Stuen Hanne Kilen, Landheim Anne, Rugkåsa Jorun, Wynn Rolf
Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway.
Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway.
BMC Health Serv Res. 2018 Apr 18;18(1):290. doi: 10.1186/s12913-018-3097-7.
Patients with severe mental illness may be subjected to Community Treatment Orders (CTOs) in order to secure that the patients adhere to treatment. Few studies have investigated the use of CTOs within an Assertive Community Treatment (ACT) setting, and little is known about how the tension between the patients' autonomy and the clinicians' responsibility to act in the patients' best interest are resolved in practice. The aim of this study was to explore the service providers' experiences with CTOs within an ACT setting.
The study was based on reviews of case files of 15 patients, eight individual qualitative in depth interviews and four focus group interviews with service providers involved in ACT and decisions related to CTOs. A modified grounded theory approach was used to analyze the data.
The main theme 'responsibility with conflicting priorities' emerged from data analysis (case file reviews, individual interviews and focus group interviews). The balance between coercive approaches and the emphasis on promoting patient autonomy was seen as problematic. The participants saw few alternatives to CTOs as long-term measures to secure ongoing treatment for some of the patients. However, participants perceived the ACT model's comprehensive scope as an opportunity to build rapport with patients and thereby better meet their needs. The team approach, the ACT providers' commitment to establish supportive relationships and the frequent meetings with patients in their home environment were highlighted. The ACT approach gave them insight into patients' everyday lives and, in some cases a greater sense of security when considering whether to take patients off CTOs.
Many of the participants viewed CTOs as helpful in securing long-term treatment for patients. CTO decision-making was described as challenging and complex and presented the providers with many dilemmas. The ACT approach was considered as helpful in that it afforded comprehensive, patient-centered support and opportunities to build rapport.
患有严重精神疾病的患者可能会被下达社区治疗令（CTO），以确保患者坚持治疗。很少有研究调查在积极社区治疗（ACT）环境中CTO的使用情况，对于在实践中如何解决患者自主权与临床医生为患者的最大利益采取行动的责任之间的紧张关系，人们知之甚少。本研究的目的是探讨服务提供者在ACT环境中使用CTO的经验。
该研究基于对15名患者病例档案的审查、对8名服务提供者进行的个人定性深度访谈以及对参与ACT和与CTO相关决策的服务提供者进行的4次焦点小组访谈。采用改良的扎根理论方法对数据进行分析。
数据分析（病例档案审查、个人访谈和焦点小组访谈）得出了主要主题“优先事项相互冲突时的责任”。强制手段与强调促进患者自主权之间的平衡被视为存在问题。参与者认为，对于确保一些患者持续接受治疗的长期措施而言，CTO几乎没有其他选择。然而，参与者认为ACT模式的广泛范围是与患者建立融洽关系从而更好地满足他们需求的一个机会。团队协作方式、ACT服务提供者致力于建立支持性的关系以及在患者家中环境频繁会面被重点提及。ACT方式使他们深入了解患者的日常生活，并且在某些情况下，在考虑是否让患者脱离CTO时更有安全感。
许多参与者认为CTO有助于确保患者接受长期治疗。CTO决策被描述为具有挑战性且复杂，给服务提供者带来了许多困境。ACT方式被认为是有帮助的，因为它提供了全面的、以患者为中心的支持以及建立融洽关系的机会。
