1. Department of Social Policy and Social Work,
The more things stay the same the more they change? How practitioners understand and approach Supervised Community Treatment
Hannah Jobling,
Department of Social Policy and Social Work,
University of York

2. Community Treatment Orders
Enacted in around 70 jurisdictions worldwide, including USA, Canada, Australia, New Zealand and UK
Introduced in England and Wales under the Mental Health Act 2007
Allow for conditions to be imposed on how mental health service users live in the community
Provide a mechanism for hospitalisation and treatment

3. CTOs: The English legal framework
Always follow a treatment section (3 or 37)
‘Mental disorder’
‘Health and safety’
Community treatment possible and available
Power of recall necessary

4. CTOs: Policy and Practice
Policy drivers:
Foundational purpose to ensure compliance
‘Revolving door’ – resources and stability
Risk management
Rehabilitation and recovery
Practice:
Broad criteria for use and clinical discretion
The use of CTOs has increased year by year
2012/13: 5218 people subject to CTOs > 10%
(Health and Social Care Information Centre, 2013)

5. The Study
To establish how the implementation of CTO policy is being realised and with what implications for the experiences of patients 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 with 18 service users and 36 practitioners
Observation of key meetings, daily practice and informal interactions
Content analysis of case files

6. Analytical framework: Governmentality
Foucauldian conception of operation of power and rule in society
Thought and action for ‘the conduct of conduct’
Governmentality as an analytical framework (Dean, 2010)…
Visibility
Rationalities
Technologies
Identity
…To understand CTOs as a particular manifestation of power

7. Practitioner ‘ways of seeing’
Maintenance – keeping people stable
the end result is that they can live out their days mentally stable with minimal involvement from services
Recovery – moving people on
You want them to be able to move on and get on with their life and live as independently as possible and sort of, make something of themselves
Protection – keeping people safe and alleviating distress
I think that being sectioned is more traumatic to the client as well because of course you've got police involvement, ambulance turning up , you know I think the recall process is easier for clients, it's much kinder
Risk – monitoring and surveillance
it allows us to monitor people that are bit riskier to others, a bit more dangerous. It gives, you know, as a bunch of professionals, more comfort, we’ve got some power over people

8. Practitioner ‘ways of thinking’
Nature of proof in practice:
Not on a CTO has proven that she deteriorates mentally, requires hospital admissions and that disrupts her life and in the small community that she lives in, the benefits for her being on a CTO outweigh the risks of...Even though she doesn’t want to be on a CTO.
We had a locum doctor take someone off section 3 because they thought they were really well, but we didn't want that to happen. We wanted him to go on a CTO. Everybody wanted the CTO to happen, So he buggered it up really, But as it is he hasn't needed it, he’s engaged. He’s fine, he doesn't need to be on one. So that's an illustration of how someone who everyone else thinks has to be on one, functions without one. And makes contact with me and engages well with me and the team, so there you go.

9. Practitioner ‘ways of thinking’
Means and ends – ethical frameworks:
Necessary
Helpful
We’re selective and because we reserve it for when we think it’s really needed, rather than for when it might be helpful. a decision to take away someone’s fundamental rights not to have things done to them that they don’t want, requires a high level of justification.
I think very quickly in your head you were thinking oh that would be great for Mr X or Mrs Z. straightaway I thought they would be perfect for a few of my clients.

10. Practitioner ‘ways of acting’
The recall mechanism:
Necessary
Helpful
We need to show some flexibility, we can't follow this rigidly or once you breach conditions then that's it, you come to hospital immediately, we have to show some...and also to remind the patient that this is what you agreed on, they might cooperate, or they might have a good reason for not doing it.
I’m actually in favour of early recall if someone is starting to become disengaged or non-adherent. I think the point is to do it early otherwise what is the point of the CTO? I'm just thinking about Eve because she's very good at masking, and we had to wait almost ten months of deteriorating until she wasn't able to mask her symptoms anymore…

11. Practitioner ‘ways of acting’
Persuasion and negotiation: flexible practice within compulsion
We actually meet him weekly but there's a requirement that we see him. It’s not specific that he engages, but we've agreed in the care plan that if he doesn't sort of turn up every second appointment, we can more assertively chase him. He doesn't like to see mental health professionals at his home so we agreed to meet him in a city centre cafe which was more agreeable to him because we didn't think it would be ethical or a good way to engage him, to insist to use the CTO, we couldn't really …whether it would have been lawful to say we're going to insist on seeing you in your own home

12. Practitioner ‘ways of acting’
Crossing the Rubicon (Dawson, 2006) and defensive decision-making:
it [recall] puts a defined responsibility on you that you will do something. I mean, there’s always emergencies come up. But it’s creating the emergency.  It’s no good saying to the… independent inquiry, well I hadn’t turned up but I thought it would be alright. If there’s no evidence of them relapsing and they’re not taking treatment then again the likelihood is they’ll still be recalled because there’s a requirement on us.
Recall cycles and Catch-22’s

13. Ways of being: subject (re)formation?
Returning to proof in practice
Externalised or internalised change?
Belief that CTO should be an agent of change: a utopian endeavour?

14. Ways of being: subject (re)formation?
Discharge:
We’ve had reservations where I said , ‘well we're constantly recalling them. Are we doing this the right way, is it the right thing?’ It’s not really doing what we planned, but its doing something that is better than the alternative., so we haven’t discharged them
When we’ve taken them off the CTO, it’s because all the evidence is they they’re complying, they’re moving forward. I hate the word insight, I don’t actually think there's such a thing, but they’re displaying something that people would call insight, so they shouldn’t be on the CTO

15. Summary
How practitioners construct the problem CTOs are meant to solve
Rationalities:
Probability, proof and uncertainty
Ethical frameworks
Technologies
Engagement with recall as a central mechanism
Perception of CTOs as a change agent: coming back to the thoughts and actions of practitioners