Community Treatment Orders in an Assertive Community Treatment setting: a qualitative study of patients, care providers and responsible clinicians

This study is part of the national research-based evaluation of the 12 first assertive community treatment (ACT) teams in Norway. ACT is a model for multidisciplinary community-based treatment teams that aim to provide a full range of medical, psychosocial and rehabilitation services to people with severe mental illness. Over 30% of the patients treated in the ACT teams were subject to community treatment orders (CTOs) at intake during the teams’ first year of operation. CTOs, which is a legal tool to compel patients with severe mental illness to adhere to outpatient treatment, have been widely used since the Norwegian Mental Health Care Act was implemented in 1961. Previous studies have shown that patients consider CTOs as a more restrictive intervention than clinicians do. Many patients experience CTOs as disempowering, and many patients feel that clinicians’ one-sided focus on medication impedes their recovery processes. In this qualitative study, Stuen and colleagues investigated how patients, ACT providers and responsible clinicians experienced CTOs and CTO decision making within the context of the relatively newly established ACT teams. Stuen and colleagues show that patients have mixed views of CTOs. However, the ACT team’s availability, the flexible combination of interventions, continued care, support and possibility to make choices were described as important improvements compared to traditional office-based mental health services. Several of the participants described a gradual transition toward regarding the CTO as an acceptable solution, provided that they received other services they found beneficial. For clinicians, CTO decisions involve dilemmas and difficult professional judgements, and they highlighted the opportunities the multidisciplinary team provided for discussions and shared responsibility for follow-up care. The ACT model’s structured approach, the daily team meetings and the sharing of ideas about how to handle clinical problems allowed for more flexibility and, they believed, more voluntary options.