Community treatment orders and care planning: How is engagement and decision‐making enacted?

Abstract Background In many jurisdictions worldwide, individuals with a mental illness may be forced to receive care and treatment in the community. In Australia, legislation states that such care should be driven by a care plan that is recovery‐focussed. Key components in the care planning process include engagement and decision‐making about a person's support needs and care options, with trust being an essential component of care planning relationships. Objective This study examines how these components were enacted during service care contacts for individuals on community treatment orders. Methods The study was located at two community mental health teams in South Australia. Ethnographic observations of care planning discussions between consumers, their carers and clinicians, and interviews with individuals from these groups, were conducted over 18 months. Carspecken's critical ethnography provided a rigorous means for examining the data to identify underlying cultural themes that were informing day‐to‐day care interactions. Results Care planning was not occurring as it was intended, with service culture and structures impeding the development of trusting relationships. Clinicians striving to work collaboratively with consumers had to navigate a service bias and culture that emphasized a hierarchy of ‘knowing’, with consumers assumed to have less knowledge than clinicians. Conclusions Services and clinicians can challenge prejudicial ethical injustice and counter this through testimonial justice and implementation of tools and approaches that support genuine shared decision‐making. Patient or Public Contribution This study included individuals with lived experience of mental illness, their carers and clinicians as participants and researchers.


| BACKGROUND
Care planning in mental health services guides the delivery of care that aims to meet individuals' personalized needs. 2 Care planning relationships have been found to be central to consumers' experiences of services, 3 with trust considered an essential component of effective therapeutic relationships. 4 Epistemic trust, or an individual's willingness to consider knowledge provided by another as trustworthy and relevant, 5 is essential in the context of care planning relationships, which are promoted as active partnerships within recovery frameworks. 6,7 In the context of mental health care, there are significant challenges that exist for consumers with regard to the development of trust, particularly for consumers who are subject to legally forced treatment. Community treatment orders (CTOs) are legislated in more than 75 jurisdictions worldwide, and require individuals to comply with treatment plans for their mental illness whilst residing in the community. 8,9 This paper reports on an ethnographic study conducted in South Australia that explored care planning with consumers on CTOs, with a focus on engagement and decision-making.
Trust is a communicative action between individuals that is contextspecific and fundamental to effective community living and health care. 4,10,11 Trust can be conceptualized as an alliance based on the belief that the trustee's best interests will be maintained by the trusted. 12 Conversely, mistrust is related to a perceived lack of control and agendas that do not align. 4 The heightened importance and necessity of trust are emphasized in mental health care due to the vulnerability of individuals seeking care from services. 4 Coercive practices in mental health care, however, are common, 13 with forced treatment consistently raised by consumers as a primary barrier to the provision of care that is supportive of positive relationships and recovery. 14,15 Consumers who are already vulnerable experience a further loss of control and power in decisionmaking about their own care. 15 Theories on trust place differing emphases on the roles of personal relationships and social systems in the formation of trust, with Giddens 16,17 emphasizing the importance of interpersonal relationships and Luhmann 18,19 emphasizing the role of systems. 20 Both theories are relevant to care planning for consumers on CTOs. CTOs can create distrust in the health care system and the clinicians and consumers within the system. 21,22 There are significant and valid justifications for consumers to have reduced trust at the interpersonal level (with clinicians) and the systems level (with services).
Such factors include the iatrogenic effects of treatment (medication side effects and coercion), 10 common features that people with a serious mental illness experience (such as paranoia) 4 and trauma experienced before and from care contacts. 19,23,24 In the context of forced treatment, consumers may not believe that clinicians or services are prioritizing their best interests.
Care planning should be collaborative, personalized and recoveryfocused, 6 however, shared decision-making (SDM); which promotes autonomy and collaboration, continues to have limited uptake in mental health services. 25 Decision-making regarding CTO use is based on clinician perceptions of consumers' level of risk, insight and perceived lack of capacity and engagement with services, specifically, medication compliance. [26][27][28] While CTOs are considered a treatment tool for enhancing consumer stability and safety, they are also used to reduce risk and prevent harm. 29,30 Although recent studies have explored decisionmaking regarding reasons for CTO use, explorations of ongoing involvement in decision-making during all care contacts whilst the person is subject to a CTO have been neglected.
Conflicts in decision-making processes exist for all participants in the care planning relationship. Consumers and carers persistently report lack of involvement in decision-making in mental health care. 31 Additionally, workers have also described differing levels of involvement and consequences in decision-making processes, with psychiatrists feeling exposed to blame for enacting forced care. 32 Despite evident conflicts for all, consumers on CTOs are the most compromised due to the inherent power differentials between them and clinicians tasked with imposing forced treatment. While some clinicians are sensitive to the tension between a person's autonomy and experience of coercion, studies report that the majority of clinicians do not ask consumers directly about this, nor consider that CTOs are coercive beyond enforcement of medication. 27,29 Research, however, continues to highlight the significant and negative impacts of coercion that consumers experience being on a CTO. 33,34 International criticism of public mental health care services emphasizes shortfalls and barriers to provision of recovery-oriented care, with forced care and care planning being key issues in these critiques. 35 The ethnographic study reported here found that consumers on CTOs were often positioned by the clinical team as 'risky' and 'insight(less)', which negatively biased clinicians who were attempting to develop alliances with individuals. 36 This paper focuses on how everyday care planning discussions between mental health clinicians and consumers impacted on the development of trust.
Given the value of and complexity for all parties of negotiating trust in the context of CTO use, an in-depth examination of care planning dialogues as they occur in day-to-day practice was conducted to elucidate barriers and facilitators to the development of trust and thereby care provision that is recovery-focused in this context.

| METHODS
Carspecken's 1 critical ethnography was the methodology applied for this study. Ethics approval was granted from the local health network and university human ethics committees (HREC/16/RAH/148). The study site was two community mental health teams in Adelaide, South Australia.   One woman and 7 men, age 19-49 years (median = 40). Contact with mental health services: ranging from 5 to 20 or more years. All individuals had been on multiple CTOs (3)(4)(5)(6)(7)(8), with many implemented consecutively. Four consumer participants had one hospital admission, one participant had two admissions and one participants had three admissions during data collection. Two consumers were linked to a forensic team during fieldwork. One consumer lived with their family, one with their partner and five consumers lived alone (with four receiving a moderate to high level of psychosocial support) and one participant resided in a community rehabilitation unit. One participant was incarcerated in prison at the conclusion of the study.

Clinicians 16
Clinicians included medical (n = 7), social workers (n = 3) and nursing (n = 6). These professional groups represented those professions with the highest staff numbers across the teams. Psychologists did take on care coordination and OTs were excluded from interviews due to the lead researcher's supervisory responsibilities. Clinicians' age range: 25-65 years (median = 49). A total of 11 clinicians had worked between 15 and 30 years in mental health care; the junior doctors had 3-6 months' experience.

Carers 6
Four consumer participants agreed for their parents to be interviewed (n = 6), two consumer participants declined for their family to be contacted and two consumers did not identify having a carer. To provide a broader carer perspective, four additional carers were recruited. All carers reported having regular contact with their relative, with three families having daily contact.
Abbreviation: CTO, community treatment order.  Table 1 presents the demographic details of the participants who engaged in the second stage of the research project: the consumer care journeys.

| THE UNDERMINING OF TRUST IN CARE PLANNING RELATIONSHIPS
The findings from this study (summarized in Table 2) illustrate how the positioning of participants (consumers, carers and clinicians) and power discrepancies (between consumers and clinicians) influenced care planning relationships and specifically, the development of mutual trust. CTOs often resulted in clinicians assuming that consumers had lesser capacity than they did, which stifled the opportunity for genuine engagement.
Clinicians striving to work collaboratively with consumers had to navigate this bias within a service culture that emphasized a hierarchy of 'knowing', with consumers positioned as having lesser knowledge than clinicians.
This positioning was influenced by the prioritisation of a narrow interpretation of risk (by services) over broader conceptualisations of stressors (by consumers and their carers). Consumers' positioning, their subsequent lack of power and care that was focused on the service priorities of treatment compliance undermined the development of trusting relationships between clinicians and consumers. Individual workers were constrained by the dominant service culture, which endorsed care that was task-based, such as ensuring medication compliance or risk assessment, rather than relational therapeutic engagement. This is encapsulated in the following statement by a carer: There's a trust issue. How can they get to trust this person?… The system in these cases doesn't seem to allow for the very thing that is the problem: the paranoia; and the need for consistency and relationship building … the whole focus is the injection rather than him … the system needs to establish a relationship with Tom other than just administering the needle. (Father-Tom, Interview) The various subthemes that conjointly served to undermine the development of trust in care planning interactions are presented.
To reflect the focus on care planning discussions, illustrations are drawn mainly from ethnographic observations of such discussions. All participants are anonymized.
Excerpts taken from a medical appointment and then follow-up clinical review for the same consumer will be used to illustrate the first three subthemes identified in Table 2. Caleb was a man in his late 40s who had been seen by mental health services for more than 20 years and had been on multiple and consecutive CTOs. The first excerpt (Box 1) is taken from a medical review.
The second excerpt (Box 2) is taken from a clinical review that occurred the following week. Clinical reviews were attended by mental health clinicians only; thus, decisions made within this context excluded the consumer and family.

| A MISMATCH OF ISSUES AND GOALS
In the medical review, Caleb clearly articulated his concerns with the medication. In general, consumers were concerned with issues related to side-effects from medications and broader life domains, and clinicians with issues related to risks related to illness and treatment. This resulted in the frequent mismatching of goals between consumers and clinicians.
Although clinicians often elicited individuals' concerns and hopes through    ician's comment that Caleb was 'fixated' with his weight minimized his experience of side effects and invalidated his concern. The impact that being on a CTO itself had on consumers was also often minimized by clinicians, who viewed the CTO as being in the background of an in-  20 The importance of reciprocity in trust is thus very relevant in this context. 12 In practice, however, the use of low-level threats by clinicians to ensure that they could trust consumers, and thereby mitigate risk, created a dynamic of mistrust in addition to emphasizing the power differential between participants. This space requires skilled and transparent communication from clinicians.
The study findings highlight the interconnectedness between interpersonal and systems trust, with care planning relationships embedded in the service system. 22 Given many consumers' previous negative experiences with care and broader systems, clinicians need to work hard to develop trust and demonstrate that they are trustworthy. This does not mean avoiding discussions about concerns of harm, but requires finding transparent ways of exploring risks with consumers and their families, including broadening their understandings of adversities that individuals face, 43 or reframing risk as needs or issues related to the person's safety. 44 Consumers have highlighted for decades that, to work in partnership, it is necessary that they are included in care planning meetings. 15 Additionally, the policy has long stated the need and benefits of including consumers and carers in decision-making. 3 Active inclusion in this study, however, remained limited to certain settings and was thereby dependent on the allocated clinicians, rather than facilitated at a systems level.
Changing clinical review formats to include consumers and carers as the norm would immediately begin to address their absence in care planning.
For a genuine change, clinicians need to critically reflect on the impact of not trusting individuals as knowers. Fricker's 45 conceptualisation of 'testimonial injustice' (the prejudicial silencing of a minority group) and the means to transform this, through the acknowledgement of this process and cultivation of 'testimonial justice' (reflexive awareness and motivation to overcome prejudice), provides a means to counter such DAWSON ET AL.
| 1865 discrimination. This critique needs to be incorporated into university and service-facilitated training programmes for clinicians, with individuals with lived experience playing a key role in the development and provision of such training. A related approach that has been proposed to challenge and reform mental health care services is that of reparative truth and reconciliation. 46 These are complex processes that bring together survivors of services and mental health clinicians, and 'aim at forging newly respectful relations and restitution for [psychiatric] harm and wrongdoing'. 46

| CONCLUSION
The findings from this ethnographic study identified that trust was a backgrounded barrier to engagement and was infrequently referenced or articulated during care discussions among clinicians and consumers on CTOs. Although the consequences of coercive practices that were compounding discrimination were often unintended, the findings highlight that for care planning to be meaningful, to promote recovery and avoid causing further harm, the profundity of these consequences needs to be acknowledged and addressed by clinicians and services. Fricker's 45 conceptualisation of prejudicial ethical injustice and the need to counter this through testimonial justice combined with tools and approaches that support genuine SDM provides a viable means for change.