In our analysis, we identified three main categories that reflected the overall finding ‘feeling more confident and secure through shared responsibility’: (1) CTO as a tool for achieving patient stability and safety, (2) CTO as a tool for containing dangerousness and preventing harm, and (3) CTO and ACT allowing for more nuanced judgments and reduced coercion. We discuss each in turn.
CTO as a tool for achieving patient stability and safety
The participants described CTOs as a useful tool to ensure that patients remained in treatment. For patients with delusions or who for other reasons were not capable of making treatment decisions, the opportunity for prolonged use of a legal mechanism was seen as helpful.
“I will continue the CTO as long as I possibly can. So, a certain time under a CTO, then one can try [voluntary treatment]. As long as I consider her to be so delusional, I won’t remove the CTO. That will be up to the Supervisory Commission to decide.”
Many patients had an extensive history of treatment discontinuation and frequent readmissions. The RCs often wanted patients to remain on medication for 1–2 years to become stabilized. Few guidelines for decision-making existed, so participants relied on their clinical judgment of patients’ present and past situation to assess the best way to proceed.
“I usually look at the past year and the so-called deterioration criterion. How likely is it that they’ll get so much worse that they can’t cope if we remove the CTO? We consider whether they understand that they need medication. So it’s a matter of going through what’s happened this past year, if things have been stable.”
Although the team could not compel patients to take medication unless a valid medication order was in place, the RCs described how they tried to persuade, negotiate or make agreements. For instance, one RC described how she had spent several years on trials and errors with medications with a patient including deferring the medication administration to the hospital for a period after several violent incidents in the patient’s flat. Eventually, they succeeded in stabilizing the patient, and this was partly attributed to finding a more effective and tolerable medication regimen, the team’s long-term commitment, and a clear division of responsibilities.
“From being in hospital 90% of the year, she’s had two short admissions during the last 2 years. There’s been great collaboration around her [residential staff, hospital clinicians and ACT], where she’s been able to try things out. But it takes time to succeed. She may not have any more insight into her illness, but at least she’s more motivated for treatment.”
Patients’ insight into their illness was presented as interdependent with the quality of the patient-clinician relationship, which in turn informed clinical judgments.
“It seems unnecessary to continue the CTO in her [another patient’s] case from my point of view. With her I manage to collaborate about medication, and use of CTOs is then by definition not justified.”
The decision to terminate the CTO was also founded on improved functioning and that the patient gradually had regained capacity to make informed treatment decisions.
“She finds … that she has her own identity, a self, and she seems more capable of sorting out what she perceives as psychotic symptoms. I think she’s managed very well.”
The CTO decision-making process must balance clinical needs and control of risk. The RCs emphasized that this made decision making complex, particularly when there was clinical uncertainty.
“I’m often afraid that something will happen because I’ve reduced the medication. (X) is one example. He’s previously been sentenced for violence, he takes drugs and threatens all kinds of stuff. In his case, I’ve agreed to gradually reduce his medications. There’s no sign of active psychosis in his case file for the last years. He has strong side effects, refuses to take his medicine, and the police get involved. He is under a compulsory medication order, and it’s one hell of a mess. So now we’ve started to reduce his Cisordinol dose, and my plan is to continue to reduce his medication until we maybe see signs that he’s getting worse. This (medication withdrawal) doesn’t agree with the expectations of the specialist wards. He’s one example”
CTO as a tool for containing dangerousness and preventing harm
For patients with concurrent substance abuse, fluctuating illness severity and a history of violence, the participants agreed that CTOs combined with ACT could be justified as a long-term safety measure to prevent harm. They described the decision to use a CTO as founded on an overall consideration of the situation and a responsible prediction of future risk, involving deliberate self-harm, aggressive behavior or violence.
“If it’s a matter of patients that have been severely ill, and committed serious violence and previously stopped taking their medicine as soon as the CTO was terminated, and they carry on taking [illicit] drugs, then I might keep the CTO for years if voluntary treatment doesn’t seem feasible.”
There was substantial variation in how the RCs discussed the legal dangerousness criterion. In some cases the RCs described repeated patterns of neglect and risk to self or others. The participants’ accounts showed substantial overlap between their interpretation of the treatment criterion and the dangerousness criterion. While some RCs explained that they mainly used the dangerousness criterion when patients had to be readmitted to hospital, a few RCs used the dangerousness criterion to justify a CTO more than others. However, as the following example shows, most agreed that it should only be used when necessary.
“I think it’s pretty ok to have him under coercion, because coercion protects society, but we see that it’s really difficult to build a therapeutic relationship with him. He’s actually a good example of the difficult considerations involved. Without the CTO, he’d just go to pieces. It would be quite reckless not to use a CTO with him.”
However, according to some RCs, it was unclear where the legal threshold for obvious and serious danger was.
“The dangerousness criterion is difficult to apply. With (X) it was a borderline case. You often solve it by writing something about it in the documents about the decision. He had a weapon and we considered there was a certain risk he might use it. You’re often asked [by the Supervisory Commission] if you want to apply it [the dangerousness criterion], but as I understand it, there’s a high threshold for dangerousness, so you often apply other criteria instead.”
For clinicians with authority to make decisions about compulsion who were not regular members of the treatment team, the lack of knowledge of the individual patient was a significant problem in the prediction of risk.
“As for assessing the risk of violence, it’s incredibly difficult to say how big the risk is that something will happen. That’s very hard to predict. (…) It might be easier if you were in a treatment position, within a team. But I’m sitting in my office, and I’m supposed to make an assessment of a patient I hardly know.”
The participants emphasized the importance of the context in which psychiatric evaluations were made. Even if collaboration with the local treatment facilities and psychiatric hospitals had been established, many RCs considered the functional split between in- and outpatient care as a challenge. Concerns were that the responsible ward clinician might initiate treatment that had previously failed or that the ACT psychiatrist was not involved in CTO discussions prior to discharge. As one ACT psychiatrist said: “We can make suggestions, but since they’re legally responsible [while patients are admitted], they make all the decisions”. A further concern was that many patients with concurrent substance abuse were prematurely discharged from the ward by the responsible inpatient clinician. In one such case with a man in his early twenties, who was often not at home and difficult to reach, the RC strove to balance care and control.
“I made a transfer because I didn’t want to have sole responsibility as long as he has a serious mental illness and makes these choices [substance abuse/crime]. When he was an inpatient, they didn’t find anything, so he was discharged on the same principles. He is not at home, has no phone and we run after him, knock on his window, and then we’re responsible for him. I think that’s difficult. I don’t like being responsible for someone I can’t get hold of at all.”
One team psychiatrist explained that patients with co-occurring substance use disorders were referred to a separate dual diagnosis team, and that she often managed to arrange need-based long-term hospital admissions. Other RCs described a different scenario; lack of beds and inter-agency collaboration for the most severely ill patients was seen as a major challenge.
“Our whole group, or our main group, which has suicidality, violence and substance abuse, has no sub-acute services. We don’t often get acute admissions for more than 2 or 3 days.”
Some RCs referred to a small subgroup of patients who had frequent encounters with the police, who were regularly transported to the acute ward, where the lack of psychiatric beds and inter-agency collaboration and increased professional liability put the clinicians’ professional responsibility on test. As one RC noted: “You’re expected to keep the situation under control, which implies that you maybe ought to have people on CTOs. For me, that’s difficult”.
Use of CTOs and ACT allows for more nuanced judgments and reduced coercion
The RCs underlined that the team approach and the focus of the ACT model on assertive engagement strategies and comprehensive service provision allowed for more nuanced judgments and increased flexibility when working with patients with chaotic lives.
“As a team we have better opportunities to adequately address the patients’ needs and provide close follow-up. I also find that we have more material to help us decide whether or not a patient should be on a CTO, and also that it’s easier to terminate the CTO. (..) Because many of us know the patients, our discussions become more composed, and more nuanced.”
Frequent patient contact and the opportunities for this contact to remain over considerable time were presented as important in reducing coercion. Feeling more confident and secure through shared responsibility was a typical way of summing this up:
“In my view, the most important things to reduce coercion are close contact, continuous follow-up care and to have good relationships”.
“We feel more confident about terminating a CTO in an ACT team.”
However, conflicting attitudes and disagreements in the team, often involving medications, were challenges the team had to manoeuver. One psychiatrist who had been in ACT since the team was established described a steep learning curve. Critical team reflections and debriefings were considered as important learning arenas.
“People joined the team with strong objections to overmedication. I was really frustrated, and also discouraged and afraid. (..). When people have been around and got some experience of the sickest patients, that kind of ideological attitude disappears. When it comes to individual patients, I’d say we do that [discuss medication]. We have lively discussions about medication, we look critically at the dose, and think about when we should start and how long we should wait.”
While daily team meetings provided an overview of each patient’s condition, in teams where the team psychiatrist or psychologist was responsible for CTO follow-up decisions, the team was also more actively involved in CTO discussions. As one RC said:
“We try to have a discussion. We look at the medical history and sum up about the patient, and then we ask everyone if they have an opinion for or against. We assess it together.”
Close follow-up care and frequent observations were used to devise a colour scheme on the teams’ blackboard with details of all the patients; different colors indicated each patient’s current situation, legal status and treatment needs. According to participants, the ACT approach afforded flexibility to provide more intensive treatment to patients in periods of extra need, including illness severity and stressful life events. It also allowed for discussions of priorities, such as whether two instead of one ACT provider should conduct home visits.
“How frequently we go and see patients depends on whether they’re in a green, yellow or red phase [on the blackboard]. If they’re actively psychotic and need close monitoring, they’re red”.
To give an example of the team’s discussion of priorities and tailored interventions, the RC described a newly enrolled patient who several ACT providers had visited regularly in a high-security ward. During the first weeks following discharge, the team had daily conversations with both the patient and the residential staff, and this was gradually reduced to 2 days a week. The team psychiatrist had recently been involved to consider further safety measures, and decided to bring the patient back to the high-security facility after serious threats against residential staff. After a few days the patient had called the team to ask for support and assistance at discharge. In this case the RC considered the team’s close follow-up and monitoring as an alternative to long-term inpatient care.
“We referred him back to the security ward on Friday and picked him up on Monday. Now he could be discharged with close follow-up care by the team. Coercion is still being used, but at a lower level than if we hadn’t been there for him.”