- Email: [email protected]
A qualitative analysis of the use of community treatment orders in Saskatchewan
International Journal of Law and Psychiatry 29 (2006) 516 – 524
A qualitative analysis of the use of community treatment orders in Saskatchewan Richard L. O'Reilly a,⁎, David L. Keegan b , Deborah Corring c , Satish Shrikhande d , Dhanapal Natarajan e a
Department of Psychiatry, The University of Western Ontario, Canada Department of Psychiatry (Emeritus),University of Saskatchewan, Canada Specialized Adult Program, Regional Mental Health Care, St. Thomas, Ontario, Canada d Vancouver Island Health Authority, British Columbia, Canada e Department of Psychiatry, University of Saskatchewan, Canada b
c
Received 3 November 2005; received in revised form 23 May 2006; accepted 6 June 2006
Abstract This study examined the opinions of patients who have been placed on a community treatment order (CTO), their relatives, mental health clinicians and representatives of community agencies about the use of CTOs in Saskatchewan. Patients were assessed using indepth interviews, while their relatives, mental health professionals and representatives of community agencies took part in facilitated focus groups. Patients had contradictory feelings about CTOs. Most experienced some degree of coercion while on the orders but many believed that CTOs provided necessary structure in their lives. Clinicians were more consistently positive but recognized the difficult choices in balancing the subject's right to self-determination with the benefits of a treatment order. Family members viewed CTOs as necessary to control a chaotic situation caused by the subject's limited insight. © 2006 Elsevier Inc. All rights reserved.
1. Introduction The use of mandatory outpatient treatment in its various forms: court-ordered outpatient committal, community treatment orders (CTOs), conditional leave, and guardianship remains controversial (O'Reilly, 2004). Research indicates that mandatory outpatient treatment reduces victimization of individuals with severe mental illness (Hiday, Swartz, Swanson, Borum, & Wagner, 2002) and increases follow-up with outpatient mental health services (Hiday & Scheid-Cook, 1991; Munetz, Grande, Kleist, & Peterson, 1996; Preston, Kisely, & Xiao, 2002; Rohland, Rohrer, & Richards, 2000; Sensky, Hughes, & Hirsch, 1991; VanPutten, Santiago, & Berren, 1988). Findings that mandatory outpatient treatment improves other outcomes, such as reducing the use of hospitalization (Fernandez & Nygard, 1990; O'Brien & Farrell, 2005; O'Keefe, Potenza, & Mueser, 1997; Zanni & deVeau, 1986), are more contentious. This debate was not resolved by the findings from two randomized control trials that essentially came to contradictory ⁎ Corresponding author. Tel.: +1 519 455 5110x47240; fax: +1 519 455 5090. E-mail address: [email protected] (R.L. O'Reilly). 0160-2527/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ijlp.2006.06.001
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
517
conclusions (Steadman et al., 2001; Swartz et al., 1999). Both studies have been criticized on methodological grounds (O'Reilly & Bishop, 2001; Szmukler & Hotopf, 2001). Some scholars have called for further randomized control trials to resolve uncertainties. Unfortunately, organizing a randomized control trial, where a legal statute is the independant variable, is extremely difficult (Dawson, 2002; Swartz et al., 1997) and it is unlikely we will see any further randomized trials in this field in the foreseeable future. Other scholars have recommended the use of qualitative research methods as a means to make an indepth assessment of the opinions of people who have been the subject of mandatory outpatient treatment (Bindman, 2002). In recent years, qualitative studies assessing the views of subjects of mandatory outpatient treatment and of other stakeholders have been reported from the US (Policy Research Associates, 1998; Steadman et al., 1999), the UK (Canvin, Bartlett, & Pinfold, 2002), Scotland (Atkinson, Garner, Gilmour, & Dyer, 2002) Australia (McDonnell & Bartholomew, 1997) and New Zealand (Gibbs, Dawson, Ansley, & Mullen, 2005; Gibbs, Dawson, Forsyth, Mullen, & Te Oranga Tonu Tanga (Maori Mental Health Team), 2004; Gibbs, Dawson, & Mullen, 2006; Romans, Dawson, Mullen, & Gibbs, 2004). In addition, older quantitative studies have sometimes included qualitative data (Adams & Hafner, 1991). In all of these studies, the subjects of mandatory outpatient treatment expressed ambivalent and sometimes contradictory views about treatment orders. Mandatory outpatient treatment was consistently reported by patients as being coercive (Adams & Hafner, 1991; Atkinson et al., 2002; Canvin et al., 2002; Gibbs et al., 2005; McDonnell & Bartholomew, 1997; Policy Research Associates, 1998) and in some studies as being maintained for too long (Gibbs & Dawson, 2005; McDonnell & Bartholomew, 1997). Patients often raised concerns about medication side effects (Adams & Hafner, 1991; Atkinson et al., 2002; Gibbs et al., 2005; McDonnell et al., 1997). However, patients also had positive things to say about treatment orders. Many reported that the orders provided security (Adams & Hafner, 1991; Canvin et al., 2002; Gibbs et al., 2005), offered more freedom than hospitalization or imprisonment (Gibbs et al., 2006) and some wanted to remain on the orders (Adams and Hafner, 1991; Atkinson et al., 2002; Canvin et al., 2002; Gibbs et al., 2005). Most subjects reported that their relationships with clinicians were not adversely affected by being placed on a treatment order (Atkinson et al., 2002; Gibbs et al., 2005; Policy Research Associates, 1998). Previous research indicated that clinicians tend to be more definitively positive about treatment orders (Atkinson et al., 2002; Pinfold, Bindman, Thornicroft, Franklin, & Hatfield, 2001; Romans et al., 2004) but may complain that the power available in the law is insufficient to manage nonadherence to treatment (O'Reilly, Keegan, & Elias, 2000) or is not used in the face of nonadherence (Romans et al., 2004). Mandatory outpatient treatment is seen as a way to engage patients who had a history of noncompliance with treatment (Gibbs et al., 2006). Psychiatrists and case managers are more likely to view treatment orders as helping rather than compromising the therapeutic relationship (Romans et al., 2004). The limited research on the views of the relatives of patients on mandatory outpatient treatment indicated that family members were generally more positive than patients about the use of treatment orders (Adams & Hafner, 1991). Family members often see a treatment order as providing support for their ill relative and report that when on a treatment order the burden of looking after the patient is shared with clinicians (Gibbs et al., 2006). This study was undertaken to compare the views on mandatory outpatient treatment of patients and other stakeholders in Canada with the view of stakeholders from other jurisdictions. We assessed the views of a wide range of parties – the subjects of CTOs, their relatives, various clinicians and key community agencies. The study is a follow-up to a postal survey of the views of Saskatchewan psychiatrists about CTOs completed in 1999 (O'Reilly et al., 2000). Saskatchewan was the first Canadian jurisdiction to introduce CTOs in 1995 (Mental Health Services Act1) followed by Ontario in 2000 (Mental Health Act2) and Nova Scotia (Involuntary Psychiatric Treatment Act3). Several of the other provinces have provisions for conditional leave and guardianship (Gray & O'Reilly, 2001). A person can be placed on a CTO in Saskatchewan if they have a mental illness that has resulted in their being involuntarily hospitalized three times in 2 years or for a total period of at least 60 days during those 2 years. Two psychiatrists must assess the patient and agree on the need for the initial CTO. The CTO can be renewed after each three-month period, again on the agreement of two psychiatrists. In Saskatchewan, a condition of being placed on a CTO is that the patient meets the inpatient committal criteria and consequently if a patient breaches the conditions of the CTO the patient can be committed to an inpatient unit. 1 2 3
Mental Health Services Act, S.S. 1984–85–86, c. M-13.1, as am., s. 24.1. Ontario, Mental Health Act, R.S.O. 1990, c. M.7, s. 33.1, as am., effective December 1, 2000. Involuntary Psychiatric Treatment Act, S.N.S. 2005, c. 42 (Not yet proclaimed).
518
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
2. Methodology We chose to study the use of CTOS in Saskatchewan as this province has the longest experience of using CTOs in Canada. The study was conducted in two centers, Regina and Saskatoon, between October 2002 and March 2003, 7 years after the introduction of CTOs. The subjects on CTOs at the time were identified by the Chief Psychiatrist of the Region and approached by their clinical psychiatrist or case manager to determine if they were willing to participate. Subjects were fully informed about the study and assured that their treatment would not be affected by their cooperation or refusal. Ethical approval was obtained from the Institutional Review Board at the University of Saskatchewan. Consenting subjects identified by their first name and research number had an interview with one of the authors (DC), an experienced qualitative researcher and occupational therapist who works in tertiary mental health care. All interviews were audiotaped and transcribed verbatim. Focus groups were held in each of the two major urban centers in Saskatchewan for relatives of subjects who were or had been on a CTO, psychiatrists who had used CTOs, case managers of patients on CTOs and staff of local community agencies (such as crisis service, police and home care operators). The same researcher noted above (DC) facilitated the focus group discussions. Participants in the focus groups were invited to attend by one of the principal researchers in each of the geographical locations, and a snowball sample of convenience was used to finalize group numbers. Each focus group consisted of six to eight members as recommended by Morgan (1988). All groups were audiotaped and transcribed verbatim. Data gathered through interviews and focus groups provided the participants' perspectives so that their “world views” form the structural framework for the report (Lincoln & Guba, 1985). Verbatim quotations from the transcripts of interviews and focus groups were analyzed. Quotations were chosen using two criteria: the quotation's ability to present the reader with the most succinct, expression of opinion, and the quotation's ability to convey the effect that CTOs have on the group in question. The data was analyzed using the constant comparative method (Glaser & Strauss, 1967). Themes identified are reflective of both frequency and importance as expressed by participants. The data were categorized under three main perspectives to reflect the views of subject, their relatives and providers. Within each perspective there were a number of themes. Categorization of data into perspectives and themes was a joint process among three researchers. 3. Results Thirty-six people were on a CTO in Saskatchewan at the time the study was undertaken. Twenty-nine of these individuals were living in one of the two health districts in which the study was conducted. Of these 29 individuals, three could not be contacted for various reasons, leaving 26 individuals who were invited to take part in the study. Eleven agreed to be interviewed and an additional three individuals who had been on a CTO in the previous 2 years were included in the study. All but one of the patients was living in the community when interviewed. The final individual had breached the conditions of a CTO and was being detained in hospital. Patients had been issued between one and eight CTOs (including current CTO) with an average of three for the group. The patients' age ranged from 20 to 70, with an average age of 44. Nine patients were diagnosed as having schizophrenia and five as having schizoaffective disorder. Fourteen family members took part in the focus groups. The family members included three sets of parents and one mother/grandmother dyad. Half of the family members were related to the subjects interviewed for the study. Two of the mother/father dyads and three other family members were related to individuals who refused or were unavailable to be interviewed. The case managers came from a variety of professional backgrounds: the majority were nurses. A total of 78 individuals provided opinions. 3.1. The perspective of the subjects 3.1.1. Requirements of a CTO In response to an inquiry “what does a CTO require you to do?” subjects usually spoke of the requirement to take their medication, and to see their doctor and case manager. Some individuals reported that they were required to live in supervised housing. ‘… remain on my medication and follow doctor's orders, you know, not go anywhere unless you tell him, sometimes I can't wait to go to try out some other city, to get out of town, get away from my family, and start new, oh I don't know I'm not sure if I even have the right to do that.’
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
519
3.1.2. Contest of will Subjects, almost without exception, found that being on a CTO was difficult to accept. ‘…the real issue was about will, whose will was stronger, and who's not getting their way with the decision about taking the medication.’ 3.1.3. Relationship with psychiatrist When asked how the CTO had affected their relationship with their psychiatrist subject responses were varied but often contained similar ambivalence. ‘it's like two panes of glass in a window never meeting but always facing each other… we had a big fight about going to hospital… going to hospital was tough to agree to but I found it helpful, and so I built up some trust in him, it was easier to go on a CTO.’ 3.1.4. Relationship with police Interactions with the police occurred for many subjects to meet requirements of the CTO, such as being escorted to receive injections of antipsychotic medication. Most were escorted without incident to the physician's office or emergency department but occasionally these interactions were problematic. ‘That happened [police arriving at her home] a few times to me…more than once…one surprised me but overall nothing bad happened to me, nothing came of it, they were just escorting me to hospital.’ 3.1.5. Subjects viewed the appeal process as futile Although all subjects recalled someone advising them of their right to appeal the CTO, many chose not to pursue this avenue either because they saw no need to, or that it appeared to be futile. ‘There is a group that I could talk [to appeal CTO] but I felt it was futile anyway, because I did talk to them once or twice and they turned me down.’ 3.1.6. Reluctant acceptance of a CTO Most subjects were compliant with a CTO once it was in place. Several subjects viewed being on a CTO as better than mandatory long-term hospitalization. ‘I don't recall but it was something to force me to take my medication but actually it was the threat of going to North Battleford [provincial psychiatric hospital] that made me try Clozaril.’ 3.1.7. Benefits of the CTO Several subjects identified benefits of CTOs, particularly those individuals who had been on the order for more than a year. They noted the CTO helped keep them healthy, provided structure in the community, and provided someone to talk to when they needed support. ‘…yea, I think I just needed a little bit of organization and structure in my life that I don't put there on my behalf, and the CTO enabled that to happen, so that sort of straightened out my plan… I was being lazy or negligent about my life planning and this caused me to more plan and organize my life effectively. 3.2. The perspective of the families 3.2.1. CTOs bring control to an out of control situation Family members struggle with the recurring crises of their relatives' illness. Everyday activities are put on hold while the family is consumed with caring for their loved one. Family members “pick up the pieces” when all else fails, and their ability to cope decreases over time.
520
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
‘There are some people who don't take medication and my husband is one of them… he looses track of his pills, then what happens is he gets sick and he won't take his pills, then he won't take his needle and its just a vicious cycle…the families take the brunt of it.’ 3.2.2. CTO process seen as too cumbersome Family members were frustrated with elements of the CTO process, which they felt were not helpful in achieving the objective of stability for their relative. Relatives felt that the duration of the CTO was too short and that excessive administrative details interfered with the ability to keep their relative on a CTO when that was necessary. ‘We have been to a judge at least three times if not four, the CTO, the last one has run out again and she knows it, and we cannot get her back in. The three months business is way too short. Two psychiatrists or whatever should renew it automatically, so we don't have to go through all this emotional stress, over and over again. 3.2.3. Experience with police Relatives were grateful to the police for their assistance when their family members refused treatment, but were sad and angry when that family member seems to be “criminalized”. ‘When the police come I wish they would come up in a plain car, but when they come up in the black and whites and coming rushing up…if people are walking down the street, what must they say. It must be a drug bust or something. …it'll take you a month to live it down. 3.3. The perspective of providers 3.3.1. Clinicians have to make tough choices Professionals struggled with the dilemma of wanting to support a subject's right to self-determination while obtaining the benefits of the stable life style they know is possible with treatment adherence. Many considered the longterm benefits of community living under a CTO to be preferable to institutional living. ‘Two people that I have on CTO right now are on it because of clear non-compliance with treatment, and it's made quite a remarkable difference for both of them. …it has made a remarkable difference in their stability and their functioning, so I think it has been of great value…to improve their quality of life and really get them on the road to better things.’ 3.3.2. CTO procedures incompatible with reality of practice and treatment Case managers, psychiatrists and community agencies reported that the procedures needed to initiate and maintain a patient on a CTO were too cumbersome. For example, the requirement to have two psychiatrists assess an individual in the community every 3 months in order to renew a CTO was seen as a major impediment to their use. Many clinicians felt there was a lack of clarity in the processes required in the use of CTOs. There was consensus that the duration of the order did not provide sufficient time for the patient to achieve stability. ‘We have had some ongoing issues with lack of clarity about the procedure to follow through. Even as much as two weeks ago I had to have a special meeting about people coming to the emergency department…it would have been nice if that stuff was all laid out very clearly for us, and that the communication mechanisms were in place as you go…it's like 10 years later and we are still stumbling through. 3.3.3. Relationship with subject always a concern Mental health professionals are keenly aware of the potential effect that a CTO can have on their relationship with a subject. They strive to maintain a therapeutic relationship but often need to accept that they are seen as the “bad guy”. ‘One of the things I think really matters is the development of a therapeutic alliance with the patient… I do not expect that I would want to put a patient on a CTO before I knew him that well…most of the patients do not have insight at all and those are the patients I find quite difficult for them to want a CTO.’
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
521
3.3.4. CTOs seen as effective in the long-term Case managers were able to readily identify subjects with previous nonadherence with medications who had been successfully managed on CTOs. ‘I have one fellow who is actually finished his CTO, was on it nine months to a year…it did work very well for him. Since going on the CTO he basically has regained his health, has become involved in treatment again, and compliant again…It's been great in his case.’ 3.3.5. Need for initial and ongoing education for doctors, police, family All providers referred to the need for regular and ongoing education of the stakeholders in the CTO process. This is necessary for all case managers, psychiatrists, police officers and family members. ‘This lady I was talking about, every month I would have to go and give these papers to the police, it was like I was doing community education every month because I was dealing with different people at the desk… 3.3.6. Need to recognize significant role that case managers play Much of the work needed to maintain a patient on a CTO falls to case managers. They need to be recognized as one of the central players in the overall process. ‘There's a lot of work in negotiating the CTOs, making sure they get done, the client is not going come and ask for them, it's up to me to make sure it's organized, and manipulating the situation to get them there to do it, to have the CTO administered. A lot of stress with the hostility, and there is so much deceit, you know in trying to convince them to get here, convince the client to get here and that kind of thing.’ 4. Discussion A major strength of this study was that it assessed the view of a wide range of stakeholders. An attempt was made to systematically recruit all patients on a CTO from the two major districts (by population) in Saskatchewan. However, only 42% of patients who were approached agreed to take part in the study and additional three patients were added to increase the number of subjects. Although patients were not randomly selected for the study, they do appear to be representative of patients on CTOs in Saskatchewan as the diagnostic profile of the patient sample, all of whom suffered from schizophrenia or schizoaffective disorder, is similar to that of a previous survey of all patients placed on a CTO in the province (Beach, 1999). The study employed two powerful qualitative research trustworthiness strategies– saturation and triangulation. Saturation is the point when further data gathered does not provide any new insights (Depoy & Gitlin, 1994). Morgan (1988) suggests that when a focus group facilitator can predict with accuracy what a participant will say, a point of saturation has been reached. He recommends a minimum of three to five focus groups to achieve saturation particularly when the focus groups are made up of homogenous participants and the topic is specific and of interest to all participants, as the subject of CTOs was to our participants. McCracken (1988) indicates that six to eight indepth interviews will usually achieve saturation when subjects are homogeneous in nature. Our study used 14 interviews (twice what is normally considered adequate) and eight focus groups (again exceeding recommendations for saturation). In addition, the use of an experienced qualitative researcher (DC) enhances the assessment of time when saturation was actually reached. Triangulation is a process that requires one or more types of data sources, methods, or researchers be used in the analytical process. (Depoy and Gitlin, 1994; Marshall & Rossman, 1989; McCracken, 1988; Morgan, 1997). Multiple data sources were used in this study (case managers, community agency representatives, psychiatrists, subjects of CTOs and family members), two data collection methods were used (focus groups and indepth interviews), and three researchers were involved in the analysis of the transcripts. Many subjects talked about coercion – “the battle of wills.” The question of coercion and free will was often raised in the context of having to take medication. Some patients complained of side effects from the medications that they were compelled to take. Other studies have noted that patients who are placed on CTOs experience coercion (Steadman et al., 1999; Canvin et al., 2002; Gibbs et al., 2005). Indeed, it would be surprising if this were not the case as CTOs
522
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
have a core coercive element. The consistency of patients' descriptions of coercion suggests that terms such as, “assisted outpatient treatment,” which appears to be deliberately euphemistic, run the risk of deemphasizing the coercion that these patients are likely to experience and should be abandoned. However, it is also important to point out that our findings were similar to those of researchers in New Zealand who noted that the actual experience of coercion by the majority of patients was much less than the strident policy debates on CTOs sometimes suggest (Gibbs et al., 2005). Specifically, we noted that many patients in our study were initially resentful of being placed on a CTO but reported that this reaction lessened with time. Their acceptance of the CTO was often associated with the belief that the order provided structure that was necessary to bring stability to their life. Once again these views are very similar to subjects' reports in studies conducted in New Zealand (Gibbs et al., 2005) and the UK (Canvin et al., 2002) that mandatory outpatient treatment provided “safety and security.” When patients in Saskatchewan saw their options as accepting a CTO or returning to hospital, their preference was to remain on the CTO. Swartz et al. came to a similar conclusion using a quantitative approach where patients with psychotic illnesses were presented with case vignettes and asked to rate different outcomes (Swartz et al., 2003). In this study, patients were most concerned about avoiding involuntary hospitalization, somewhat concerned about avoiding interpersonal violence or conflict but least concerned about avoiding outpatient commitment. Stone developed the concept of the “Thank you theory” which proposes that if involuntary hospital commitment is justifiable we would expect patients to be grateful when they have recovered from their illness (Stone, 1975). Studies of involuntary hospitalization confirm high levels of acceptance of inpatient committal (Bradford, McCann, & Merskey, 1986; Kane et al., 1983; Toews, el-Guebaly, & Leckie, 1981). Should we expect CTOs to also meet the “Thank you theory” standard? As CTOs are primarily used for patients with chronically impaired insight we might not expect many to ever endorse the use of coerced outpatient treatment (Swartz, Swanson, & Monahan, 2003). However, as in the New Zealand study (Gibbs et al., 2005), many patients in Saskatchewan stated that they agreed with the decision to place them on a CTO. Perhaps the positive findings in the current and previous studies are due to systematic bias. Patients who agreed to participate in research studies may have reached some level of insight and developed some positive regard for treatment orders. Those who refused to participate may not have attained any insight and so may resent the CTO application. Support for this possibility comes from the observation of Swartz, Wagner, Swanson, and Elbogen (2004) who found that those who reject mandated treatment as ineffective and unfair, tend to be more symptomatic and to lack insight. The inclusion of relatives of patients who refused to be interviewed offsets this bias to an extent and is especially important if refusal of patients to participate is associated with a poorer outcome on the CTO. Relatives were very positive about CTOs and some reported that they had been essential in bringing stability to the chaos in the patient's life. However, a prominent finding was that families had a high level of frustration with the mental health system. Relatives of patients on CTOs viewed themselves as taking the brunt of the burden when the system fails. Relatives were also critical of many of the administrative aspects of initiating and renewing CTOs, which they viewed as a barrier to effective treatment. As has been found elsewhere (Atkinson et al., 2002; Pinfold et al., 2001; Romans et al., 2004) most mental health clinicians in Saskatchewan felt that the orders were helpful for specific patients. However, psychiatrists and case managers criticized the administrative burden associated with CTOs. There was a consensus amongst the relatives, clinicians and representatives from the community agencies that a three-month duration for a CTO was too short. One relative pointed out that the time of renewal of a CTO could reignite conflict. Past research suggests that improved outcomes from using mandatory outpatient treatment are most likely when the treatment order has been in place for at least 6 months (Swanson et al., 2000; Swartz et al., 1999) and perhaps 6 months is a more practical duration for treatment orders. When the study was undertaken, CTOs had been used for 7 years. This represented a mature system where it would be expected that initial problems in implementation and operation of the legislation would have been resolved. However, many stakeholders noted they had encountered a lack of knowledge or uncertainty about the use of CTOs even among mental health care workers and police who would be expected to be familiar with the procedures. 5. Conclusion Many of the themes that emerged from this study were similar to those from non-Canadian jurisdictions despite the use of different models of mandatory outpatient treatment in those jurisdictions. The study confirms that there are
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
523
negative aspects of mandatory outpatient treatment, particularly the common experience of coercion. However, the degree of reported coercion appears to be much less than suggested during policy debates. It was also apparent that there is a diverse range of opinions amongst patient on CTOs. For example, while most patients reported little or no disruption of the therapeutic relationships, a few remained very angry with their clinicians. Family members, clinicians and representatives of community agencies were much less ambivalent about their support for CTOs. Many of the nonpatient stakeholders focused on technical and educational failings of the CTO system in Saskatchewan, which in their view limited the utility of the orders. Surprisingly, little of the extensive literature on the efficacy of CTOs addresses this important observation. Acknowledgements The authors appreciate the financial assistance provided by Saskatchewan Health. We would like to thank all the participants for providing us their time and experience. Also appreciated was the assistance provided by Ms. Donna Herman and Joanne Chapman. References Adams, N. H., & Hafner, R. J. (1991). Attitudes of psychiatric patients and their relatives to involuntary treatment. Australian and New Zealand Journal of Psychiatry, 25(2), 231−237. Atkinson, J. M., Garner, H. C., Gilmour, W. H., & Dyer, J. A. T. (2002). Changes to leave of absence in Scotland: The view of patients. The Journal of Forensic Psychiatry, 13(2), 315−328. Beach, A. (1999). Community treatment orders in the context of comprehensive community-based mental-health services: How did Saskatchewan get there? Evaluation on utilization to date. [Abstract]. Penetanguishene Conference on Mental Health Services Restructuring and Public Safety. Bindman, J. (2002). Involuntary outpatient treatment in England and Wales. Current Opinion in Psychiatry, 15(6), 595−598. Bradford, B., McCann, S., & Merskey, H. (1986). A survey of involuntary patients' attitudes towards their commitment. Psychiatric Journal of the University of Ottawa, 11(3), 162−165. Canvin, K., Bartlett, A., & Pinfold, V. (2002). A ‘bittersweet pill to swallow’: Learning from mental health service users' responses to compulsory community care in England. Health and Social Care in the Community, 10(5), 361−369. Dawson, J. (2002). Randomised controlled trials of mental health legislation. Medical Law Review, 10(3), 308−321. Depoy, E., & Gitlin, L. N. (1994). Introduction to research: Multiple strategies for health and human services. St. Louis, MO: Mosby. Fernandez, G. A., & Nygard, S. (1990). Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hospital and Community Psychiatry, 41(9), 1001−1004. Gibbs, A., Dawson, J., Ansley, C., & Mullen, R. (2005). How patients in New Zealand view community treatment orders. Journal of Mental Health, 14(4), 357−368. Gibbs, A., Dawson, J., Forsyth, H., & Mullen, R. Te Oranga Tonu Tanga (Maori Mental Health Team). (2004). Maori experience of community treatment in Otago, New Zealand. Australia and New Zealand Journal of Psychiatry, 38(10), 830−835. Gibbs, A., Dawson, J., & Mullen, R. (2006). Community treatment orders for people with serious mental illness: A New Zealand study. British Journal of Social Work. http://bjsw.oxfordjournals.org/cgi/reprint/bch392?ijkey=XaBvWzS9Rq8Lvgo&keytype=ref Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Hawthorne, NY: Aldine: Chicago. Gray, J. E., & O'Reilly, R. L. (2001). Clinically significant differences among Canadian mental health acts. Canadian Journal of Psychiatry, 46(4), 315−321. Hiday, V. A., & Scheid-Cook, T. L. (1991). Outpatient commitment for “revolving-door” patients: Compliance and treatment. Journal of Nervous and Mental Disorders, 179(2), 83−88. Hiday, V. A., Swartz, M. S., Swanson, J. W., Borum, R., & Wagner, H. R. (2002). Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry, 159(8), 1403−1411. Kane, J. M., Quitkin, F., Rifkin, A., Wegner, J., Rosenberg, G., & Borenstein, M. (1983). Attitudinal changes of involuntarily committed patients following treatment. Archives of General Psychiatry, 40(4), 374−377. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications, Inc. Marshall, C., & Rossman, G. B. (1989). Designing qualitative research. Newbury Park, CA: Sage Publications, Inc. McCracken, G. (1988). The long interview. Newbury Park, CA: Sage Publications, Inc. McDonnell, E., & Bartholomew, T. (1997). Community treatment orders in Victoria: Emergent issues and anomalies. Psychiatry, Psychology and Law, 4, 25−36. Morgan, D. L. (1988). Focus groups as qualitative research. London: Sage. Morgan, D. L. (1997). Focus groups as qualitative research (2nd Ed.) Thousand Oaks, CA: Sage. Munetz, M. R., Grande, T., Kleist, J., & Peterson, G. A. (1996). The effectiveness of outpatient civil commitment. Psychiatric Services, 47(1), 1251−1253. O'Brien, A. M., & Farrell, S. J. (2005). Community treatment orders: Profile of a Canadian experience. Canadian Journal of Psychiatry, 50(1), 27−30. O'Keefe, C., Potenza, D. P., & Mueser, K. T. (1997). Treatment outcomes for severely mentally ill patients on conditional discharge to communitybased treatment. Journal of Nervous and Mental Disorders, 185(6), 409−411.
524
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
O'Reilly, R. (2004). Why are community treatment orders controversial? Canadian Journal of Psychiatry, 49(9), 579−584. O'Reilly, R., & Bishop, J. (2001). Assessing the New York City involuntary outpatient treatment program. Psychiatric Services, 52(11), 1533−1534. O'Reilly, R. L., Keegan, D. L., & Elias, J. W. (2000). A survey of the use of community treatment orders by psychiatrists in Saskatchewan. Canadian Journal of Psychiatry, 45, 79−81. Pinfold, V., Bindman, J., Thornicroft, G., Franklin, D., & Hatfield, B. (2001). Persuading the persuadable: Evaluating compulsory treatment in England using Supervised Discharge Orders. Social Psychiatry and Psychiatric Epidemiology, 36(5), 260−266. Policy Research Associates. (1998). Final report on the Research study of the New York involuntary outpatient commitment pilot program. Delmar, NY: Author. Preston, N. J., Kisely, S., & Xiao, J. (2002). Assessing the outcome of compulsory psychiatric treatment in the community: Epidemiological study in Western Australia. British Medical Journal, 324(7348), 1244−1246. Rohland, B. M., Rohrer, J. E., & Richards, C. C. (2000). The long-term effect of outpatient commitment on service use. Administration and Policy in Mental Health, 27(6), 383−394. Romans, S., Dawson, J., Mullen, R., & Gibbs, A. (2004). How mental health clinicians view community treatment orders: A national New Zealand survey. Australia and New Zealand Journal of Psychiatry, 38(10), 836−841. Sensky, T., Hughes, T., & Hirsch, S. (1991). Compulsory psychiatric treatment in the community. I. A controlled study of compulsory community treatment with extended leave under the Mental Health Act: Special characteristics of patients treated and impact of treatment. British Journal of Psychiatry, 158, 792−799. Steadman, H. J., Dennis, D. L., Gounis, K., Hopper, K., Roche, B., Richmond, L., et al. (1999). Assessing the operation of a New York City program for involuntary outpatient commitment. Research in Community and Mental Health, 10, 31−56. Steadman, H. J., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., et al. (2001). Assessing the New York involuntary outpatient commitment pilot program. Psychiatric Services, 52(3), 330−336. Stone, A. A. (1975). Mental health and law: A system in transition. Rockville, Md.: National Institute of Mental Health, Center for Studies of Crime and Delinquency. Swanson, J. W., Swartz, M. S., Borum, R., Hiday, V. A., Wagner, H. R., & Burns, B. J. (2000). Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. British Journal of Psychiatry, 176, 324−331. Swartz, M. S., Burns, B. J., George, L. K., Swanson, J., Hiday, V. A., Borum, R., et al. (1997). The ethical challenges of a randomized controlled trial of involuntary outpatient commitment. Journal of Mental Health Administration, 24(1), 35−43. Swartz, M., Swanson, J., & Monahan, J. (2003). Endorsement of personal benefit of outpatient commitment among persons with severe mental illness. Psychology, Public Policy, and Law, 9, 70−93. Swartz, M. S., Swanson, J. W., Wagner, H. R., Burns, B. J., Hiday, V. A., & Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry, 156(12), 1968−1975. Swartz, M. S., Swanson, J. W., Wagner, H. R., Hannon, M. J., Burns, B. J., & Shumway, M. (2003). Assessment of four stakeholder groups' preferences concerning outpatient commitment for persons with schizophrenia. American Journal of Psychiatry, 160(6), 1139−1146. Swartz, M. S., Wagner, H. R., Swanson, J. W., & Elbogen, E. B. (2004). Consumers' perceptions of the fairness and effectiveness of mandated community treatment and related pressures. Psychiatric Services, 55(7), 780−785. Szmukler, G., & Hotopf, M. (2001). Effectiveness of involuntary outpatient commitment. American Journal of Psychiatry, 158(4), 653−654. Toews, J., el-Guebaly, N., & Leckie, A. (1981). Patients' reactions to their commitment. Canadian Journal of Psychiatry, 26(4), 251−254. Van Putten, R. A., Santiago, J. M., & Berren, M. R. (1988). Involuntary outpatient commitment in Arizona: A retrospective study. Hospital and Community Psychiatry, 39(9), 953−958. Zanni, G., & deVeau, L. (1986). Inpatient stays before and after outpatient commitment. Hospital and Community Psychiatry, 37(9), 941−942.
A qualitative analysis of the use of community treatment orders in Saskatchewan Richard L. O'Reilly a,⁎, David L. Keegan b , Deborah Corring c , Satish Shrikhande d , Dhanapal Natarajan e a
Department of Psychiatry, The University of Western Ontario, Canada Department of Psychiatry (Emeritus),University of Saskatchewan, Canada Specialized Adult Program, Regional Mental Health Care, St. Thomas, Ontario, Canada d Vancouver Island Health Authority, British Columbia, Canada e Department of Psychiatry, University of Saskatchewan, Canada b
c
Received 3 November 2005; received in revised form 23 May 2006; accepted 6 June 2006
Abstract This study examined the opinions of patients who have been placed on a community treatment order (CTO), their relatives, mental health clinicians and representatives of community agencies about the use of CTOs in Saskatchewan. Patients were assessed using indepth interviews, while their relatives, mental health professionals and representatives of community agencies took part in facilitated focus groups. Patients had contradictory feelings about CTOs. Most experienced some degree of coercion while on the orders but many believed that CTOs provided necessary structure in their lives. Clinicians were more consistently positive but recognized the difficult choices in balancing the subject's right to self-determination with the benefits of a treatment order. Family members viewed CTOs as necessary to control a chaotic situation caused by the subject's limited insight. © 2006 Elsevier Inc. All rights reserved.
1. Introduction The use of mandatory outpatient treatment in its various forms: court-ordered outpatient committal, community treatment orders (CTOs), conditional leave, and guardianship remains controversial (O'Reilly, 2004). Research indicates that mandatory outpatient treatment reduces victimization of individuals with severe mental illness (Hiday, Swartz, Swanson, Borum, & Wagner, 2002) and increases follow-up with outpatient mental health services (Hiday & Scheid-Cook, 1991; Munetz, Grande, Kleist, & Peterson, 1996; Preston, Kisely, & Xiao, 2002; Rohland, Rohrer, & Richards, 2000; Sensky, Hughes, & Hirsch, 1991; VanPutten, Santiago, & Berren, 1988). Findings that mandatory outpatient treatment improves other outcomes, such as reducing the use of hospitalization (Fernandez & Nygard, 1990; O'Brien & Farrell, 2005; O'Keefe, Potenza, & Mueser, 1997; Zanni & deVeau, 1986), are more contentious. This debate was not resolved by the findings from two randomized control trials that essentially came to contradictory ⁎ Corresponding author. Tel.: +1 519 455 5110x47240; fax: +1 519 455 5090. E-mail address: [email protected] (R.L. O'Reilly). 0160-2527/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ijlp.2006.06.001
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
517
conclusions (Steadman et al., 2001; Swartz et al., 1999). Both studies have been criticized on methodological grounds (O'Reilly & Bishop, 2001; Szmukler & Hotopf, 2001). Some scholars have called for further randomized control trials to resolve uncertainties. Unfortunately, organizing a randomized control trial, where a legal statute is the independant variable, is extremely difficult (Dawson, 2002; Swartz et al., 1997) and it is unlikely we will see any further randomized trials in this field in the foreseeable future. Other scholars have recommended the use of qualitative research methods as a means to make an indepth assessment of the opinions of people who have been the subject of mandatory outpatient treatment (Bindman, 2002). In recent years, qualitative studies assessing the views of subjects of mandatory outpatient treatment and of other stakeholders have been reported from the US (Policy Research Associates, 1998; Steadman et al., 1999), the UK (Canvin, Bartlett, & Pinfold, 2002), Scotland (Atkinson, Garner, Gilmour, & Dyer, 2002) Australia (McDonnell & Bartholomew, 1997) and New Zealand (Gibbs, Dawson, Ansley, & Mullen, 2005; Gibbs, Dawson, Forsyth, Mullen, & Te Oranga Tonu Tanga (Maori Mental Health Team), 2004; Gibbs, Dawson, & Mullen, 2006; Romans, Dawson, Mullen, & Gibbs, 2004). In addition, older quantitative studies have sometimes included qualitative data (Adams & Hafner, 1991). In all of these studies, the subjects of mandatory outpatient treatment expressed ambivalent and sometimes contradictory views about treatment orders. Mandatory outpatient treatment was consistently reported by patients as being coercive (Adams & Hafner, 1991; Atkinson et al., 2002; Canvin et al., 2002; Gibbs et al., 2005; McDonnell & Bartholomew, 1997; Policy Research Associates, 1998) and in some studies as being maintained for too long (Gibbs & Dawson, 2005; McDonnell & Bartholomew, 1997). Patients often raised concerns about medication side effects (Adams & Hafner, 1991; Atkinson et al., 2002; Gibbs et al., 2005; McDonnell et al., 1997). However, patients also had positive things to say about treatment orders. Many reported that the orders provided security (Adams & Hafner, 1991; Canvin et al., 2002; Gibbs et al., 2005), offered more freedom than hospitalization or imprisonment (Gibbs et al., 2006) and some wanted to remain on the orders (Adams and Hafner, 1991; Atkinson et al., 2002; Canvin et al., 2002; Gibbs et al., 2005). Most subjects reported that their relationships with clinicians were not adversely affected by being placed on a treatment order (Atkinson et al., 2002; Gibbs et al., 2005; Policy Research Associates, 1998). Previous research indicated that clinicians tend to be more definitively positive about treatment orders (Atkinson et al., 2002; Pinfold, Bindman, Thornicroft, Franklin, & Hatfield, 2001; Romans et al., 2004) but may complain that the power available in the law is insufficient to manage nonadherence to treatment (O'Reilly, Keegan, & Elias, 2000) or is not used in the face of nonadherence (Romans et al., 2004). Mandatory outpatient treatment is seen as a way to engage patients who had a history of noncompliance with treatment (Gibbs et al., 2006). Psychiatrists and case managers are more likely to view treatment orders as helping rather than compromising the therapeutic relationship (Romans et al., 2004). The limited research on the views of the relatives of patients on mandatory outpatient treatment indicated that family members were generally more positive than patients about the use of treatment orders (Adams & Hafner, 1991). Family members often see a treatment order as providing support for their ill relative and report that when on a treatment order the burden of looking after the patient is shared with clinicians (Gibbs et al., 2006). This study was undertaken to compare the views on mandatory outpatient treatment of patients and other stakeholders in Canada with the view of stakeholders from other jurisdictions. We assessed the views of a wide range of parties – the subjects of CTOs, their relatives, various clinicians and key community agencies. The study is a follow-up to a postal survey of the views of Saskatchewan psychiatrists about CTOs completed in 1999 (O'Reilly et al., 2000). Saskatchewan was the first Canadian jurisdiction to introduce CTOs in 1995 (Mental Health Services Act1) followed by Ontario in 2000 (Mental Health Act2) and Nova Scotia (Involuntary Psychiatric Treatment Act3). Several of the other provinces have provisions for conditional leave and guardianship (Gray & O'Reilly, 2001). A person can be placed on a CTO in Saskatchewan if they have a mental illness that has resulted in their being involuntarily hospitalized three times in 2 years or for a total period of at least 60 days during those 2 years. Two psychiatrists must assess the patient and agree on the need for the initial CTO. The CTO can be renewed after each three-month period, again on the agreement of two psychiatrists. In Saskatchewan, a condition of being placed on a CTO is that the patient meets the inpatient committal criteria and consequently if a patient breaches the conditions of the CTO the patient can be committed to an inpatient unit. 1 2 3
Mental Health Services Act, S.S. 1984–85–86, c. M-13.1, as am., s. 24.1. Ontario, Mental Health Act, R.S.O. 1990, c. M.7, s. 33.1, as am., effective December 1, 2000. Involuntary Psychiatric Treatment Act, S.N.S. 2005, c. 42 (Not yet proclaimed).
518
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
2. Methodology We chose to study the use of CTOS in Saskatchewan as this province has the longest experience of using CTOs in Canada. The study was conducted in two centers, Regina and Saskatoon, between October 2002 and March 2003, 7 years after the introduction of CTOs. The subjects on CTOs at the time were identified by the Chief Psychiatrist of the Region and approached by their clinical psychiatrist or case manager to determine if they were willing to participate. Subjects were fully informed about the study and assured that their treatment would not be affected by their cooperation or refusal. Ethical approval was obtained from the Institutional Review Board at the University of Saskatchewan. Consenting subjects identified by their first name and research number had an interview with one of the authors (DC), an experienced qualitative researcher and occupational therapist who works in tertiary mental health care. All interviews were audiotaped and transcribed verbatim. Focus groups were held in each of the two major urban centers in Saskatchewan for relatives of subjects who were or had been on a CTO, psychiatrists who had used CTOs, case managers of patients on CTOs and staff of local community agencies (such as crisis service, police and home care operators). The same researcher noted above (DC) facilitated the focus group discussions. Participants in the focus groups were invited to attend by one of the principal researchers in each of the geographical locations, and a snowball sample of convenience was used to finalize group numbers. Each focus group consisted of six to eight members as recommended by Morgan (1988). All groups were audiotaped and transcribed verbatim. Data gathered through interviews and focus groups provided the participants' perspectives so that their “world views” form the structural framework for the report (Lincoln & Guba, 1985). Verbatim quotations from the transcripts of interviews and focus groups were analyzed. Quotations were chosen using two criteria: the quotation's ability to present the reader with the most succinct, expression of opinion, and the quotation's ability to convey the effect that CTOs have on the group in question. The data was analyzed using the constant comparative method (Glaser & Strauss, 1967). Themes identified are reflective of both frequency and importance as expressed by participants. The data were categorized under three main perspectives to reflect the views of subject, their relatives and providers. Within each perspective there were a number of themes. Categorization of data into perspectives and themes was a joint process among three researchers. 3. Results Thirty-six people were on a CTO in Saskatchewan at the time the study was undertaken. Twenty-nine of these individuals were living in one of the two health districts in which the study was conducted. Of these 29 individuals, three could not be contacted for various reasons, leaving 26 individuals who were invited to take part in the study. Eleven agreed to be interviewed and an additional three individuals who had been on a CTO in the previous 2 years were included in the study. All but one of the patients was living in the community when interviewed. The final individual had breached the conditions of a CTO and was being detained in hospital. Patients had been issued between one and eight CTOs (including current CTO) with an average of three for the group. The patients' age ranged from 20 to 70, with an average age of 44. Nine patients were diagnosed as having schizophrenia and five as having schizoaffective disorder. Fourteen family members took part in the focus groups. The family members included three sets of parents and one mother/grandmother dyad. Half of the family members were related to the subjects interviewed for the study. Two of the mother/father dyads and three other family members were related to individuals who refused or were unavailable to be interviewed. The case managers came from a variety of professional backgrounds: the majority were nurses. A total of 78 individuals provided opinions. 3.1. The perspective of the subjects 3.1.1. Requirements of a CTO In response to an inquiry “what does a CTO require you to do?” subjects usually spoke of the requirement to take their medication, and to see their doctor and case manager. Some individuals reported that they were required to live in supervised housing. ‘… remain on my medication and follow doctor's orders, you know, not go anywhere unless you tell him, sometimes I can't wait to go to try out some other city, to get out of town, get away from my family, and start new, oh I don't know I'm not sure if I even have the right to do that.’
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
519
3.1.2. Contest of will Subjects, almost without exception, found that being on a CTO was difficult to accept. ‘…the real issue was about will, whose will was stronger, and who's not getting their way with the decision about taking the medication.’ 3.1.3. Relationship with psychiatrist When asked how the CTO had affected their relationship with their psychiatrist subject responses were varied but often contained similar ambivalence. ‘it's like two panes of glass in a window never meeting but always facing each other… we had a big fight about going to hospital… going to hospital was tough to agree to but I found it helpful, and so I built up some trust in him, it was easier to go on a CTO.’ 3.1.4. Relationship with police Interactions with the police occurred for many subjects to meet requirements of the CTO, such as being escorted to receive injections of antipsychotic medication. Most were escorted without incident to the physician's office or emergency department but occasionally these interactions were problematic. ‘That happened [police arriving at her home] a few times to me…more than once…one surprised me but overall nothing bad happened to me, nothing came of it, they were just escorting me to hospital.’ 3.1.5. Subjects viewed the appeal process as futile Although all subjects recalled someone advising them of their right to appeal the CTO, many chose not to pursue this avenue either because they saw no need to, or that it appeared to be futile. ‘There is a group that I could talk [to appeal CTO] but I felt it was futile anyway, because I did talk to them once or twice and they turned me down.’ 3.1.6. Reluctant acceptance of a CTO Most subjects were compliant with a CTO once it was in place. Several subjects viewed being on a CTO as better than mandatory long-term hospitalization. ‘I don't recall but it was something to force me to take my medication but actually it was the threat of going to North Battleford [provincial psychiatric hospital] that made me try Clozaril.’ 3.1.7. Benefits of the CTO Several subjects identified benefits of CTOs, particularly those individuals who had been on the order for more than a year. They noted the CTO helped keep them healthy, provided structure in the community, and provided someone to talk to when they needed support. ‘…yea, I think I just needed a little bit of organization and structure in my life that I don't put there on my behalf, and the CTO enabled that to happen, so that sort of straightened out my plan… I was being lazy or negligent about my life planning and this caused me to more plan and organize my life effectively. 3.2. The perspective of the families 3.2.1. CTOs bring control to an out of control situation Family members struggle with the recurring crises of their relatives' illness. Everyday activities are put on hold while the family is consumed with caring for their loved one. Family members “pick up the pieces” when all else fails, and their ability to cope decreases over time.
520
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
‘There are some people who don't take medication and my husband is one of them… he looses track of his pills, then what happens is he gets sick and he won't take his pills, then he won't take his needle and its just a vicious cycle…the families take the brunt of it.’ 3.2.2. CTO process seen as too cumbersome Family members were frustrated with elements of the CTO process, which they felt were not helpful in achieving the objective of stability for their relative. Relatives felt that the duration of the CTO was too short and that excessive administrative details interfered with the ability to keep their relative on a CTO when that was necessary. ‘We have been to a judge at least three times if not four, the CTO, the last one has run out again and she knows it, and we cannot get her back in. The three months business is way too short. Two psychiatrists or whatever should renew it automatically, so we don't have to go through all this emotional stress, over and over again. 3.2.3. Experience with police Relatives were grateful to the police for their assistance when their family members refused treatment, but were sad and angry when that family member seems to be “criminalized”. ‘When the police come I wish they would come up in a plain car, but when they come up in the black and whites and coming rushing up…if people are walking down the street, what must they say. It must be a drug bust or something. …it'll take you a month to live it down. 3.3. The perspective of providers 3.3.1. Clinicians have to make tough choices Professionals struggled with the dilemma of wanting to support a subject's right to self-determination while obtaining the benefits of the stable life style they know is possible with treatment adherence. Many considered the longterm benefits of community living under a CTO to be preferable to institutional living. ‘Two people that I have on CTO right now are on it because of clear non-compliance with treatment, and it's made quite a remarkable difference for both of them. …it has made a remarkable difference in their stability and their functioning, so I think it has been of great value…to improve their quality of life and really get them on the road to better things.’ 3.3.2. CTO procedures incompatible with reality of practice and treatment Case managers, psychiatrists and community agencies reported that the procedures needed to initiate and maintain a patient on a CTO were too cumbersome. For example, the requirement to have two psychiatrists assess an individual in the community every 3 months in order to renew a CTO was seen as a major impediment to their use. Many clinicians felt there was a lack of clarity in the processes required in the use of CTOs. There was consensus that the duration of the order did not provide sufficient time for the patient to achieve stability. ‘We have had some ongoing issues with lack of clarity about the procedure to follow through. Even as much as two weeks ago I had to have a special meeting about people coming to the emergency department…it would have been nice if that stuff was all laid out very clearly for us, and that the communication mechanisms were in place as you go…it's like 10 years later and we are still stumbling through. 3.3.3. Relationship with subject always a concern Mental health professionals are keenly aware of the potential effect that a CTO can have on their relationship with a subject. They strive to maintain a therapeutic relationship but often need to accept that they are seen as the “bad guy”. ‘One of the things I think really matters is the development of a therapeutic alliance with the patient… I do not expect that I would want to put a patient on a CTO before I knew him that well…most of the patients do not have insight at all and those are the patients I find quite difficult for them to want a CTO.’
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
521
3.3.4. CTOs seen as effective in the long-term Case managers were able to readily identify subjects with previous nonadherence with medications who had been successfully managed on CTOs. ‘I have one fellow who is actually finished his CTO, was on it nine months to a year…it did work very well for him. Since going on the CTO he basically has regained his health, has become involved in treatment again, and compliant again…It's been great in his case.’ 3.3.5. Need for initial and ongoing education for doctors, police, family All providers referred to the need for regular and ongoing education of the stakeholders in the CTO process. This is necessary for all case managers, psychiatrists, police officers and family members. ‘This lady I was talking about, every month I would have to go and give these papers to the police, it was like I was doing community education every month because I was dealing with different people at the desk… 3.3.6. Need to recognize significant role that case managers play Much of the work needed to maintain a patient on a CTO falls to case managers. They need to be recognized as one of the central players in the overall process. ‘There's a lot of work in negotiating the CTOs, making sure they get done, the client is not going come and ask for them, it's up to me to make sure it's organized, and manipulating the situation to get them there to do it, to have the CTO administered. A lot of stress with the hostility, and there is so much deceit, you know in trying to convince them to get here, convince the client to get here and that kind of thing.’ 4. Discussion A major strength of this study was that it assessed the view of a wide range of stakeholders. An attempt was made to systematically recruit all patients on a CTO from the two major districts (by population) in Saskatchewan. However, only 42% of patients who were approached agreed to take part in the study and additional three patients were added to increase the number of subjects. Although patients were not randomly selected for the study, they do appear to be representative of patients on CTOs in Saskatchewan as the diagnostic profile of the patient sample, all of whom suffered from schizophrenia or schizoaffective disorder, is similar to that of a previous survey of all patients placed on a CTO in the province (Beach, 1999). The study employed two powerful qualitative research trustworthiness strategies– saturation and triangulation. Saturation is the point when further data gathered does not provide any new insights (Depoy & Gitlin, 1994). Morgan (1988) suggests that when a focus group facilitator can predict with accuracy what a participant will say, a point of saturation has been reached. He recommends a minimum of three to five focus groups to achieve saturation particularly when the focus groups are made up of homogenous participants and the topic is specific and of interest to all participants, as the subject of CTOs was to our participants. McCracken (1988) indicates that six to eight indepth interviews will usually achieve saturation when subjects are homogeneous in nature. Our study used 14 interviews (twice what is normally considered adequate) and eight focus groups (again exceeding recommendations for saturation). In addition, the use of an experienced qualitative researcher (DC) enhances the assessment of time when saturation was actually reached. Triangulation is a process that requires one or more types of data sources, methods, or researchers be used in the analytical process. (Depoy and Gitlin, 1994; Marshall & Rossman, 1989; McCracken, 1988; Morgan, 1997). Multiple data sources were used in this study (case managers, community agency representatives, psychiatrists, subjects of CTOs and family members), two data collection methods were used (focus groups and indepth interviews), and three researchers were involved in the analysis of the transcripts. Many subjects talked about coercion – “the battle of wills.” The question of coercion and free will was often raised in the context of having to take medication. Some patients complained of side effects from the medications that they were compelled to take. Other studies have noted that patients who are placed on CTOs experience coercion (Steadman et al., 1999; Canvin et al., 2002; Gibbs et al., 2005). Indeed, it would be surprising if this were not the case as CTOs
522
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
have a core coercive element. The consistency of patients' descriptions of coercion suggests that terms such as, “assisted outpatient treatment,” which appears to be deliberately euphemistic, run the risk of deemphasizing the coercion that these patients are likely to experience and should be abandoned. However, it is also important to point out that our findings were similar to those of researchers in New Zealand who noted that the actual experience of coercion by the majority of patients was much less than the strident policy debates on CTOs sometimes suggest (Gibbs et al., 2005). Specifically, we noted that many patients in our study were initially resentful of being placed on a CTO but reported that this reaction lessened with time. Their acceptance of the CTO was often associated with the belief that the order provided structure that was necessary to bring stability to their life. Once again these views are very similar to subjects' reports in studies conducted in New Zealand (Gibbs et al., 2005) and the UK (Canvin et al., 2002) that mandatory outpatient treatment provided “safety and security.” When patients in Saskatchewan saw their options as accepting a CTO or returning to hospital, their preference was to remain on the CTO. Swartz et al. came to a similar conclusion using a quantitative approach where patients with psychotic illnesses were presented with case vignettes and asked to rate different outcomes (Swartz et al., 2003). In this study, patients were most concerned about avoiding involuntary hospitalization, somewhat concerned about avoiding interpersonal violence or conflict but least concerned about avoiding outpatient commitment. Stone developed the concept of the “Thank you theory” which proposes that if involuntary hospital commitment is justifiable we would expect patients to be grateful when they have recovered from their illness (Stone, 1975). Studies of involuntary hospitalization confirm high levels of acceptance of inpatient committal (Bradford, McCann, & Merskey, 1986; Kane et al., 1983; Toews, el-Guebaly, & Leckie, 1981). Should we expect CTOs to also meet the “Thank you theory” standard? As CTOs are primarily used for patients with chronically impaired insight we might not expect many to ever endorse the use of coerced outpatient treatment (Swartz, Swanson, & Monahan, 2003). However, as in the New Zealand study (Gibbs et al., 2005), many patients in Saskatchewan stated that they agreed with the decision to place them on a CTO. Perhaps the positive findings in the current and previous studies are due to systematic bias. Patients who agreed to participate in research studies may have reached some level of insight and developed some positive regard for treatment orders. Those who refused to participate may not have attained any insight and so may resent the CTO application. Support for this possibility comes from the observation of Swartz, Wagner, Swanson, and Elbogen (2004) who found that those who reject mandated treatment as ineffective and unfair, tend to be more symptomatic and to lack insight. The inclusion of relatives of patients who refused to be interviewed offsets this bias to an extent and is especially important if refusal of patients to participate is associated with a poorer outcome on the CTO. Relatives were very positive about CTOs and some reported that they had been essential in bringing stability to the chaos in the patient's life. However, a prominent finding was that families had a high level of frustration with the mental health system. Relatives of patients on CTOs viewed themselves as taking the brunt of the burden when the system fails. Relatives were also critical of many of the administrative aspects of initiating and renewing CTOs, which they viewed as a barrier to effective treatment. As has been found elsewhere (Atkinson et al., 2002; Pinfold et al., 2001; Romans et al., 2004) most mental health clinicians in Saskatchewan felt that the orders were helpful for specific patients. However, psychiatrists and case managers criticized the administrative burden associated with CTOs. There was a consensus amongst the relatives, clinicians and representatives from the community agencies that a three-month duration for a CTO was too short. One relative pointed out that the time of renewal of a CTO could reignite conflict. Past research suggests that improved outcomes from using mandatory outpatient treatment are most likely when the treatment order has been in place for at least 6 months (Swanson et al., 2000; Swartz et al., 1999) and perhaps 6 months is a more practical duration for treatment orders. When the study was undertaken, CTOs had been used for 7 years. This represented a mature system where it would be expected that initial problems in implementation and operation of the legislation would have been resolved. However, many stakeholders noted they had encountered a lack of knowledge or uncertainty about the use of CTOs even among mental health care workers and police who would be expected to be familiar with the procedures. 5. Conclusion Many of the themes that emerged from this study were similar to those from non-Canadian jurisdictions despite the use of different models of mandatory outpatient treatment in those jurisdictions. The study confirms that there are
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
523
negative aspects of mandatory outpatient treatment, particularly the common experience of coercion. However, the degree of reported coercion appears to be much less than suggested during policy debates. It was also apparent that there is a diverse range of opinions amongst patient on CTOs. For example, while most patients reported little or no disruption of the therapeutic relationships, a few remained very angry with their clinicians. Family members, clinicians and representatives of community agencies were much less ambivalent about their support for CTOs. Many of the nonpatient stakeholders focused on technical and educational failings of the CTO system in Saskatchewan, which in their view limited the utility of the orders. Surprisingly, little of the extensive literature on the efficacy of CTOs addresses this important observation. Acknowledgements The authors appreciate the financial assistance provided by Saskatchewan Health. We would like to thank all the participants for providing us their time and experience. Also appreciated was the assistance provided by Ms. Donna Herman and Joanne Chapman. References Adams, N. H., & Hafner, R. J. (1991). Attitudes of psychiatric patients and their relatives to involuntary treatment. Australian and New Zealand Journal of Psychiatry, 25(2), 231−237. Atkinson, J. M., Garner, H. C., Gilmour, W. H., & Dyer, J. A. T. (2002). Changes to leave of absence in Scotland: The view of patients. The Journal of Forensic Psychiatry, 13(2), 315−328. Beach, A. (1999). Community treatment orders in the context of comprehensive community-based mental-health services: How did Saskatchewan get there? Evaluation on utilization to date. [Abstract]. Penetanguishene Conference on Mental Health Services Restructuring and Public Safety. Bindman, J. (2002). Involuntary outpatient treatment in England and Wales. Current Opinion in Psychiatry, 15(6), 595−598. Bradford, B., McCann, S., & Merskey, H. (1986). A survey of involuntary patients' attitudes towards their commitment. Psychiatric Journal of the University of Ottawa, 11(3), 162−165. Canvin, K., Bartlett, A., & Pinfold, V. (2002). A ‘bittersweet pill to swallow’: Learning from mental health service users' responses to compulsory community care in England. Health and Social Care in the Community, 10(5), 361−369. Dawson, J. (2002). Randomised controlled trials of mental health legislation. Medical Law Review, 10(3), 308−321. Depoy, E., & Gitlin, L. N. (1994). Introduction to research: Multiple strategies for health and human services. St. Louis, MO: Mosby. Fernandez, G. A., & Nygard, S. (1990). Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hospital and Community Psychiatry, 41(9), 1001−1004. Gibbs, A., Dawson, J., Ansley, C., & Mullen, R. (2005). How patients in New Zealand view community treatment orders. Journal of Mental Health, 14(4), 357−368. Gibbs, A., Dawson, J., Forsyth, H., & Mullen, R. Te Oranga Tonu Tanga (Maori Mental Health Team). (2004). Maori experience of community treatment in Otago, New Zealand. Australia and New Zealand Journal of Psychiatry, 38(10), 830−835. Gibbs, A., Dawson, J., & Mullen, R. (2006). Community treatment orders for people with serious mental illness: A New Zealand study. British Journal of Social Work. http://bjsw.oxfordjournals.org/cgi/reprint/bch392?ijkey=XaBvWzS9Rq8Lvgo&keytype=ref Glaser, B., & Strauss, A. (1967). The discovery of grounded theory. Hawthorne, NY: Aldine: Chicago. Gray, J. E., & O'Reilly, R. L. (2001). Clinically significant differences among Canadian mental health acts. Canadian Journal of Psychiatry, 46(4), 315−321. Hiday, V. A., & Scheid-Cook, T. L. (1991). Outpatient commitment for “revolving-door” patients: Compliance and treatment. Journal of Nervous and Mental Disorders, 179(2), 83−88. Hiday, V. A., Swartz, M. S., Swanson, J. W., Borum, R., & Wagner, H. R. (2002). Impact of outpatient commitment on victimization of people with severe mental illness. American Journal of Psychiatry, 159(8), 1403−1411. Kane, J. M., Quitkin, F., Rifkin, A., Wegner, J., Rosenberg, G., & Borenstein, M. (1983). Attitudinal changes of involuntarily committed patients following treatment. Archives of General Psychiatry, 40(4), 374−377. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications, Inc. Marshall, C., & Rossman, G. B. (1989). Designing qualitative research. Newbury Park, CA: Sage Publications, Inc. McCracken, G. (1988). The long interview. Newbury Park, CA: Sage Publications, Inc. McDonnell, E., & Bartholomew, T. (1997). Community treatment orders in Victoria: Emergent issues and anomalies. Psychiatry, Psychology and Law, 4, 25−36. Morgan, D. L. (1988). Focus groups as qualitative research. London: Sage. Morgan, D. L. (1997). Focus groups as qualitative research (2nd Ed.) Thousand Oaks, CA: Sage. Munetz, M. R., Grande, T., Kleist, J., & Peterson, G. A. (1996). The effectiveness of outpatient civil commitment. Psychiatric Services, 47(1), 1251−1253. O'Brien, A. M., & Farrell, S. J. (2005). Community treatment orders: Profile of a Canadian experience. Canadian Journal of Psychiatry, 50(1), 27−30. O'Keefe, C., Potenza, D. P., & Mueser, K. T. (1997). Treatment outcomes for severely mentally ill patients on conditional discharge to communitybased treatment. Journal of Nervous and Mental Disorders, 185(6), 409−411.
524
R.L. O'Reilly et al. / International Journal of Law and Psychiatry 29 (2006) 516–524
O'Reilly, R. (2004). Why are community treatment orders controversial? Canadian Journal of Psychiatry, 49(9), 579−584. O'Reilly, R., & Bishop, J. (2001). Assessing the New York City involuntary outpatient treatment program. Psychiatric Services, 52(11), 1533−1534. O'Reilly, R. L., Keegan, D. L., & Elias, J. W. (2000). A survey of the use of community treatment orders by psychiatrists in Saskatchewan. Canadian Journal of Psychiatry, 45, 79−81. Pinfold, V., Bindman, J., Thornicroft, G., Franklin, D., & Hatfield, B. (2001). Persuading the persuadable: Evaluating compulsory treatment in England using Supervised Discharge Orders. Social Psychiatry and Psychiatric Epidemiology, 36(5), 260−266. Policy Research Associates. (1998). Final report on the Research study of the New York involuntary outpatient commitment pilot program. Delmar, NY: Author. Preston, N. J., Kisely, S., & Xiao, J. (2002). Assessing the outcome of compulsory psychiatric treatment in the community: Epidemiological study in Western Australia. British Medical Journal, 324(7348), 1244−1246. Rohland, B. M., Rohrer, J. E., & Richards, C. C. (2000). The long-term effect of outpatient commitment on service use. Administration and Policy in Mental Health, 27(6), 383−394. Romans, S., Dawson, J., Mullen, R., & Gibbs, A. (2004). How mental health clinicians view community treatment orders: A national New Zealand survey. Australia and New Zealand Journal of Psychiatry, 38(10), 836−841. Sensky, T., Hughes, T., & Hirsch, S. (1991). Compulsory psychiatric treatment in the community. I. A controlled study of compulsory community treatment with extended leave under the Mental Health Act: Special characteristics of patients treated and impact of treatment. British Journal of Psychiatry, 158, 792−799. Steadman, H. J., Dennis, D. L., Gounis, K., Hopper, K., Roche, B., Richmond, L., et al. (1999). Assessing the operation of a New York City program for involuntary outpatient commitment. Research in Community and Mental Health, 10, 31−56. Steadman, H. J., Gounis, K., Dennis, D., Hopper, K., Roche, B., Swartz, M., et al. (2001). Assessing the New York involuntary outpatient commitment pilot program. Psychiatric Services, 52(3), 330−336. Stone, A. A. (1975). Mental health and law: A system in transition. Rockville, Md.: National Institute of Mental Health, Center for Studies of Crime and Delinquency. Swanson, J. W., Swartz, M. S., Borum, R., Hiday, V. A., Wagner, H. R., & Burns, B. J. (2000). Involuntary out-patient commitment and reduction of violent behaviour in persons with severe mental illness. British Journal of Psychiatry, 176, 324−331. Swartz, M. S., Burns, B. J., George, L. K., Swanson, J., Hiday, V. A., Borum, R., et al. (1997). The ethical challenges of a randomized controlled trial of involuntary outpatient commitment. Journal of Mental Health Administration, 24(1), 35−43. Swartz, M., Swanson, J., & Monahan, J. (2003). Endorsement of personal benefit of outpatient commitment among persons with severe mental illness. Psychology, Public Policy, and Law, 9, 70−93. Swartz, M. S., Swanson, J. W., Wagner, H. R., Burns, B. J., Hiday, V. A., & Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry, 156(12), 1968−1975. Swartz, M. S., Swanson, J. W., Wagner, H. R., Hannon, M. J., Burns, B. J., & Shumway, M. (2003). Assessment of four stakeholder groups' preferences concerning outpatient commitment for persons with schizophrenia. American Journal of Psychiatry, 160(6), 1139−1146. Swartz, M. S., Wagner, H. R., Swanson, J. W., & Elbogen, E. B. (2004). Consumers' perceptions of the fairness and effectiveness of mandated community treatment and related pressures. Psychiatric Services, 55(7), 780−785. Szmukler, G., & Hotopf, M. (2001). Effectiveness of involuntary outpatient commitment. American Journal of Psychiatry, 158(4), 653−654. Toews, J., el-Guebaly, N., & Leckie, A. (1981). Patients' reactions to their commitment. Canadian Journal of Psychiatry, 26(4), 251−254. Van Putten, R. A., Santiago, J. M., & Berren, M. R. (1988). Involuntary outpatient commitment in Arizona: A retrospective study. Hospital and Community Psychiatry, 39(9), 953−958. Zanni, G., & deVeau, L. (1986). Inpatient stays before and after outpatient commitment. Hospital and Community Psychiatry, 37(9), 941−942.