How clinicians make decisions about CTOs in ACT: a qualitative study

Area of Science:

• Psychiatry
• Mental Health Services Research
• Clinical Decision-Making

Background:

• Assertive Community Treatment (ACT) teams in Norway piloted from 2009-2011.
• 38% of patients in the first year were under Community Treatment Orders (CTOs).
• High CTO use in Western countries lacks robust evidence of effectiveness.

Purpose of the Study:

• Explore clinician reasoning and decision-making regarding CTOs in an ACT setting.
• Investigate factors influencing continued use, hospital recall, and discontinuation of CTOs.

Main Methods:

• Semi-structured interviews with eight responsible clinicians.
• Analysis of patient case files and observations of treatment planning meetings.
• Modified grounded theory approach for data analysis.

Main Results:

• Multidisciplinary team approach and shared responsibility facilitated nuanced assessments and flexible CTO solutions.
• Treatment need was the primary justification for CTOs.
• Significant variation existed in clinicians' legal interpretation and application of the dangerousness criterion.

Conclusions:

• CTO continuation decisions involved multiple interacting risk factors, often for patients referred from secure facilities.
• While treatment need was the main justification, CTOs were also used to contain dangerousness and prevent harm.
• Clinician reasoning for CTOs is complex, influenced by team dynamics and legal interpretations.