The Efficacy of Involuntary Treatment in the Community

SUMMARY

Since the passing of the Mental Health Act (1986), Victoria, Australia, has implemented Community Treatment Orders (CTOs) as an alternative to involuntary inpatient admission for patients who are assessed as unable to be treated less restrictively but in an effort to avoid frequent hospital admissions. It is estimated that currently 3,000 people are annually placed on CTOs in this Australian state. The following article will review existing international and national literature on the subject of forms of involuntary treatment in the community before reporting on the findings of a research project that focused on gaining both consumer and service provider perspectives on the efficacy of CTOs. The research method was largely qualitative, involving three focus groups attended by 30 consumers, as well as 18 individual interviews with service providers. The aim of the project was to offer a voice to both consumers and service providers about their experiences and views of current practice and policy implementation in an area that can have a profound effect on the rights of consumers. Findings suggest that CTOs involve complex decision-making that tests professionals' ability to make judgements about legal and clinical processes. Consumers were generally dissatisfied with many aspects of the use of CTOs and both groups tended to view CTOs as stigmatising and disempowering. There were a variety of views expressed about the process of admission, discharge, and community supports. The article concludes by discussing the findings in the context of existing national and international literature and makes a number of recommendations about law reform, and service provision.     

Coping with Compulsion: Women's Views of Being on a Community Treatment Order

Abstract

An interview-based study of 42 people with serious mental illness was undertaken in New Zealand during the early 2000s. Of the 42 people, 10 were women. The women were either currently on a Community Treatment Order or had been recently discharged from a long period of being on a Community Treatment Order. Analysis of the original interview data revealed how these women experienced both benefits and limitations under conditions of compulsory community treatment. The women's key workers, clinicians, and nominated family members were also interviewed. The findings indicate that women considered the overall advantages of Community Treatment Orders to outweigh the disadvantages. Advantages included: greater access to treatment and respite care in hospital; and an increased sense of safety and reassurance for women and their families. Disadvantages included: some restrictions, such as where women resided; feelings of stigma; and having to comply with treatment with the threat of being returned to hospital if they did not. Overall, Community Treatment Orders made a significant impact on the lives of the 10 women but they also allowed the women to remain out of hospital long enough to rebuild their lives and maintain their close relationships.     

Using Social Work Theory and Values to Investigate the Implementation of Community Treatment Orders

Abstract

This paper establishes the value of a social work investigation of good practice with people on Community Treatment Orders in the context of social work's longstanding interest in the ethical challenges of working with involuntary clients. The emancipatory values of social work were used to guide this research, thereby ensuring the participation of consumers and their families or carers. Critical social work theory provided an important theoretical base. A mixed methods approach was undertaken, including a cluster analysis and case studies. Five principles of good social work practice emerged from the qualitative data: (a) use and develop direct practice skills; (b) take a human rights perspective; (c) focus on goals and desired outcomes; (d) aim for quality of service delivery; and, (e) enhance and enable the role of key stakeholders. These principles are briefly presented along with recommendations for practice and service development.     

Resilience,mental health and Assertive Community Treatment

Clinicians try to promote resilience by building an effective therapeutic relationship with their clients. Assertive Community Treatment (ACT) is an established approach for providing services to individuals with severe mental illness who have not fared well in the regular mental health system. This work underscores the importance of a resilient therapeutic relationship in preventing relapse and assuring adherence to therapeutic outcomes. Persistent psychiatric illness takes a toll on the resilience of the client, while the relationship work takes a toll on the resilience of the clinician. This article explores the concept of relational resilience between clinician and client as a dynamic process of shared success and failure, progress and regression through cycles of crisis, stabilization, relapse, and partial recovery. This is a qualitative study exploring how ACT clinicians promote and sustain resilience and is based on interviews with social workers, nurses, occupational and recreational therapists, coordinators, and psychiatrists.     

You’re Deaf? Breaking through Myths for Effective Therapeutic Practice

ABSTRACT

Most mental health practitioners provide services to hearing clients and might be unprepared when a deaf individual requests services. The purpose of this article is to explore commonly held stereotypes and myths about deaf people and to provide guidance to clinicians who encounter deaf clients in their practices. Myths and stereotypes can affect the way clinicians perceive their clients’ needs. This can lead to miscommunication, misunderstanding, and misinformation, which can harm the therapeutic relationship, thus making effective therapy unattainable. Clinicians should reframe these beliefs and overcome barriers to make way for the therapeutic process to begin.     

Culturally Competent Substance Abuse Treatment with Latinos

Abstract

The Latino population in the United States is a complex and multifaceted population. Latinos are a very dynamic and mobile cultural group. The 2000 United States Census registered Latinos in practically every state. Clinicians involved in assessing and treating Latinos must consider a complex set of environmental and systemic cultural factors that have a direct impact on their problem and potential healing. Treatment must begin by systematically assessing the cultural fit between clinicians and clients.     

Forensic Assertive Community Treatment: Recidivism,hospitalization, and the role of housing and support

While Assertive Community Treatment (ACT) is considered an evidence-based service model, there is limited evidence regarding the effectiveness of an adaptation of the model, Forensic Assertive Community Treatment (FACT), for persons with serious mental illness who also have significant criminal justice system involvement. Using a multimethod approach, this article combines quantitative and qualitative data to review baseline information and nine-month follow-up recidivism, hospitalization, and housing outcomes for individuals enrolled in a FACT program. Findings suggest substance use, housing, and FACT team members’ support played an important role in clients’ prison reentry experiences.     

Accredited Mental Health Social Work in Australia: A Reality Check

Abstract

Accredited mental health social workers (AMHSWs) have a great deal to offer the clients they see in their private practices, many of whom have complex needs. However, they are constrained by the inflated expectations Government has about evidence-based psychological interventions. The restrictions placed on the professional private practice of AMHSWs by Federal Government Medicare funding of a narrow set of psychological interventions ultimately limits the services received by clients. In this article, the findings of a survey of AMHSWs are presented, highlighting the tensions between individualised responses promoted by Medicare payments, and those premised on principles of social justice and social inclusion.     

Integrative Behavioral Health Clinic: A Model for Social Work Practice,Community Engagement,and In Vivo Learning

ABSTRACT

Missouri did not expand Medicaid, leaving about 500,000 Missourians without health insurance. To address community needs and provide additional social work training opportunities, a free integrated behavioral health clinic was established. This article discusses the need, describes the clinic, and presents 1-year evaluation results. Sixty-nine clients received services, and 30 students received intensive training during the first year. Almost half of the clients were diagnosed with depressive disorders, and more than half had comorbid medical conditions. Psychiatric symptoms were lower following treatment. Quality of life increased in physical and psychological domains. Collaborative clinics with social work and medical students are a viable option for experiential learning and providing quality care for uninsured or underinsured people with comorbid medical conditions.     

Addiction Treatment with Deaf and Hard of Hearing People: An Application of the CENAPS Model

ABSTRACT

Alcohol and drug addiction is a significant problem among deaf and hard of hearing people. Looking through a Deaf culture lens, treatment for alcohol and drug addiction is key for providing care for deaf and hard of hearing clients. Using the CENAPS model, an applied cognitive-behavioral therapy program is recommended for addiction treatment. The CENAPS model provides clinicians with tools for stabilizing deaf and hard of hearing clients, supporting their transition to early recovery. Educating the client about the stages of relapse and the stages of recovery, clinicians using this model can better treat and prepare deaf and hard of hearing clients for long-term recovery.     

Data-Mining Client Concerns in Adolescent Mental Health Services

Summary

Via a practice-based research collaboration, clinicians, supervisors, and managers in an urban adolescent mental health program studied previously collected intake information concerning adolescent risk exposures, behaviors, worries, and self-assessed coping. In addition, desire to talk with a mental health counselor about specific risks and worries was systematically analyzed with the aim of generating practice insights into the clinical challenge of engaging urban adolescents in mental health services. Though provided with research consultation, practitioners were full participants in all aspects of the researchprocess. This organizational development process placed strains on the participants and organization, but many benefits were derived from it. One significant benefit was that mining the expressed concerns of clients gave participants a powerful vehicle for reshaping services. The organization came to see its clients as more than mere service recipients, resulting in a recommitment to Youth Development principles and a renewed effort to increase direct client participation in organizational life.     

Peer Discussion and Client Motivation in Men's Domestic Violence Programs: An Australian Qualitative Interview Study

Abstract

Relationships Australia NSW and Baptist Community Services NSW & ACT, through its BCS LifeCare Counselling & Family Services program, collaborated to explore client perceptions of men's domestic violence programs. Recruitment targeted male clients and their female partners, across six locations in New South Wales, Australia. In total, 63 qualitative interviews were gathered from 28 participants, between 2007 and 2009, at program intake, program completion and 6-month follow-up. The focus of this article is on the 20 male interviews conducted with 14 participants at program completion (10) and at 6-month follow-up (10). Recurring themes from these interviews indicate the potentially disruptive effect of client dialogue on group dynamics. While positive group discussion has the potential to enhance client motivation, negative peer discussions, external to group sessions, can diminish group functioning and client motivation for these participants. The paradoxical nature of the group-intervention experience is explored in light of these accounts. Suggestions for men's domestic violence program facilitation and research are outlined.     

Mutual Benefits: Developing Relational Service Approaches Within Centrelink

Abstract

The machinery of income support can have considerable influence in people's lives, creating opportunities for social work but also tensions: access to vulnerable people, but not always on their terms. This paper argues that the challenge to social work is about more than holding on to professional discretion. It considers how social workers can influence service delivery approaches to work more relationally, pursuing a more equal involvement of clients, and recognising the complex interactive context of social and community life. The authors trace the development of such an approach within the Australian Government human services delivery agency Centrelink in Logan, Queensland, and briefly consider a parallel innovation in Newcastle, New South Wales. The authors suggest that grounding a large institutional social service agency in the realities of client and community experiences has mutual benefits, creating a more humanising, cooperative space, and displacing inefficient and sometimes tragic cycles of misunderstanding, confrontation, and disconnection.     

Social Media and Social Work: The Challenges of a New Ethical Space

ABSTRACT

Social media and other online technologies have transformed communication between social workers and service users, with many practitioners engaging and working with clients through social networking sites. While there are numerous ethical issues associated with online practice related to con?dentiality, dual relationships, and boundary crossing, there is lack of clarity about how to deal with such issues. This article uses a case example to develop a nuanced understanding of ethical issues and ethical behaviour in online spaces. We argue that social workers need to link their knowledge of the complex interplay between discourses that underpin daily practice like those related to power, permanency, authorship, audience, embodiment, and professionalism to social media created spaces. In doing this, social workers must retain their commitment to ethical values and critical reflective practice. We conclude with recommendations for education, research, and practice.     

Enhancing Health-Conscious Behaviors Among Clients in Substance Abuse Treatment Programs

The physical health of substance abuse clients significantly deteriorates because of the client’s prolonged abuse of alcohol and other drugs and accompanying behaviors. The purposes of this study are (a) to understand how substance abuse clinicians think about the health needs of their clients, (b) to identify the mechanisms through which clinicians seek to enhance health-conscious behaviors among their clients, and (c) to identify how substance abuse clinicians view their role in enhancing health-conscious behaviors among their clients. A qualitative study was conducted using in-depth, semistructured interviews with substance abuse clinicians (N = 16) from 4 substance abuse treatment centers. Using the theory of planned behavior as a framework for understanding the promotion of health-conscious behaviors in substance abuse treatment, the findings suggest that substance abuse clinicians are capable of enhancing health-conscious behaviors among clients in substance abuse programs.     

The Dartmouth Assertive Community Treatment Scale (DACTS). A generalizability study

Generalizability theory was used to assess the reliability of the Dartmouth Assertive Community Treatment Scale (DACTS), which was developed to assess treatment reliability to assertive community treatment (ACT). Program staff and local evaluators who were participating in a national demonstration program to serve homeless mentally ill clients provided data. The total scale score for the DACTS demonstrated acceptable internal consistency and interrater reliability. Although the stability of the total DACTS score was quite low, many items on the DACTS were quite stable. The generalizability analyses provide additional detail on the effects of site, occasion, and site by occasion interactions on the reliability of the DACTS.     

Social Work Roles in Drug Treatment with Youth

ABSTRACT

Social workers working with youth, who are prescribed psychotropic medication, are routinely faced with tasks pertaining to psychopharmacologic treatment. Little is known, however, about how these workers contribute to the medication treatment process or the impact of their contributions. The purpose of this national survey of social workers practicing with youth was to explore three areas: (1) the frequency of medication-related functions with adolescent clients; (2) the worker, client, and contextual factors associated with greater involvement; and (3) social workers' perceptions of the effects of greater involvement on treatment processes and outcomes. Our findings suggested that in relation to medication treatment, social workers more frequently interfaced with clients than physicians, and that various treatment context and individual factors are associated with greater involvement. Social workers also perceived their involvement as associated with some desirable treatment processes/outcomes, especially the inclusion of adolescents in decision-making.     

Transforming Into Men Who Matter: Increasing Empathy in Domestic Abuse Treatment

ABSTRACT

Men referred to domestic abuse treatment are typically involuntary clients, ranging from being legally mandated to being under significant pressure from others to attend. Such treatment programs have mixed results in achieving change in abusive behaviours. Most programs emphasise taking responsibility for abusive behaviour by examining the precursor thinking beliefs and values, with less attention paid to learning new interpersonal skills that replace antisocial behaviours with prosocial alternatives. Empathy provides a measurable moderator of moving beyond simply acknowledging responsibility for past abuse into learning and applying prosocial relationship enhancement skills with their treatment cohort, families, and significant others. This paper describes a program that builds empathy skills through a series of program and mentalisation tasks that include routine client feedback using the Partners for Change Outcome Management System (PCOMS). Evidence of increased retention and statistically significant changes in empathy using the Social Empathy Index are provided from a previous study examining the same program. The practice and research implications for domestic abuse clients and other involuntary populations are discussed.

IMPLICATIONS

• Involuntary clients continue to have high dropout rates across a range of client populations and are a challenge to engage in the change process. With the application of the client feedback tools and relationship enhancement skills described in this paper professionals can more effectively engage other types of involuntary clients in their change efforts.

• The focus on empathy and relationship enhancement skills can lead to reduced treatment dropout across involuntary client populations referred for substance use, domestic violence, or other offender behaviours.

     

Predicting Emotions in Everyday Social Interactions

Abstract

Social workers appreciate that emotions are an important component of the human experience. Advances in sociology offer improvements in measuring, explaining, and predicting emotions. However, empirical appraisals of theories are limited, based on researcher fabricated events, and have yet to compare theories. The purpose of this study was to test and evaluate the predictive abilities of two theories that have potential to inform social work practice and research: Affect Control Theory (ACT) and Social Interactional Theory (SIT). From subject- provided social interactions, findings demonstrate the ability of both theories to predict ordinary emotion. Whereas SIT predictions were generally more precise, this accuracy would have been lost without the precise emotion measurement capabilities of ACT.     

Managing Risk in Community Care of Older People: Perspectives from the Frontline

Abstract

Since the mid-1980s, Australian governments have focused on expanding community and home-based services for older people. This has led to increased levels of dependency, vulnerability, and complexity to be managed in the community. Consequently, aged care services have had to develop mechanisms for regulating and managing these increased risks, and risk management has become more central to the practices of professional workers in this field. This paper reports on some findings from a large-scale study that explores the way risk management policies have been translated into practice by community-based services in Victoria, Australia. Drawing on interviews with 18 frontline and management professionals employed in community aged care, we found that these workers were wrestling with a diverse and new range of institutional risks beyond those encountered in the actual delivery of frontline care. We found that these workers experienced “risk” in four different contexts, which often created demands for contradictory or conflicting responses. Here we examine these “contexts of risk practice”: professional workers' relationships with their clients, relationships with other service providers, the unregulated nature of the home as a work environment, and community expectations about the management of risk. Despite tensions that frequently arose, workers expressed strong professional commitments to their clients and were motivated to find positive resolutions amid competing interests. We conclude that tensions experienced by workers were embedded in the structural dimensions of institutional relationships and the systematic absence of shared understandings of “acceptable” risks in the community care of older people, rather than in the failure of professional agency.