exacerbating problems for individuals, carers, staff and the broader system of care. This study highlights that lived experience of both consumers and their supporters can make an important contribution to mental health services and its ongoing reform.
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Affiliation(s)
- Lisa M Brophy
- Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, 4/207 Bouverie Street, Carlton, VIC 3010 Australia ; Mind Australia, 86-92 Mount Street, Heidelberg, VIC 3084 Australia
| | - Catherine E Roper
- Consumer Academic, Centre for Psychiatric Nursing, School of Health Sciences, University of Melbourne, Level 6 Alan Gilbert Building, 161 Barry Street, Carlton, VIC 3053 Australia
| | - Bridget E Hamilton
- Department of Nursing, School of Health Sciences, University of Melbourne, Level 6 Alan Gilbert Building, 161 Barry Street, Carlton, VIC 3053 Australia ; St Vincent's Mental Health, 41 Victoria Parade, Fitzroy, VIC 3065 Australia
| | - Juan José Tellez
- Melbourne Social Equity Institute, University of Melbourne, 201 Grattan Street, Carlton, VIC 3053 Australia
| | - Bernadette M McSherry
- Melbourne Social Equity Institute, University of Melbourne, 201 Grattan Street, Carlton, VIC 3053 Australia ; Melbourne Law School, University Square, 185 Pelham Street, Carlton, VIC 3035 Australia ; Faculty of Law, Monash University, 15 Ancora Imparo Way, Wellington Road, Clayton, VIC 3800 Australia
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Lawn S, Delany T, Pulvirenti M, Smith A, McMillan J. A qualitative study examining the presence and consequences of moral framings in patients' and mental health workers' experiences of community treatment orders. BMC Psychiatry 2015; 15:274. [PMID: 26541546 PMCID: PMC4635603 DOI: 10.1186/s12888-015-0653-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 10/19/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Mental health recovery involves acknowledging the importance of building the person's capacity for agency. This might be particularly important for patients on community treatment orders (CTOs - which involve enforced treatment for their mental illness), given limited international evidence for their effectiveness and underlying concerns about the use of coercion by workers and systems of care towards this population of people with mental illness. METHODS This study sought to understand how the meaning of CTOs is constructed and experienced, from the perspective of patients on CTOs and workers directly administering CTOs. Qualitative interviews were conducted with South Australian community mental health patients (n = 8) and mental health workers (n = 10) in 2013-14. During thematic analysis of data, assisted by NVIVO software, the researchers were struck by the language used by both groups of participants and so undertook an examination of the moral framings apparent within the data. RESULTS Moral framing was apparent in participants' constructions and evaluations of the CTO experience as positive, negative or justifiable. Most patient participants appeared to use moral framing to: try to understand why they were placed on a CTO; make sense of the experience of being on a CTO; and convey the lessons they have learnt. Worker participants appeared to use moral framing to justify the imposition of care. Empathy was part of this, as was patients' positive right to services and treatment, which they believed would only occur for these patients via a CTO. Workers positioned themselves as trying to put themselves in the patients' shoes as a way of acting virtuously towards them, softening the coercive stick approach. Four themes were identified: explicit moral framing; best interests of the patient; lessons learned by the patient; and, empathy. CONCLUSIONS Experiences of CTOs are multi-layered, and depend critically upon empathy and reflection on the relationship between what is done and how it is done. This includes explicit examination of the moral framing present in everyday interactions between mental health workers and their patients in order to overcome the paradox of the moral grey zone between caring and controlling. It suggests a need for workers to receive ongoing empathy training.
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Affiliation(s)
- Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Flinders Drive, Adelaide, 5042, Australia.
| | - Toni Delany
- Southgate Institute for Health, Society and Equity, Flinders University, Flinders Drive, Adelaide, 5042 Australia
| | - Mariastella Pulvirenti
- Discipline of Public Health, Flinders University, Flinders Drive, Adelaide, 5042 Australia
| | | | - John McMillan
- The Bioethics Centre, University of Otago, Frederick Street, Dunedin, 9016 New Zealand
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Vine R, Komiti A. Carer experience of Community Treatment Orders: implications for rights based/recovery-oriented mental health legislation. Australas Psychiatry 2015; 23:154-7. [PMID: 25653304 DOI: 10.1177/1039856214568216] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Our aim was to determine the views and experiences of carers of people with severe mental illness in regard to Community Treatment Orders (CTOs). METHOD Questionnaires were posted using the mailing lists of two well-established carer support organisations in Victoria. The questionnaires included information about the person with a mental illness, the carer and their experience of care (ECI) and knowledge of recovery (RKI). RESULTS In total, 278 questionnaires were sent and 63 returned, of which 62 provided valid data. Those who responded were predominantly female (90%) and older (mean age 63 years), and were the carer of a person with a severe and recurrent mental illness. Some 60% had experience of caring for a person on a CTO. Most felt the CTO had been of benefit, and in 89% the person relapsed and needed further treatment when the CTO was stopped. CONCLUSION Mental health legislation is shifting to bring a greater focus on rights, individual choice and autonomy in line with recovery-oriented care. This study describes the impact of severe mental illness and decisions in relation to CTOs on carers.
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Affiliation(s)
- Ruth Vine
- Executive Director NorthWestern Mental Health, Melbourne Health, Parkville, VIC, Australia
| | - Angela Komiti
- Department of Psychiatry, the University of Melbourne, Parkville, VIC, Australia
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