Paper Review: An Australian perspective on Community Treatment Orders

A review of  ‘Using Social Work Theory and Values to Investigate the Implementation of Community Treatment Orders, Australian Social Work, 66:1, 72-85, DOI: 10.1080/0312407X.2011.651727‘ Lisa Brophy and Fiona McDermott 2013

Introduction

By looking at this paper, I am reviewing some of the content to make it more accessible and combining a summary of what I find to be the key points, with my own understanding and interpretation. I am no expert and I am no academic. I am interested and with that proviso, I will continue.

I came across this paper as I was looking at the way that ethics and values reflect on social work decision-making and while my focus is more on decisions made about best interests and mental capacity, there is a clear line in comparison with studies completed in other areas, particularly the use of compulsion in social work and how we, as practitioners respond to it. I found the explanation of the methodology and the theoretical approach clear and helpful in my own thinking on two levels.

I’m interested in research design and comparing the robustness of the evidence gathered and different approaches taken, and secondly, when looking at how I integrate theory, both social work theory and broader social research theories into both my own practice and my research work, the most useful learning is reading papers where it has been done and other doctorate level theses available through EThOS (British Library free repositary of over 500,000 theses – and worth checking).

Background to the study

This is a paper written for Australian Social Work. It is looking at the use of community treatment orders specifically in the state of Victoria, Australia. It seems that CTOs have a longer history than their use in the UK and at the time of writing, the authors claim that there are around 5000 current CTOs. The paper looks at how compulsion links with social work values and practice particularly around theoretical perspectives. It is useful as it links the use of theory to practice in a setting where compulsion is used and reflects the tensions in the social worker’s role. It was definitely something that spoke to me, not just in terms of the research, which is useful for my own work in this area, but more interestingly, perhaps, for me when I go to work on Monday to consider with people I work with who do not choose to work with me and, indeed, are compelled to do so.

Methodology

Looking at the methodology, it is a mixed methods study. This means that there are both qualitative and quantitative aspects to the study. I tend to enjoy reading the methodology parts of papers. To me, it is what distinguishes research from opinion and most of the papers I read are pure qualitative studies, not by design, but because I am trying to learn more about qualitative research so approach this by reading more papers where these approaches have been taken.

This project started with a broad-ranging cluster analysis of 164 people who were on the community treatment orders used in Victoria, Australia. Cluster analysis is a specific quantitative methodological approach to using statistics to establish common ‘clusters’ of data, in this case, types of people who would be subject to community treatment orders. The specific methodology may be related to creating clustering algorithms and assigning different features so that the types or clusters emerge from the data. With some biographical and socioeconomic factors being allowed to emerge from the data, this allowed researchers to use the emerging key ‘clusters’ to identify a smaller group of people, reflecting some of the key ‘clusters’ identified, to be interviewed in more detail using semi-structured interviews. This was followed up with additional interviews of family or carers, case managers (presumably, although this is not explicit, who would be for the most part, social workers) and doctors involved.

There were then follow up interviews conducted after 6-12 months with people involved around the use of CTOs including those subject to them, professionals involved in working with them and family or carers. Additional interviews were undertaken with those involved in tribunal (or equivalent) hearings, senior managers and those involved in policy.

This is a brief summary so does not include all the complexities but it does reflect the thought process behind the choices of methodologies involved and reflects back how social work theories have led to each of these steps, including the involvement of people who are subject to these orders being at the heart of the process of researching about them.

Outcomes

The paper identified ‘significant clusters’ relating to being ‘connected’, ‘young males’, ‘chaotic’. The research team used these differing clusters to recruit for the interview stages of the research study.

The researchers, linking back to previous studies which had looked at the use of CTOs, identified five principles which could improve practice based on the interviews. While, they identified that these principles reflected some of the guidance currently in use in practice, the difference that the research was able to tap into was to highlight diversity within the groups of people subject to CTOs. I think these principles are valuable to reflect on and while this research is about a specific intervention in Victoria, Australia. It isn’t an enormous leap to see how they may reflect some potential to improve practice in areas where compulsion is used by and with social workers.

The following are identified on p78 of the paper:

• Use and develop direct practice skills
• Take a human rights perspective
• Focus on goals and desired outcomes
• Aim for quality of service delivery
• Enhance and enable the role of key stakeholders

Theoretical perspective

The paper establishes it’s focus on the framework of critical theory, which allows a discussion about the role of power in social work and particularly in areas of social work where compulsion is used. This is also carried through to understanding the role of power within research. The authors have acknowledged this and reference their awareness of the principles of emancipatory research by ensuring that those who are subject to CTOs have been central to the research design. One of the principles the authors reflect, is that of empowerment and by giving people a voice through research carried out about them, it is enabling change to be made.

Additional reflections and gaps

I think of this research both in connection to my own studies and my own work. The first thing that jumped to my mind is that the need to have an international perspective when it is relevant but to be aware of the differences as well. This study is very much about one system of compulsion within mental health with adults. I don’t know the age range or diagnosis types of those who were interviewed and didn’t need to for the scope of the study. One thing that struck me, which may, very well reflect differently to a social worker based in London, is the analysis of race. This is not as a criticism of this study but one which might have different focus in different settings. Critical theory looks at the differing, sometimes competing and often co-existing ‘labels’ determined by studies and organisations to typify people who receive different types of input and I am particularly interested in where internal biases from professionals might impact outcomes.

Learning for practice

The key learning that I have taken from this study is an understanding of how we work within paternalistic frameworks of compulsion as social workers and I found some of the discussion around theoretical approaches and particularly the use of critical theory, to be most useful in both identifying this tension and acknowledging some of the hypocrisy between values which say they promote empowerment but work within frameworks which can be the most oppressive. The authors acknowledge this tension in trying to pull out ‘best practice’ guidance using the input of those subject to these interventions, while also acknowledging the purpose of the study was not to challenge the existence of CTOs and frameworks of compulsion, but that doesn’t mean we can’t and shouldn’t, indeed, we should, continue to constantly challenge the way we work with compulsion in mental health care and look at other options.

Regarding the specific good practice identified, as listed above, some are about organisational needs, such as ensuring that social workers have specific training and space to reflect on the use of compulsion in practice, rather than just being expected to ‘pick it up on the job’. As social workers in the UK, if we are trained as AMHPs, there will be a focus on this as part of the training, but that doesn’t mean there isn’t room for more learning as this training is not necessary to work with people who are compelled to work with social workers. And it is not enough in itself to give people training at key points and then leave them too it. This is the way one can become overly familiar with compulsion as a tool and desensitised to it. We need to guard against this which can be done through supervision and reflection.

An interesting aspect of the human rights perspective, was identified as well – which recommended ensuring people who are under compulsion are aware of their rights and why the limitations to liberty have been imposed. The study refers to procedural fairness and thoughtful decision-making being a key factor. This phrase is something we can always work harder on.

Involving other stakeholders, and in my role, I am thinking particularly of family members, friends, carers, is something that I can always do better. It is true that sometimes the conversations are not easy and there are issues of confidentiality around information sharing but support can be offered and must be in order to work best for people. There are other stakeholders in the form of commissioners, regulators etc but for my own work ‘on the ground’ the involvement of those people around the person I am working with is the key learning.

Finally, the importance of being able to deliver a quality service when people are compelled to have treatment is something that I might not be able to change individually, but it is key factor and it certainly reflected my concerns as an AMHP when I was practising as one (I am no longer warranted). If we compel someone to a hospital admission but the hospital care is poor, we can be complicit in harm rather than help. It is difficult to justify compelling someone to treatment when the treatment is of a poor quality. This is something we must always challenge and complacency can be easy.

Conclusion

I am no academic, but sometimes finding papers which can speak to me in practice can provide a real motivation to the value of research and the importance of being aware of what research is and has happened around the world that can lead to better outcomes tomorrow. What’s more, we can tell our managers that we can link our need for additional training (for example) to evidence.

I’m not pretending my analytical skills are on a par with any academic, they aren’t. But by trying to portray what I can take from this paper, I am hoping that it will encourage others to read more where the papers are accessible, at least, and learn about the profession and how it has and will continue to grow.

I’m absolutely sure as I’ve read through this paper, there are key points I’ve missed, misunderstandings and poor analysis. I am not setting myself up as a font of knowledge but rather, in my ramblings, hoping to take an opportunity for others to try to learn with me but the original research is always the best place to start, rather than any commentary I might be able to ramble through.