Community Treatment Orders: A Tale of Two Policy Transfers Hannah Jobling University of York, Social Policy and Social Work Department ECSWR 2012

Overview CTOs and their growth as an international phenomenon The ‘fault-lines’ that exist between CTO policy regimes A typology of CTO regimes What this means for practice What this means for research

What are CTOs? 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 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) Supposed to be for ‘revolving door’ service users So for example not to drink alcohol or where to live. Conditions mostly relate to the taking of medication. The majority of people on CTOs tend to be diagnosed with schizophrenia, so medication in this sense means anti-psychotic drugs. The ability of the CTO to detain and forcibly treat means they are a ‘carrot and stick’ approach – if you stay well and keep to your conditions, then you can be free to live in the community. So as the quote suggests CTOs are a legislative mechanism to extend compulsion from the hospital into the community. Revolving door users means those who have a history of non-compliance and who go through rapid and continuous cycles of release, deterioration and re-detainment.

Policy Transfer: A Brief History ‘Least Restrictive’ CTOs Early 1980s: US policy initiative ‘Preventative’ CTOs 1990s: policy transfer to Australia, New Zealand, Israel, Canada 2005: Scotland Mental Health Act 2007: England and Wales Only exist in some countries – not Europe (?) Least restrictive – alternative to detention - Developed within the context of the user rights movement as a way of maximising individual liberty by minimising involuntary hospitalisation. Didn’t work within the American legal system due to dangerousness criteria – therefore preventative CTOs developed, which are put in place either before someone reaches the threshold for hospitalisation, or more commonly after they have been released. Therefore supposed to be aimed at a particular group of individuals – those classed as ‘revolving door’ users, From the US spread to other countries. Interesting to note the type of countries where CTOs are enacted, English-speaking, western liberal democracies. Different attitudes to mental health? Different purposes? However within this ‘type’, how CTOs are enacted depends very much on the culture of the country.

Question Does anyone know of CTOs (or similar provision) being used in other countries?

CTO Policy ‘Fault-lines’ CTO policy regimes can be characterised by approaches to: Risk Capacity Reciprocity Conditions for use Judicial approval The concept of CTO Policy Fault-lines has been taken from Dawson (2005). Fault-lines – concepts which are treated differently in different countries legislation on CTOs. Tends to reflect the country's existing approach to mental health legislation. So in the USA may reflect approach to liberty and what is constitutional. Risk: The level of risk to self or others that has to be present before someone is placed on a CTO. For example in England, the phrase is “ necessary for health and safety” which offers rather flexible criterion. Whereas in the states is risk of 'serious harm' and level of dangerousness. Capacity: Basically, some countries have what are called capacity clauses in their CTO legislation – that a person must not have the capacity to make an informed decision to comply voluntarily with treatment. It has been suggested that if there is a low risk criteria, then there should be a stringent capacity test and vice versa – this would ensure that in the cases where a serious harm is not present, then a person's ability to make their own decision on treatment was respected. Reciprocity: It has been argued that if you are going to take away someone's freedom in the community, then they should rightfully get something in return – substantial and supportive services tailored to their needs. Seen in this way, CTOs are a contract that binds not only the service user, but also services. Also helps to protect against CTOs simply being used only as a control measure. Again some countries have clear reciprocity clauses that state it has to be demonstrated that the person will receive those services before a CTO can be imposed. Conditions for use: There are varying levels of pre-conditions in different countries that have to be met before a person can be placed on a CTO. For example in Canada and USA CTO legislation says that the person has to have been detained on a number of occasions over the last 2 or 3 years. In the USA can also be because has caused serious harm to others in the last 2 or 3 years. Also that has previously been given the opportunity to engage voluntarily. This is supposed to ensure that they are targeted at 'revolving door' service users and don't draw in a much wider group who are voluntarily engaging and who don't have a history of being in and out of hospital or of being a risk. In other countries, the only condition is that is an inpatient detained under mental health legislation. Judicial approval: Finally some countries, such as in the USA require that the practitioner has to apply to court with evidence in order to secure a CTO. Whereas in other countries, it is only up to the practitioner to make that decision.

CTO Policy Regimes: A Typology Risk Level Capacity clause Reciprocity clause Conditions for use Judicial approval England Low No Weak NZ Medium W. Aus Vic, Aus Yes Scotland Sas, CA High Strong Ont, CA USA So if we take all of these fault-lies together for each country, we can see a distinct typology of CTO policy regimes forming. At the top we have countries with very 'loose' legislative criteria – England for example has a low risk level – 'health and safety', no clause saying that the person is not able to make their own decisions, no clause saying that the service has to provide a certain level of care and support in return, no preconditions – can apply to any inpatient facing discharge, including those on their first admission, no history of risk and those who may agree to voluntary treatment. Indeed, the Care Quality Commission (2010) analysed 208 CTO cases and found 30% of them did not have a history of non-compliance or disengagement and therefore could be classed as having the potential to be treated voluntarily. It's interesting in England's case that despite the government always saying CTOs were aimed at revolving door patients, when the legislation was going through, the House of Lords tried to insert more pre-conditions and the government overturned them, stating it would exclude patients who might benefit and would limit clinical judgement. Contrast with USA and Canada, and to a certain extent Scotland which have much more tightly defined criteria. See handout of legislative comparison.

CTO Policy Regimes and Practice Variability in use of CTOs: High numbers of CTOs in NZ and Australia (Lawton-Smith, 2005) England: Expected 400-600 a year, 2008- 2011 CTOs issued av. 347 per month (CQC, 2011). Practitioner discretion and decision-making Role of social workers in applying CTOs in England

Research Responses to Policy Questions 1 Mainly (quasi) experimental (primarily from USA) Ambiguous findings and not generalisable (Churchill et al, 2007) Still used as evidence-base (Hansard, July 2007) RCTs, matched studies, before and after studies Effectiveness has not substantively been shown by these studies. E.g. the two RCTs that been carried out in the USA had various methodological difficulties which meant their findings were not reliable. More importantly for the purpose of this presentation, because these research designs depend on internal validity – this doesn’t necessarily work for external validity when used for a policy initiative such as CTOs which are so diverse across countries.

Research Responses to Policy Questions 2 In order to understand more about policy transfer to practice, need to extend research to explore the processes of practice: How decisions are made throughout a CTO What factors influence these decisions What ethical and practical issues are raised The involvement of service users and carers And the experiences of those affected by CTOs Whilst effectiveness studies are important, little attention has been paid to the process of how policy is being translated into practice. I would argue that in policy regimes like England where the use of CTOs depends so much on practitioner discretion and where the potential is high for practice to be diverse, this is an aspect that it would be valuable to study. Could also supplement causality questions – why do people use them, why do they think they work or not.*come back to this*

Question Could it be anticipated that we might find comparable themes in such research appearing across diverse policy regimes? Small number of qualitative studies (NZ, Aus, Canada) Surprising thematic consistency in stakeholder views Ambivalence: Security and coercion Conducting qualitative research on CTOs of this nature has the potential to develop internationally recognisable themes further

An Ethnography of CTOs Able to see how CTO policy is being translated into practice by exploring: sociocultural processes in specific settings and the perspectives and activities of individuals/agents Using a range of methods: Participant observation Interviews Document analysis Over time and across settings There are a number of ways we could research the processes of CTO use. The methodology I have chosen for my PhD is an ethnographic approach – I chose this because I believe it will enable an insight into the culture of CTO practice in ways previous more general Interview-only qualitative research has not.

What other kinds of process-focused research would be appropriate? Question What other kinds of process-focused research would be appropriate?

Questions Does anyone know of CTOs (or similar provision) being used in other countries? Could it be anticipated that we might find comparable themes in such research appearing across diverse policy regimes? What other kinds of process-focused research would be appropriate?

References Care Quality Commission (2011), Monitoring the use if the Mental Health Act in 2010/11, London: Care Quality Commission Churchill R. et al, (2007), International experiences of using community treatment orders, London: DoH Dawson, J., (2005), Community Treatment Orders: International Comparisons, NZ: Otago University Print Hansard (Lords). 2nd July 2007, column 847 Lawton-Smith (2005), A Question of Numbers: The potential impact of community-based treatment orders in England and Wales, London: King’s Fund