Participants shared their perspective that medication was often helpful for the clients they worked with. Alongside this however, was the sense that medication alone was
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insufficient. David reflected upon the balance required between ensuring engagement and enabling recovery:
“It’s against the ethos of Assertive Outreach in many ways, because you know, our focus of engagement with people on, not necessarily inflicting a medical model on them, on recovery model and someone’s abilities to make choices about the way in which they sort of, the journey of recovery they take... But actually, Assertive Outreach has always involved, you know, detaining people against their will and at times when they’re really unwell. So in some respect you could argue that that’s nothing new” (David, lines 76-89).
This engendered mixed feelings about the place of the CTO alongside the provision of holistic care. Whilst some criticised the CTO for being ‘overly medical’ in the way that it focused only on medication compliance, there was simultaneous consensus that the involvement of psychosocial treatments as part of compulsory criteria was inappropriate.
“I haven’t yet come across a situation where it’s going to be beneficial to, you know actually force someone to go to OT [occupational therapy] sessions, or a therapeutic group or whatever it is, because I think you have to let someone make that decision. So that’s one thing- I think even if you did put that in place you’d then have to say “ok, are we prepared to recall someone to hospital because they didn’t go to their therapeutic group?” (David, lines 737-751).
Participants shared their experiences of criteria in a way which suggested the use of stipulations beyond the standard issues of where a client must live and what type of medication a client should take, remained unresolved. There was a consensus that although value could be seen in implementing these models, they may not fit with a compulsory way of working.
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“We’ve made definite decisions not to include- although we thought it might be a good idea- we’ve not included conditions that you engage with a drugs worker or anything like that, or abstinence... But yeah, I think we’ve tried to be a bit more sensible with those things. Because I think if you’re forcing someone into a therapeutic, you know, trying to force someone to engage in BFT [Behavioural Family Therapy] seems a bit counterintuitive, you need to have a bit of volition to do it themselves in order to change.” (James, lines 811-822).
Participants had clearly stated that being on a CTO did not restrict a client’s access to any of the other therapeutic treatments offered by the team. Despite this, it was suggested that the emphasis of the CTO to medication may divert the focus back to ‘the illness’, and essentially be insufficient.
“I think just putting someone on a CTO with medication is erm a little shortsighted, I think if the person is going on a CTO for their improvement, or for their safety, then I think something else should be offered as well, like a course maybe they’d be interested in, computer, home studies... something to really help that person recover.” (Katherine, lines 629- 636)
Several participants suggested that the CTO had introduced a new dynamic to the therapeutic relationship and Chloe described in more detail the tension that this could place upon her usual way of working.
“I think it’s a difficult one, because you do, you know, I’m an O.T. but I am a care co-ordinator and we work as a team, so it’s kind of, I do feel sometimes I can’t be too precious about what I will and won’t be involved in. And I do see the role for medication and I think in some cases it’s very difficult to get therapeutic gains without medication, and often it is a stepping stone for OT and further work for the
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person to be treated properly with medication in the first place.” (Chloe, lines 891- 903)
Finally, whilst all participants overtly acknowledged the value of working holistically, there was perhaps an underlying feeling from some that medication formed ‘the treatment’ with other, arguably less realistic, therapeutic models being added on. Here Heather responded to a question about where she would prioritise extra resources.
“There’s... all kinds of issues that have gone on in childhood that we never, you know, we never really speak about, we never really ask to be fair... Probably because the resources isn’t there, you know, to mop up the spillage, do you know what I mean type thing? If someone did spill their guts out, you know.” (Heather, lines 706-721)
“I mean it depends on the individual and risk stuff, doesn’t it? Because it’s all right this psycho-babble, but if someone’s risky, then you’ve gotta protect public and themselves.” (Heather, lines 273-277)