1
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Practitioner Perspectives About Managing Community Treatment Orders (CTOs) in England and the Importance of Social Influences. Community Ment Health J 2022; 58:1584-1591. [PMID: 35445909 DOI: 10.1007/s10597-022-00974-2] [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: 09/21/2021] [Accepted: 04/04/2022] [Indexed: 01/27/2023]
Abstract
Previous research in England has suggested a medical acceptance of Community Treatment Order (CTO) coercion, but none have explored the importance of social influences on practitioner decision making. A sample of 181 practitioners with Mental Health Act responsibilities completed an online survey. They recorded their perspectives about the influence of medical and social items. Sixteen questionnaire items were subdivided into three operational aspects: discharge, renewal, and recall. Medical item averages scored significantly higher as influences than social items (medical items mean = 4.43; social items mean = 3.58; t = - 19.38, p = 0.001). The influence of separate medical and social factors was evidenced by exploratory factor analysis when related to discharge and renewal, but not for recall, where items divided into factors that resembled 'risk' and 'disengagement'. Participants' scores showed no statistically significant difference for a practitioner's professional allegiance. The findings demonstrate that social influences are a homogeneous influence on managing CTOs, in addition to the higher scoring influence of medical factors.
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2
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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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3
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Finding Common Ground for Diverging Policies for Persons with Severe Mental Illness. Psychiatr Q 2020; 91:1193-1208. [PMID: 32857286 DOI: 10.1007/s11126-020-09821-7] [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] [Indexed: 10/23/2022]
Abstract
Two diametrically opposed positions predominate discourse for the care and treatment of persons with severe mental illness: anti-deinstitutionalization and anti-institutionalization. Both share the same goal of ensuring best quality of life for those with severe psychiatric disorders, but pathways to achieving this goal are very different and have resulted in much contention. Supporters of each position espouse a different belief system regarding people with psychiatric disorders and their presumed capabilities, placing varying emphasis on maximizing protection of the community versus protection of individual rights, and result in contrasting mental health policies and practice orientations. The authors delineate the history from which these positions evolved, consequent views, and policies and practices that emerged from these differing attitudes. The article culminates in a proposed practice approach that offers a more balanced approach to serving adults with mental illness -navigating risk management by preserving freedom and opportunities of risk while affording mutually satisfactory "risk control."
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4
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Shaw L, Nunns M, Briscoe S, Anderson R, Thompson Coon J. A "Rapid Best-Fit" model for framework synthesis: Using research objectives to structure analysis within a rapid review of qualitative evidence. Res Synth Methods 2020; 12:368-383. [PMID: 33006277 DOI: 10.1002/jrsm.1462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/03/2020] [Accepted: 09/28/2020] [Indexed: 11/08/2022]
Abstract
The short time frame associated with rapid reviews can be challenging for researchers conducting qualitative evidence synthesis. In these circumstances a Best-Fit Framework Synthesis, drawing upon existing theory and/or research, may be conducted to rapidly make sense of qualitative evidence. This article discusses a "Rapid Best-Fit" approach to conducting Framework Synthesis within an 6-week rapid systematic review of qualitative evidence. In the absence of a suitable theoretical model to inform the synthesis, we drew upon our research objectives to structure a framework, and to identify the studies which contained the most relevant data. Themes from these studies were used to revise the initial framework before inductive thematic synthesis finalized theme content. This "Rapid Best-Fit" approach yielded results aligned with the needs of the commissioners of the review and is a useful addition to qualitative synthesis methods, allowing for the incorporation of diverse views and experiences into fast-paced decision making scenarios.
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Affiliation(s)
- Liz Shaw
- College of Medicine and Health, University of Exeter, St Lukes Campus, University of Exeter, Devon, Exeter, EX1 2LU, UK
| | - Michael Nunns
- College of Medicine and Health, University of Exeter, St Lukes Campus, University of Exeter, Devon, Exeter, EX1 2LU, UK
| | - Simon Briscoe
- College of Medicine and Health, University of Exeter, St Lukes Campus, University of Exeter, Devon, Exeter, EX1 2LU, UK
| | - Rob Anderson
- College of Medicine and Health, University of Exeter, St Lukes Campus, University of Exeter, Devon, Exeter, EX1 2LU, UK
| | - Jo Thompson Coon
- College of Medicine and Health, University of Exeter, St Lukes Campus, University of Exeter, Devon, Exeter, EX1 2LU, UK
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5
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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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6
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Plahouras JE, Mehta S, Buchman DZ, Foussias G, Daskalakis ZJ, Blumberger DM. Experiences with legally mandated treatment in patients with schizophrenia: A systematic review of qualitative studies. Eur Psychiatry 2020; 63:e39. [PMID: 32406364 PMCID: PMC7355163 DOI: 10.1192/j.eurpsy.2020.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Patients with severe mental illness, including schizophrenia, may be legally mandated to undergo psychiatric treatment. Patients’ experiences in these situations are not well characterized. This systematic review of qualitative studies aims to describe the experiences of patients with schizophrenia and related disorders who have undergone legally mandated treatment. Methods: Four bibliographic databases were searched: CINAHL Plus (1981–2019), EMBASE (1947–2019), MEDLINE (1946–2019), and PsycINFO (1806–2019). These databases were searched for keywords, text words, and medical subject headings related to schizophrenia, legally mandated treatment and patient experience. The reference lists of included studies and systematic reviews were also investigated. The identified titles and abstracts were reviewed for study inclusion. A thematic analysis was completed for the synthesis of positive and negative aspects of legally mandated treatment. Results: A total of 4,008 citations were identified. Eighteen studies were included in the final synthesis. For the thematic analysis, results were collated under two broad themes; positive patient experiences and negative patient experiences. Patients were satisfied when their autonomy was respected, and dissatisfied when it was not. Patients often retrospectively recognized that their treatment was beneficial. Furthermore, negative aspects of the treatment included deficits in communication and a lack of information. Conclusions: Intervention research has historically focused on clinical outcomes and the quantitative aspects of treatment. Thus, this study provides insight into the qualitative aspects of patients’ experiences with legally mandated treatment. Recognizing these opinions and experiences can lead to better attitudes toward treatment for patients with schizophrenia and related psychiatric illnesses.
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Affiliation(s)
- Joanne E Plahouras
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, OntarioCanada
| | - Shobha Mehta
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, OntarioCanada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada.,Bioethics Department, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - George Foussias
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Zafiris J Daskalakis
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, OntarioCanada.,Campbell Family Mental Health Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel M Blumberger
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, OntarioCanada.,Campbell Family Mental Health Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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7
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Simms-Sawyers C, Miles H, Harvey J. An exploration of perceived coercion into psychological assessment and treatment within a low secure forensic mental health service. PSYCHIATRY, PSYCHOLOGY, AND LAW : AN INTERDISCIPLINARY JOURNAL OF THE AUSTRALIAN AND NEW ZEALAND ASSOCIATION OF PSYCHIATRY, PSYCHOLOGY AND LAW 2020; 27:578-600. [PMID: 33679199 PMCID: PMC7901700 DOI: 10.1080/13218719.2020.1734981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Psychologists working within forensic mental health (FMH) services face challenges around supporting clients' informed consent when engaging in psychological assessment and treatment. Given that there is little research in this area, this qualitative study interviewed ten forensic inpatients from a low secure FMH service, to determine the impact of any perceived coercion to engage with psychologists. Interviews were transcribed and subject to Thematic Analysis. Three over-arching themes emerged from the analysis: 'Awareness of Coercive Power', 'Experiencing and Responding to Coercion' and 'Psychological Treatment is Helpful, But…'. Participants perceived coercion to engage with psychologists. Perceived coercion led to psychological distress, wanting to resist, and superficial engagement. Despite this, therapeutic alliance was established with the psychologist but the quality of the therapeutic alliance was compromised. The findings have implications for psychologists working in FMH services. Suggestions for reducing perceived coercion and future directions for research are discussed.
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Affiliation(s)
| | - Helen Miles
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Kent Forensic & Specialist Care Group, Kent & Medway NHS & Social Care Partnership Trust (KMPT) & Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Joel Harvey
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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8
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Løvsletten M, Husum TL, Granerud A, Haug E. Outpatient commitment in mental health services from a municipal view. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2020; 69:101550. [PMID: 32241457 DOI: 10.1016/j.ijlp.2020.101550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/01/2020] [Accepted: 02/05/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Outpatient commitment (OC) is a legal decision for compulsory mental health care when the patient stays in his or her own home. Municipal health-care workers have a key role for patients with OC decision, but little is known about how the legislation system with OC works from the municipality's point of view. METHOD The present study has a quantitative descriptive design using an electronic questionnaire sent to health-care workers in the municipalities that participated. The study included health-care workers from the mental health services in two counties in Norway who have experience with psychosis and OC decisions. RESULTS There were 230 people who received the questionnaire. The sample consisted of various health professionals from both small and large municipalities.The results show which tasks they have in follow-up of patients in the municipalities. CONCLUSION From the municipality's point of view, there are no significant differences in follow-up for patients with or without an OC decision, apart from conversations about medication. An individual plan is rarely used to facilitate follow-up, although this is the statutory right of patients with OC decisions. The health-care workers lack knowledge and education about the OC scheme. The cooperation between municipalities and the specialist health-care services is not clearly defined.
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Affiliation(s)
- Maria Løvsletten
- Innlandet Hospital Trust, Division Psykisk Helsevern, Postboks 104, NO-2381 Brumunddal, Norway; Faculty of Public Health, Inland Norway University of Applied Science, Elverum, Norway; Helsam, Universitet I, Oslo, Norway.
| | - Tonje Lossius Husum
- Centre for Medical Ethics, Institute for Health & Society, University of Oslo, Norway
| | - Arild Granerud
- Faculty of Public Health, Inland Norway University of Applied Science, Elverum, Norway
| | - Elisabeth Haug
- Division of Mental Health Care, Innlandet Hospital Trust, 2840 Reinsvoll, Norway
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9
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What's the Function of Outpatient Commitment? ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 48:1-3. [PMID: 32088815 DOI: 10.1007/s10488-020-01027-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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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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11
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Campbell J, Davidson G, McCusker P, Jobling H, Slater T. Community treatment orders and mental health social work: Issues for policy and practice in the UK and Ireland. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 64:230-237. [PMID: 31122634 DOI: 10.1016/j.ijlp.2019.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/20/2019] [Accepted: 04/02/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Jim Campbell
- School of Social Policy, Social Work and Social Justice, University College Dublin, Ireland.
| | - Gavin Davidson
- School of Social Sciences, Education and Social Work, Queen's University Belfast, United Kingdom of Great Britain and Northern Ireland
| | - Pearse McCusker
- School of Social and Political Science, University of Edinburgh, United Kingdom of Great Britain and Northern Ireland
| | - Hannah Jobling
- Department of Social Policy and Social Work, University of York, United Kingdom of Great Britain and Northern Ireland
| | - Tom Slater
- School of Social Sciences, Cardiff University, United Kingdom of Great Britain and Northern Ireland
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12
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Rugkåsa J, Nyttingnes O, Simonsen TB, Benth JŠ, Lau B, Riley H, Løvsletten M, Christensen TB, Austegard ATA, Høyer G. The use of outpatient commitment in Norway: Who are the patients and what does it involve? INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:7-15. [PMID: 30616856 DOI: 10.1016/j.ijlp.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/04/2018] [Accepted: 11/01/2018] [Indexed: 06/09/2023]
Abstract
PURPOSE Despite one of the longest histories of using Outpatient Commitment (OC), little is known about the use in the Norwegian context. Reporting from the Norwegian Outpatient Commitment Study, this article aims to: establish the profile of the OC population in Norway; ascertain the legal justification for the use of OC and what OC involves for patients; investigate possible associations between selected patient and service characteristics and duration of OC, and; explore potential differences based on gender or rurality. METHODS A retrospective multi-site study, extracting data from the medical records of all patients on OC in six large regional hospitals in 2008-12, with detailed investigation over 36 months of the subsample of patients on first ever OC-order in 2008-09. We use descriptive statistics to establish the profile of the OC population and the legal justification for and the content of OC, and logistic regression to examine factors associated with duration of OC over 36 months. RESULTS 1414 patients were on OC over the 5 years, and 274 had their first OC in 2008-09. The sample included more men than woman, and three-quarters were diagnosed with schizophrenia. They had long service histories, including involuntary admissions. The legal justification for all OC-orders was the need for treatment, and 18% were additionally justified by dangerousness. The option to initiate OC directly from the community was not used in any of the 274 first ever OC-orders. While 98% of patients were prescribed psychotropic medication, under half had an Involuntary Treatment Order, which under the Norwegian OC regime is required in addition to the OC-order to oblige patients to accept treatment (usually medication). 60% of patients had ≥2 clinical contacts monthly. There were some gender differences in descriptive analyses with men generally being worse off, but no clear pattern in terms of rurality. Patients in the sample had been on OC between one week and 20 years. The median duration of OC over 36 months was 365 days. Three factors contributed to longer duration: the use of the dangerousness criterion; a diagnosis of schizophrenia disorder, and; considerable problems with substance abuse. CONCLUSION The characteristics of the OC population in Norway are very similar to that reported in other jurisdictions. Medication seems to be the central focus of OC, yet additional Involuntary Treatment Orders are imposed for less than half of patients. While all OC-orders were justified by the need to ensure treatment, risk seems to be a concern for a subgroup of patients who are kept on for longer. How the 2017 amendment to the mental health act, which precludes compulsion for competent patients unless danger is present, will affect OC use, remains to be seen. Further studies should specifically focus on variation in the use of OC, including at the level of individual clinicians.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway; Centre for Care Research, University of South-Eastern Norway, 3900 Porsgrunn, Norway.
| | - Olav Nyttingnes
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway; R&D Department Mental Health, Akershus University Hospital, 1478 Lørenskog, Norway.
| | - Tone Breines Simonsen
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, 0318 Blindern, Norway; Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway
| | - Bjørn Lau
- Lovisenberg Diaconal Hospital, Norway
| | - Henriette Riley
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway
| | - Maria Løvsletten
- Division of Mental Health Care, Innlandet Hospital Trust, Postboks 104, NO-2381 Brumunddal, Norway
| | | | | | - Georg Høyer
- Institute of Community Medicine, UiT-Norway's Arctic University, 9037 Tromsø, Norway
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13
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Jobling H. The legal oversight of community treatment orders: A qualitative analysis of tribunal decision-making. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:95-103. [PMID: 30616860 DOI: 10.1016/j.ijlp.2018.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/19/2018] [Accepted: 12/05/2018] [Indexed: 06/09/2023]
Abstract
Community treatment orders (CTOs) have been in place in various jurisdictions for over three decades, and yet are still a controversial aspect of mental health provision. One of the ethical concerns CTOs may engender is how difficult it can be to secure discharge from them, which in some jurisdictions can result in service users being subject to compulsion in the community indefinitely. Given the questions that can therefore be raised about the discharge process, it is important to understand the role of the mental health tribunal as a key safeguard in the management of CTOs. However, whilst a substantial body of literature exists on CTOs and on various aspects of tribunal practice in inpatient settings respectively, relatively little has been written about the role of the tribunal in the oversight of CTO discharge decisions. This article presents the results of an eight month ethnographic investigation into CTO use in England, focusing on the factors which contribute to tribunal decisions. A total of 62 participants were involved in the study, including 18 service users on CTOs, 36 mental health practitioners and 8 tribunal chairs. A combination of interviews, observations and documentary analysis are drawn upon to illustrate tribunal decision-making practice on CTOs. The key themes reported on are: the mediating influence of participant presentation and interaction in tribunals; tribunal framing and interpretation of insight and risk; and the importance of timing to tribunals, both in terms of the perceived stability of a service user's social circumstances, and the length of the CTO. The findings highlight the cumulative and interrelated effect of such factors on tribunal decision-making, and point to how tribunal judgements are heavily weighted towards upholding CTOs, with the implications that holds for individual rights.
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Affiliation(s)
- Hannah Jobling
- Department of Social Policy and Social Work, University of York, York YO10 5DD, UK.
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14
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McMillan J, Lawn S, Delany-Crowe T. Trust and Community Treatment Orders. Front Psychiatry 2019; 10:349. [PMID: 31164842 PMCID: PMC6536151 DOI: 10.3389/fpsyt.2019.00349] [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: 11/12/2018] [Accepted: 05/02/2019] [Indexed: 11/13/2022] Open
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.
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Affiliation(s)
- John McMillan
- Bioethics Centre, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Sharon Lawn
- Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, SA, Australia
| | - Toni Delany-Crowe
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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15
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Shaw L, Nunns M, Briscoe S, Anderson R, Thompson Coon J. Experiences of the ‘Nearest Relative’ provisions in the compulsory detention of people under the Mental Health Act: a rapid systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06390] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundService users detained for assessment and/or treatment under the Mental Health Act 1983 (MHA 1983) are allocated a ‘Nearest Relative’ (NR). The NR has access to confidential information about the service user and can make decisions about their care and treatment. Tensions exist regarding the identification, displacement and powers of the NR.ObjectivesTo examine the experiences of service users, carers and relevant professionals of the NR provisions of the MHA 1983, and the equivalent Named Person (NP) provisions in Scotland. Five research objectives were defined: understanding the experiences of and issues associated with (1) the identification of the NR, (2) the displacement of the NR, (3) confidentiality and information-sharing, (4) access to support from carers and (5) making decisions about treatment or care.Data sourcesSeven bibliographic databases were searched: MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Social Policy and Practice (via Ovid), Health Management Information Consortium (via Ovid), Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost) and Applied Social Sciences Index and Abstracts (via ProQuest). Citation searching, author contact and grey literature searches were conducted.Review methodsA rapid systematic review was conducted in 6 weeks. Evidence published after 1998 from the UK pertaining to the experiences of those involved in compulsory detention under the MHA 1983 (or UK variants), including service users, carers, family members, NRs, NPs, mental health professionals, policy-makers and lawyers, was sought. Study selection, data extraction and critical appraisal were completed independently by two reviewers. We looked for data about experiences, which were obtained through qualitative means or surveys. Included studies containing several paragraphs of participant quotations and/or author interpretations were entered into a framework synthesis; the rest were summarised descriptively. The framework synthesis was based on the five research objectives and refined using the findings of key studies from England and Scotland and an inductive thematic analysis.ResultsTwenty studies were included with 12 prioritised for framework synthesis. Four themes emerged: (1) issues regarding the identification of the NR/NP, (2) confidentiality and information-sharing, (3) enabling the use of the NR/NP role and (4) the importance of maintaining relationships. The involvement of service users in choosing their representative and the role of services in supporting the NR/NP was identified as important.LimitationsThere is little recent evidence to inform this important and complex discussion. The review was rigorously conducted despite the short time scale; however, a more in-depth, iterative thematic analysis of all the included studies may have provided additional insights into the mechanisms underpinning the issues.ConclusionsThe NR provisions of the MHA 1983 are complex and of significant importance to individuals detained under the Mental Health Act and their carers. This rapid review provides specific examples of issues that individuals may experience. More research is needed to aid understanding of this complex topic.Future workPrimary research specifically focused on the perceived and actual use and impact of the NR provisions in England and Scotland.Study registrationThis study is registered as PROSPERO CRD42018088237.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Liz Shaw
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, College of Medicine and Health, Exeter, UK
| | - Michael Nunns
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, College of Medicine and Health, Exeter, UK
| | - Simon Briscoe
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, College of Medicine and Health, Exeter, UK
| | - Rob Anderson
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, College of Medicine and Health, Exeter, UK
| | - Jo Thompson Coon
- Exeter Health Services and Delivery Research Evidence Synthesis Centre, College of Medicine and Health, Exeter, UK
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Abstract
SummaryIn the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.Learning Objectives• Gain an overview of the development and use of CTOs in the UK and internationally• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future
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Rugkåsa J, Canvin K. Carer involvement in compulsory out-patient psychiatric care in England. BMC Health Serv Res 2017; 17:762. [PMID: 29162096 PMCID: PMC5698997 DOI: 10.1186/s12913-017-2716-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is an expectation in current heath care policy that family carers are involved in service delivery. This is also the case with compulsory outpatient mental health care, Community Treatment Orders (CTOs) that were introduced in England in 2008. No study has systematically investigated family involvement through the CTO process. METHOD We conducted qualitative interviews with 24 family carers to ascertain their views and experiences of involvement in CTOs. The transcripts were subjected to thematic analysis that incorporated both deductive and inductive elements. RESULTS We found significant variation in both the type and extent of family carer involvement throughout the CTO process (initiation, recall to hospital, renewal, tribunal hearings, discharge). Some were satisfied with their level of involvement while others felt (at least partly) excluded or that they wanted to be more involved. Some wanted less involvement than what they had. From the interviews we identified key factors shaping carers' involvement. These included: perceptions of patient preference; concern over the relationship to the patient; carers' knowledge of the CTO and of the potential for carer involvement; access to and relationships with health professionals; issues of patient confidentiality; opportunities for private discussions, and; health professionals limiting involvement. These factors show that health professionals have many opportunities to facilitate, or hinder, carer involvement. The various roles attributed to carers, such 'proxy' for patient decision, 'gatekeeper' to services, 'mother' or 'expert carer', however, conflict with one another and make the overall role unclear. CONCLUSIONS There is a need for clarification of the expectations of carers in individual care situations, for carers to be equipped with the information they need to in order to be involved, and for services to find flexible and innovative ways of ensuring continuous, open communication. The introduction of CTOs in England has not been successful in its ambition for carer involvement.
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Affiliation(s)
- Jorun Rugkåsa
- Health Services Research Unit, Akershus University Hospital, 1478 Lørenskog, Norway
- Centre for Care Research, University College of Southeast Norway, Porsgrunn, Norway
| | - Krysia Canvin
- Department of Psychiatry, University of Oxford, England, UK
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Morrison P, Stomski NJ, Whitely M, Brennan P. Understanding advocacy practice in mental health: a multidimensional scalogram analysis of case records. J Ment Health 2017; 27:127-134. [PMID: 28480771 DOI: 10.1080/09638237.2017.1322183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few studies have examined mental health consumers' motives for seeking advocacy assistance. AIMS This study aimed to identify factors that influenced mental health consumers' use of advocacy services. METHODS The analysis was based on 60 case records that were sourced from a community advocacy service. Each record was dichotomously coded across 11 variables to generate a series of categorical data profiles. The data set was then analysed using multidimensional scalogram analysis to reveal key relationships between subsets of variables. RESULTS The results indicated that mental health consumers commonly reported a sense of fear, which motivated them to contact the advocacy service in the hope that advocates could intervene on their behalf through effective communication with health professionals. Advocates often undertook such intervention either through attending meetings between the consumer and health professionals or contacting health professionals outside of meetings, which was typically successful in terms of achieving mental health consumers' desired outcome. The resolution of most concerns suggests that they were often legitimate and not the result of a lack of insight or illness symptoms. CONCLUSION Health professionals might consider exploring how they respond when consumers or carers raise concerns about the delivery of mental health care.
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Affiliation(s)
- Paul Morrison
- a School of Health Professions, Murdoch University , Murdoch , Western Australia , Australia
| | - Norman J Stomski
- a School of Health Professions, Murdoch University , Murdoch , Western Australia , Australia
| | - Martin Whitely
- b Health Policy and Research, Health Consumers Council (WA) , East Perth , Western Australia , Australia , and
| | - Pip Brennan
- c Health Consumers Council (WA) , East Perth , Western Australia , Australia
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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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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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Banks LC, Stroud J, Doughty K. Community treatment orders: exploring the paradox of personalisation under compulsion. HEALTH & SOCIAL CARE IN THE COMMUNITY 2016; 24:e181-e190. [PMID: 26290439 DOI: 10.1111/hsc.12268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 06/04/2023]
Abstract
The introduction of supervised community treatment, delivered through community treatment orders (CTOs) in England and Wales, contrasts with the policy of personalisation, which aims to provide service users autonomy and choice over services. This article draws upon findings from a primarily qualitative study which included 72 semi-structured interviews (conducted between January and December 2012) with practitioners, service users and nearest relatives situated within a particular NHS Trust. The article also refers to a follow-on study in which 30 Approved Mental Health Practitioners were interviewed. The studies aimed to develop a better understanding of how compulsory powers are being used in the community, within a policy context that emphasises personalisation and person-centred care in service delivery. Findings from the interview data (which were analysed thematically) suggest that service users were often inadequately informed about the CTO and their legal rights. Furthermore, they tended to be offered little, or no, opportunity to make choices and have involvement in the making of the CTO and setting of conditions. Retrospectively, however, restrictions were often felt beneficial to recovery, and service users reported greater involvement in decisions at review stage. Areas of good practice are identified through which person-centred care can be better incorporated into the making of CTOs.
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Affiliation(s)
- Laura Catherine Banks
- Social Science Policy and Research Centre, School of Applied Social Science, University of Brighton, Brighton, UK.
| | - Julia Stroud
- School of Applied Social Science, University of Brighton, Brighton, UK
| | - Karolina Doughty
- Social Science Policy and Research Centre, School of Applied Social Science, University of Brighton, Brighton, UK
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Söderström O, Empson LA, Codeluppi Z, Söderström D, Baumann PS, Conus P. Unpacking ‘the City’: An experience-based approach to the role of urban living in psychosis. Health Place 2016; 42:104-110. [DOI: 10.1016/j.healthplace.2016.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 08/29/2016] [Accepted: 09/12/2016] [Indexed: 12/01/2022]
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Riley H, Lorem GF, Høyer G. Community treatment orders – what are the views of decision makers? J Ment Health 2016; 27:97-102. [DOI: 10.1080/09638237.2016.1207230] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Henriette Riley
- Division of Mental Health and Substance Abuse, University Hospital of North Norway, Tromsø, Norway,
- Department of Community Medicine, The Arctic University of Norway, Tromsø, Norway, and
| | - Geir Fagerjord Lorem
- Department of Health and Care Sciences, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway
| | - Georg Høyer
- Department of Community Medicine, The Arctic University of Norway, Tromsø, Norway, and
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Heun R, Dave S, Rowlands P. Little evidence for community treatment orders - a battle fought with heavy weapons. BJPsych Bull 2016; 40:115-8. [PMID: 27280029 PMCID: PMC4887726 DOI: 10.1192/pb.bp.115.052373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This editorial discusses the pros and cons of community treatment orders (CTOs) from the perspective of community general adult psychiatry. There is little scientific evidence supporting the application of CTOs. Preconditions of a CTO to work are likely to be met by few patients. The time for the application of a CTO may be better spent for patient-centred care until there is sufficient new and robust evidence that identifies the patients that might profit.
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Affiliation(s)
- Reinhard Heun
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Subodh Dave
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
| | - Paul Rowlands
- Derbyshire Healthcare NHS Foundation Trust, Derby, UK
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"Care or control?": a qualitative study of staff experiences with outpatient commitment orders. Soc Psychiatry Psychiatr Epidemiol 2016; 51:747-55. [PMID: 26873613 PMCID: PMC4846739 DOI: 10.1007/s00127-016-1193-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE Outpatient commitment orders are being increasingly used in many countries to ensure follow-up care of people with psychotic disorders after discharge from hospital. Several studies have examined outpatient commitment in relation to use of health care services, but there have been fewer studies of health professionals' experiences with the scheme. The purpose of this study was to examine health professionals' experiences with patients subject to outpatient commitment. METHODS This was a focus group study using a descriptive and exploratory approach. The study was based on three focus group interviews with a total of 22 participants. Data were analysed using qualitative content analysis. RESULTS The study showed that health professionals had a positive attitude towards outpatient commitment and considered it necessary for patients with psychosis who lacked insight and did not collaborate on treatment. At the same time their attention to patients' lack of insight could lead to a paternalistic approach more than measures to enhance patient autonomy. This challenged their therapeutic relationship with the patient. CONCLUSION Health professionals found it difficult to combine control with therapeutic care, but gave greater emphasis to patients' need for treatment and continuity of care than to their autonomy. This dilemma indicates a need to discuss whether increased attention to patients' autonomy rather than insight into their illness would improve treatment cooperation and reduce the use of coercion.
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