Policy Ethnography: Creating Stories of Causality Hannah Jobling, PhD student Department of Social Policy and Social Work, University of York

Overview Community Treatment Orders (CTOs) in England and Wales Ethnography as the methodological approach Findings – CTOs in practice: The creation of a typology Stories of causality: How we can ‘read’ these findings to help develop an understanding of who CTOs work for in what circumstances (context), why (mechanisms) and with what consequences (outcomes) Realism and ethnography

CTOs: Background Enacted in around 70 jurisdictions worldwide, including USA, Canada, Australia, New Zealand Introduced in England and Wales under the Mental Health Act 2007, became ‘live’ in late 2008. Allow for conditions to be imposed on how mental health service users live in the community Provide a mechanism for detention and treatment enforcement if conditions are not met, or health & safety concerns CTOs “enforce community treatment outside (and independently) of the hospital, contain specific mechanisms for enforcement and/or revocation and are authorised by statute” (Churchill et al, 2007, 20) Three drivers highlighted in policy and research literature: Revolving door (resources) Risk management Rehabilitation and recovery

CTOs: Research Responses to Policy Problems CTOs probably the most controversial aspect of new Act: On one hand – help to engage service users, reduce rates of hospitalisation, improve clinical outcomes and promote stability On the other – extend compulsion, result in unnecessary coercion, loss of rights and neglect of alternative options A lot of research (mainly outside the UK): (Quasi) experimental > Outcomes > Hospitalisation rates, treatment compliance etc. Methodological difficulties and equivocal findings (Churchill et al, 2007). Surveys > mostly psychiatrists > mostly positive Qualitative research > Focus groups and interviews > families (mostly positive) and service users (ambivalence)

An Ethnography of CTOs Considerable scope for finding out how CTOs are practiced and what that might mean A CTO ethnography: Enables “the particular context of social actors and groups and the social matrices of their thoughts and behaviour” (Swanson, 2010, 185) to be accounted for Connects stakeholder experiences to CTO-related events as they occur Allows for CTOs to be viewed as a process, unfolding over time, mediated by contextual factors Illuminates what CTO practice looks and feels like – joins abstract political concerns with concrete ethical dilemmas And by doing all this, enables why, for who and when questions to be asked about CTO outcomes

The Study Aim: To find out in what ways CTOs are being implemented and with what implications for the practice and experiences of service users and practitioners. Case study design: Two Trusts > One AOT in each Trust > 18 CTO cases across the field sites Fieldwork took place over 8 months and tracked the progress of the 18 cases: Interviews (some repeat) with 18 service users and 20 practitioners Observation of key meetings, daily practice and informal interactions Content analysis of case files Additional research activities: Key informant interviews with 16 practitioners Content analysis of Trust policy

Analysis Combination of narrative and thematic approaches: Progress over time in cases – looking backwards and forwards Conceptual patterns across cases Observations and interviews – narratives as making agency (or lack of) meaningful – interplay of context and action Formation of CTO pathways by using ‘configurational’ maps (Sayer, 2000) to cluster narratives Development of a CTO typology: Active/Passive, Acceptance/Resistance, plus additional categories of Subversion and Ambivalence Institutional means and societal goals (Merton)plus actions individuals take in response to these

Case study: Active acceptance James Active acceptance something to be worked at from initial discharge Taking ownership – ‘it belongs to me’ Taking control - ‘I felt that part of my Community Treatment Order and part of my injections were in conflict because I didn’t feel in control of my injections. I was being told you’ve got to have them. It felt like the responsibility had been taken out of my hands. It was in the hands of the nurses here and the doctors here and I thought, well, that’s not fair because my CTO says I’ve got to be responsible; I’ve got to be in charge and then, when I went up to the medical centre and they started doing it, I settled down a bit better.’ Key factors: Negotiation of medication Collaborative work – ‘mutuality of accounts’ Making sense of the CTO – developing purpose On-going explanation and development of legal consciousness

Case study: Active Resistance Active resistance either through use of legal mechanisms or avoidance Sheila Bioethical balancing act – ‘she’s not a risk to others or really to herself, but It’s a really tight-knit community where she lives and everyone knows her. She’d only just built up trust again there and now…So I think it’s about supporting her in the community really’ Reinforcement of barriers to care and support – ‘she’s not on my side’ No hope of discharge by either Sheila or her care coordinator Key factors: Repeat recalls – reinforcing cycles of resistance ‘Surface’ work Making sense of the CTO – previous difficult experiences

Stories of Causality Context affects the way individuals respond to the programme concept, which in turn influences the ways they interact with programme intervention strategies, which then form outcomes. Context Refers both to the characteristics of those individuals made subject to a policy programme and the institutional and micro-social factors that mediate their experiences. Complex interactions between personal values and beliefs, and past and present experiences of services, medication and relationships with professionals. Mechanisms Refers to the “process of how individuals interpret and act upon the intervention strategies” (Pawson and Tilley, 2004, 6). Recall as an intervention paradox Outcomes Multiple intended and unintended consequences of relationship between mechanisms and context. Judging ‘success’ or ‘failure’ Moving beyond ‘effectiveness = ethically sound’

Realism and ethnography Bridge between positivism and interpretivism Generative rather than predictive explanation of causality Mid-range theory and generalisation In policy arena, associated with mixed methods Sayer (2000) – ‘intensive designs’ Hammersley and Atkinson (2007) – ethnography and subtle realism Thick description and developing a sense of verisimilitude - ‘saying something of something’

References Churchill, R, Owen, G, Singh, S & Hotopf, M, (2007), International Experiences of Using Community Treatment Orders, London: Institute of Psychiatry, Kings College London. Hammersley, M. and Atkinson, P. (2007), Ethnography: Principles in Practice, (3rd Ed.) London: Routledge. Pawson, R. and Tilly, N. (2004), Realist Evaluation, London: Cabinet Office Sayer, A. (2000), Realism and Social Science, London: Sage Swanson, J. (2010), ‘What would Mary Douglas do? A commentary on Kahan et al., “Cultural cognition and public policy: The case of outpatient commitment laws”’, Law and Human Behaviour, 34, 176-185. This paper is under review for a special issue of the Journal Qualitative Social Work: ‘Ethnography – Practice and Theory in Social Work Research’.