Trust and Community Treatment Orders

The therapeutic relationship from the perspective of patients and nurses in the first days of admission: A cross-sectional study in acute mental health units

The therapeutic relationship (TR) is essential in mental health nursing care and plays a fundamental role in the understanding and treatment of the patient's health status. Despite being a bidirectional construct, limited evidence is available to shed light on this issue in mental health units and even less so in the first days of admission. This study aimed to examine the association and differences between nurses' and patients' perspectives on the establishment of the therapeutic relationship in acute mental health units during the first days of hospitalization. A cross-sectional study was carried out in 12 Spanish mental health units. Data were collected from patients and nurses using the Working Alliance Inventory-Short (WAI-S) questionnaire. A total of 234 cases were analysed, including 234 patients and 58 nurses. The results showed a positive association between nurses' and patients' perspectives on the therapeutic relationship, but also revealed significant differences on each WAI-S dimension. Nurses assigned higher scores compared to patients on the perception of the quality of the therapeutic relationship. The dimensions with the greatest weight from the patients' perspective regarding the quality of the therapeutic relationship were the perception of greater agreement on goals and tasks among nurses. This study demonstrates the importance of establishing shared goals and tasks with nurses from the first days of hospitalization to improve the quality of the therapeutic relationship as perceived by patients. These findings underline the need to consider the different perspectives of both parties to promote a high-quality therapeutic relationship.

Community-based models of care facilitating the recovery of people living with persistent and complex mental health needs: a systematic review and narrative synthesis

Objective

This study aims to assess the effectiveness of community-based models of care (MoCs) supporting the recovery of individuals who experience persistent and complex mental health needs.

Method

We conducted a systematic review and narrative synthesis of MoC studies reporting clinical, functional, or personal recovery from October 2016 to October 2021. Sources were Medline, EMBASE, PsycInfo, CINAHL, and Cochrane databases. Studies were grouped according to MoC features. The narrative synthesis was led by our researchers with lived experience.

Results

Beneficial MoCs ranged from well-established to novel and updated models and those explicitly addressing recovery goals and incorporating peer support: goal-focused; integrated community treatment; intensive case management; partners in recovery care coordination; rehabilitation and recovery-focused; social and community connection-focused; supported accommodation; and vocational support. None of our diverse group of MoCs supporting recovery warranted a rating of best practice. Established MoCs, such as intensive case management, are promising practices regarding clinical and functional recovery, with potential for enhancements to support personal recovery. Emerging practice models that support personal and functional recovery are those where consumer goals and priorities are central.

Conclusion

Evidence for established models of care shows that there is a need for inevitable evolution and adaptation. Considering the high importance of effective MoCs for people experiencing persistent and complex mental health needs, further attention to service innovation and research is required. Greater emphasis on the inclusion of lived and living experience in the design, delivery, implementation, and research of MoCs is needed, to enhance MOCs' relevance for achieving individual consumer recovery outcomes.

Health professionals' experience of treatment of patients whose community treatment order was revoked under new capacity-based mental health legislation in Norway: qualitative study

BACKGROUND

Norway introduced capacity-based legislation in mental healthcare on 1 September 2017 with the aim of increasing patient autonomy and legal protection and reducing the use of coercion. The new legislation was expected to be particularly important for patients under community treatment orders (CTOs).

AIMS

To explore health professionals' experiences of how capacity-based legislation affects healthcare services for patients whose compulsory treatment order was revoked as a result of being assessed as having capacity to consent.

METHOD

Nine health professionals responsible for treatment and care of patients whose CTO was revoked owing to the new legislation were interviewed in depth from September 2019 to March 2020. We used a hermeneutic approach to the interviews and analysis of the transcripts.

RESULTS

The participants found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They also felt a need for more frequent assessments of patients' condition and capacity to consent and more flexibility between levels of care.

CONCLUSIONS

The study shows that health professionals found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They sought closer dialogue with patients, providing information and advice, and more frequently assessing patients' condition to adjust treatment and care to enable them to retain their capacity to consent. This could be challenging and required competence, continuity and close collaboration between personnel in different healthcare services at primary and specialist level.

Increased autonomy with capacity-based mental health legislation in Norway: a qualitative study of patient experiences of having come off a community treatment order

Background

Capacity-based mental health legislation was introduced in Norway on 1 September 2017. The aim was to increase the autonomy of patients with severe mental illness and to bring mental health care in line with human rights. 

The aim of this study is to explore patient experiences of how far the new legislation has enabled them to be involved in decisions on their treatment after they were assessed as capable of giving consent and had their community treatment order (CTO) revoked due to the change in the legislation.

Method

Individual in-depth interviews were conducted from September 2019 to March 2020 with twelve people with experience as CTO patients. Interviews were transcribed and analysed using thematic analysis inspired by hermeneutics.

Results

Almost all interviewees were receiving the same health care over two years after their CTO was terminated. Following the new legislation, they found it easier to be involved in treatment decisions when off a CTO than they had done in periods without a CTO before the amendment. Being assessed as having capacity to consent had enhanced their autonomy, their dialogues and their feeling of being respected in encounters with health care personnel. However, several participants felt insecure in such encounters and some still felt passive and lacking in initiative due to their previous experiences of coercion. They were worried about becoming acutely ill and again being subjected to involuntary treatment.

Conclusion

The introduction of capacity-based mental health legislation seems to have fulfilled the intention that treatment and care should, as far as possible, be provided in accordance with patients’ wishes. Systematic assessment of capacity to consent seems to increase the focus on patients’ condition, level of functioning and opinions in care and treatment. Stricter requirements for health care providers to find solutions in cooperation with patients seem to lead to new forms of collaboration between patients and health care personnel, where patients have become more active participants in their own treatment and receive help to make more informed choices.

The therapeutic relationship in the context of involuntary treatment orders: The perspective of nurses and patients

WHAT IS KNOWN ON THE SUBJECT?: Involuntary treatment orders are increasingly being used around the world to allow the treatment of individuals living with a mental illness deemed incapable of giving consent and who are actively refusing treatment. The use of involuntary treatment orders can impact the nurse-patient therapeutic relationship, which is essential to offer quality care and promote recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Nurses and patients do not agree on the possibility to develop a therapeutic relationship, with nurses believing they can build a bond with the patients despite the challenges imposed by the involuntary treatment order, and patients rejecting this possibility. Nurses caring for patients on involuntary treatment orders feel obligated to apply the conditions of this measure, even if it damages the relationship with their patients. This difficult aspect of their work leads them to question their role in relation to the management of involuntary treatment orders. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware of the reasons why patients on involuntary treatment orders do not believe in the possibility of building a therapeutic relationship. Nurses need to reflect on and express their concerns about the damaging effects that managing involuntary treatment orders conditions can have on the nurse-patient therapeutic relationship. ABSTRACT: Introduction Involuntary treatment orders (ITO) can impact the nurse-patient therapeutic relationship (TR) negatively. Despite the increasing use of ITOs around the world, few studies have explored their influence on the TR from the perspectives of nurses and patients. Aim To describe the TR in the context of ITOs as reported by nurses and individuals living with a mental illness. Method Secondary data analysis of qualitative interviews with nurses (n = 9) and patients (n = 6) was performed using content analysis. Results Participants described the TR as fundamentally embedded in a power imbalance amplified by the ITO, which was discussed through the conflicting roles of nurses, the legal constraints imposed on patients and nurses, the complex relation between the ITO and the TR, and the influence of mental healthcare settings' context. Discussion Nurses and patients' views were opposed, questioning the authenticity of the relationship. Implications for Practice Nurses should be aware of the patients' lack of faith in the TR to ensure that they are sensitive to patients' behaviours that may falsely suggest that a relationship is established. Further studies should explore ways to alleviate the burden of the management of ITOs on nurses and allow for a trusting relationship to be build.

Use of compulsory community treatment in mental healthcare: An integrative review of stakeholders' opinions

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.

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

Community treatment orders (CTOs) require individuals with a mental illness to accept treatment from mental health services. CTO legislation in South Australia states that treatment and care should be recovery-focused, although justification for use is predominantly risk-based, and care often coercive. Although CTOs are contested, individuals, families, and clinicians frequently engage in care planning within this context. This paper examines how the concepts of risk and risk management impact care planning from the perspectives of individuals on CTOs, their families, and clinicians. Ethnographic methods of observation and interview provided a detailed account of the perspectives of each group over an 18-month period from two community mental health teams in South Australia. Findings show that care planning occurred within a culture of practice dominated by risk. Risk, however, was understood differently by each participant group, with the dominant narrative informed by biogenetic understandings of mental illness. This dominance impacted on the positioning of participant groups in care planning, focus of care contacts, and care options available. To improve care experiences and outcomes for individuals on CTOs, narrow conceptualizations of risk and recovery need to broaden to include an understanding of personal and social adversities individuals face. A broader understanding should reposition participants in the care planning context and rebalance care discussions, from a focus on clinical recovery to recovering citizenship.

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

Background

In many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery‐focussed. Key components in the care planning process include engagement and decision‐making about a person's support needs and care options, with trust being an essential component of care planning relationships.

Objective

This study examines how these components were enacted during service care contacts for individuals on community treatment orders.

Methods

The study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day‐to‐day care interactions.

Results

Care planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of ‘knowing’, with consumers assumed to have less knowledge than clinicians.

Conclusions

Services and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision‐making.

Patient or Public Contribution

This study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.