Community treatment orders and care planning: a critical ethnography

Author: Suzanne Dawson

Dawson, Suzanne, 2021 Community treatment orders and care planning: a critical ethnography, Flinders University, College of Nursing and Health Sciences

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Community treatment orders (CTOs) are widely contested due to efficacy, ethical, relational and human rights concerns. In Australia, CTO rates are comparatively high, with significant variation across regions highlighting the impact of broader issues on usage. Regardless of the debate, individuals, their families and clinicians are frequently required to engage within this context. CTO legislation states that treatment and care should be recovery-focused, although care is often experienced as coercive. In community mental health services, care planning occurs between individuals with the aim of conjointly developing plans to guide recovery-based mental health care; the process, however, is situated within broader systems and structures. This study has sought to understand the interpersonal and broader systems issues that impact on the care planning process. Carspecken’s (1996) critical ethnography is the methodology that has underpinned this examination. Ethnographic methods of observation and interview have provided a detailed account of the multiple perspectives of individuals on CTOs, their families and clinicians over an 18-month period in two community mental health teams in Adelaide. This included following 8 individuals’ care journeys with services over 12 months.

Findings reveal how care practices, and service and cultural structures, are perpetuating stigma, discrimination and harm for individuals on CTOs in a community mental health setting. Despite mental health legislation and policy assigning priority to recovery-informed care values, mental health services’ emphasis on risk and risk management made it challenging for mental health clinicians in this study to work with individuals in ways that aligned with recovery values. Although some clinicians were working within a recovery-informed approach, coercive practices were occurring at the site which were facilitated at a systems level. Structurally, the biomedical model remained the dominant framework informing care contacts (at the micro level), service structures (at the meso level) and service options, policy and allocation of funds (at the macro level). Subsequently, care planning was not always being used as intended. Clinicians were found to foreground service needs over the needs of the person on the CTO in the care planning process, although many clinicians were frustrated with this position. Costs of this service focus on risk included a devaluing of the therapeutic relationship, silencing of consumers’ and carers’ voices in the care planning process, and reinforcing and compounding a service culture of risk and discrimination which disempowered consumers.

Social theories of risk and trust are used to illuminate the findings and provide an exploration of possible means for cultural change. This requires a de-emphasis of the paradigm of disease and an emphasis of the paradigm of discrimination through implementation of strategies, approaches and interventions that are supportive of individuals’ recovering citizenship. While there is scope for change at the clinical interface in care planning discussions, change is required at the systems level to support recovery-focused practice.

Keywords: Community treatment orders, care planning, risk, recovery, ethnography

Subject: Primary Health Care thesis

Thesis type: Doctor of Philosophy
Completed: 2021
School: College of Nursing and Health Sciences
Supervisor: Professor Eimear Muir Cochrane