Stuen Hanne Kilen, Landheim Anne, Rugkåsa Jorun, Wynn Rolf
1Norwegian National Advisory Unit on Concurrent Substance Abuse and Mental Health Disorders, Innlandet Hospital Trust, Brummundal, Norway.
2Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway.
Int J Ment Health Syst. 2018 Sep 22;12:51. doi: 10.1186/s13033-018-0230-2. eCollection 2018.
The first 12 Norwegian assertive community treatment (ACT) teams were piloted from 2009 to 2011. Of the 338 patients included during the teams' first year of operation, 38% were subject to community treatment orders (CTOs). In Norway as in many other Western countries, the use of CTOs is relatively high despite lack of robust evidence for their effectiveness. The purpose of the present study was to explore how responsible clinicians reason and make decisions about the continued use of CTOs, recall to hospital and the discontinuation of CTOs within an ACT setting.
Semi-structured interviews with eight responsible clinicians combined with patient case files and observations of treatment planning meetings. The data were analysed using a modified grounded theory approach.
The participants emphasized that being part of a multidisciplinary team with shared caseload responsibility that provides intensive services over long periods of time allowed for more nuanced assessments and more flexible treatment solutions on CTOs. The treatment criterion was typically used to justify the need for CTO. There was substantial variation in the responsible clinicians' legal interpretation of dangerousness, and some clinicians applied the dangerousness criterion more than others.
According to the clinicians, many patients subject to CTOs were referred from hospitals and high security facilities, and decisions regarding the continuation of CTOs typically involved multiple and interacting risk factors. While patients' need for treatment was most often applied to justify the need for CTOs, in some cases the use of CTOs was described as a tool to contain dangerousness and prevent harm.
挪威首批12个积极社区治疗（ACT）团队于2009年至2011年进行了试点。在这些团队运营的第一年纳入的338名患者中，38%的患者接受了社区治疗令（CTO）。与许多其他西方国家一样，挪威CTO的使用相对较高，尽管缺乏有力证据证明其有效性。本研究的目的是探讨在ACT环境中，负责的临床医生如何推理并就CTO的持续使用、召回医院以及CTO的终止做出决策。
对8名负责的临床医生进行半结构化访谈，并结合患者病例档案以及对治疗计划会议的观察。使用改良的扎根理论方法对数据进行分析。
参与者强调，作为一个分担病例责任的多学科团队的一员，长时间提供强化服务能够对CTO进行更细致入微的评估，并提供更灵活的治疗方案。治疗标准通常被用来证明CTO的必要性。负责的临床医生对危险性进行的法律解释存在很大差异，一些临床医生比其他医生更多地应用危险性标准。
临床医生表示，许多接受CTO的患者是从医院和高度戒备设施转诊而来的，关于CTO延续的决策通常涉及多个相互作用的风险因素。虽然患者的治疗需求最常被用来证明CTO的必要性，但在某些情况下，CTO的使用被描述为一种控制危险性和预防伤害的工具。
