Benefits of Structures and Boundaries

Each participant communicated the sense of individuality involved in the CTO, both in terms of its application and clients’ responses to it. There were benefits discussed,

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relating to staff and clients and these revolved around the use of boundaries and structure.

“They seem to find something reassuring and containing about a structure, I wonder sometimes with some people if it’s also about... the acceptance of their mental health problems in some way. It’s almost kind of like “I know I’ve got a problem but I don’t personally want to recognise it, but I know I don’t like taking medication but I know that it keeps me well. If it’s imposed by somebody else, I could almost stand back from it and accept the problems I have in my own way and tolerate and accept the medication, but I don’t feel like I have to own that decision to take it.” (Diane, lines 29-41)

Heather talked about the way clients who had a personality disorder may “struggle with boundaries” (lines 12-13). She returned to this point later in the interview: “You know, if they’re difficult to work with and they can’t have their own boundaries, sometimes to create some boundaries for them actually makes them feel quite safe” (lines 786-789).

Jane described the increase in clients with personality issues being seen by the team since the changes in the Mental Health Act (lines 617-618) and described the CTO as being “in some ways [it] can be another boundary that’s very very clear and very easy to work against, but again, with people with personality disorders, they’re really going to push against it” (lines 626-630).

The impact of personality issues was discussed as one possible variable to accepting compulsive powers; this was evaluated by David:

“I suppose it does sort of go against the grain really about how you approach someone with personality disorder because I think it’s in virtually all cases, it’s key that the person takes responsibility for their own actions and to actually do

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something where you’re compelling them to, you know, do particular things, then that could be potentially harmful because they’re not able to then take responsibility. On the other hand, when someone is so chaotic and so, things are so difficult and there’s psychosis involved as well, then sometimes you need to put in boundaries which they could then find helpful” (David, lines 9-10).

Cohort effects were also mentioned by a number of participants in relation to the idea that some clients tend not to question the advice of a medic, and so for those people compliance may occur more easily.

“Some people can be quite old school and ‘the medic is right’... we’ve got some people that say “I’ve been told to by the doctor therefore I must”- and were they on discharge before without the CTO they probably would take the medication for a few months, ‘because they’d been told to by the doctor’ then they would start dropping it down. We’ll go back and say ‘look- Dr X says you need to take these, he’s written it out on the CTO and you need to continue don’t you?” and he’ll be like “yeah I do, don’t I” and carry on.” (Jane, lines 672-684)

Other participants suggested that past experience of other services and experiences of previous relationships may influence how a client responds to the control of a CTO. Diane talked about this in relation to attachment style:

“I think it’s about your relationship between the client and the worker and that’s hugely biased by, kind of early experiences and attachment styles and possibly kind of some, kind of elements of recovery and insight styles” (Jane, lines 908-913). For staff boundaries also appeared to be important. Information was said to be logged more clearly as a result of the CTO, and there were policies which could be followed in a structured way to ‘protect staff’ in their decision making. James described how CTO structure could make the work of staff easier:

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“I think for some people, there’s, it kind of works post discharge because it has, it has a structure similar to the kind of, some of the structure of the hospital that can give us clinicians a better chance of getting in to see people and making sure the treatment’s going as it should do” (James, lines 385-390). He later described how the recall process had “definitely less stress and anxiety for staff” because of its “explicit and clear” nature (James, lines 721-725).

Whilst benefits to staff were acknowledged, the idea that staff were also coerced by the CTO arose.

“I think, they seemed really heavy handed and I think part of the concern is that they, they do, once they’re there as legislation, once they’re there as an option, it can feel like it forces your hand a bit, because in the past where you’ve been able to take decisions because that’s not even there as an option you’ve got to be able to satisfy that it, it shouldn’t be used, and it’s kind of almost looking at it the other way round, rather than looking at ‘what are the options we’ve got?’” (James, lines 267- 278).

“But I think it’s quite clearly about, you know, “what would happen if something happened? How would that be reviewed? What would the questions be? And I think sometimes we feel the questions would be “why haven’t you know, if that person’s risk is linked to their mental health and their mental health is linked to their acceptance of their medication... why haven’t you done something about it?” (Diane, lines 144-152)

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