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Oct. 24, 2018

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Social Work: Community Treatment Orders and Assertive Community Treatment

A collaboration with the Homewood Health Centre’s Research Institute allowed us to conduct the first Canadian study to examine the perspectives of clients who are or have been on a Community Treatment Order (CTO) and, at the same time, were being served by an Assertive Community Treatment (ACT) Team.

The study, “Exploratory study of the use of community treatment orders with clients of an Ontario ACT team," found that all the participants who were or had been on CTOs and simultaneously receiving services from the ACT team, felt very negative about having been placed on a CTO initially. Although many continued to feel that the CTO had not been necessary, some acknowledged that their lives had improved in the months following being placed on the CTO. Some participants said that they felt shame and a loss of dignity when they were placed on the CTO. Others said that the CTO increased the stigma associated with a diagnosis of mental illness.

Many of the participants had positive things to say about the clinicians who were members of the ACT team, and it appeared that their attitude towards the CTO was influenced by the degree of trust they felt for members of the team. Some recognized that these professionals were trying to help them, and a few considered them to be “like friends.”

The clinicians we interviewed stressed that placing a client on a CTO was always a last resort. They tended to see it as a “protective measure” and “a safety net.” The decision is considered carefully by the team members, and the family is involved whenever possible. They also talked about making every effort to avoid having to enforce the CTO, which can involve asking the police to bring the client to see a psychiatrist. They said their experience has led them to believe that employing a CTO for certain clients prevents rehospitalization or at least reduces the number of rehospitalizations for these clients. They also stressed that the outcome of the CTO is very much affected by the quality of the relationship they are able to develop with the client. It was evident that they invest much effort in developing a positive therapeutic rapport with their clients.

Two students were involved in this study. Cara Grosset (current doctoral candidate) served as research associate and interviewer of the study’s participants. She was participated in the analysis of the data. Master of Social Work graduate (2015) Stephanie Engel assisted with the review of relevant literature.

Through this study we were intrigued to learn that this ACT team, overall, viewed the appropriate use of CTOs with difficult-to-treat clients as having positive outcomes. This was somewhat unexpected because the literature reveals considerable debate regarding the effectiveness of what is considered to be a coercive intervention.

The next step for this project is to follow up on the interesting issues identified through this work. One of the issues identified in this study was clients’ concerns about the stigma associated with being diagnosed with a mental illness. Magnus is currently involved in several studies exploring the difficulties faced by individuals diagnosed with serious mental illness and the stigma associated with it.

We hope that the findings from this exploratory study stimulate further research regarding the effectiveness of the combination of CTOs and ACT. Questions that need to be addressed include:

  • Do other ACT teams have similar experiences with this combination of outpatient services?
  • Does the support of a well-functioning and caring ACT team consistently mitigate clients’ negative feelings about the coercive aspects of community treatment orders?

We hope our study will influence mental health professionals and policy makers responsible for the treatment of persons diagnosed with serious mental illness. In particular, we hope this study will contribute to the provision of adequate funding for Assertive Community Treatment teams so that all persons who are placed on a CTO can access the services and support that an ACT team can provide. Our study suggests that having the support of a well-functioning ACT team may increase the helpfulness of a Community Treatment Orders for at least some individuals with serious and persistent mental illness.

We wish to acknowledge the contributions of the ACT Team psychiatrist Dr. Linda McColl and Irene Dullart, MSW. We also thank the clients and the other staff members of the ACT Team for their participation.

We would also like to acknowledge funding provided by Mitacs and the Homewood Health Research Institute for this study.

About the Researchers

Carol Stalker is a Professor Emeritus of the Lyle S. Hallman Faculty of Social Work. She has been funded by the Canadian Institutes for Health Research and practiced front-line social work for over 20 years before becoming a professor. For Carol, who worked for many years in mental health settings, this research reflects her long-standing interest in effective interventions with individuals living with mental illness. 

Magnus Mfoafo- M’Carthy is an associate professor in the Lyle S. Hallman Faculty of Social Work. He has more than 15 years of social work practice experience in New York, British Columbia and Ontario. In 2017 he received a grant to contribute knowledge about West African disability stigma through the competitive Social Sciences and Humanities Research Council (SSHRC) Insight Grant program. For Magnus, whose work experience with clients placed on a CTO spanned a period of 10 years, this research was a continuation of his interest in psychiatric consumers’ experiences of these orders. His doctoral research involved interviewing psychiatric consumers in the Toronto area regarding their thoughts and feelings about being placed on a CTO.

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