The ties that bind? The practice of supervised community treatment in English mental health services

The treatment and control of individuals with severe mental health difficulties in the community has long been positioned as a problem in need of a solution. This thesis investigates one recently introduced ‘solution’ in English mental health services - community treatment orders (CTOs) - enacted under the Mental Health Act (2007). CTOs work by imposing conditions on how service users live in the community, as well as allowing for them to be recalled for treatment in hospital if they fail to meet these conditions, and/or they are deemed to be a risk to themselves or others. Their introduction has brought with it debate on the ethical implications of extending compulsory treatment into the community, with opinion on their use strongly divided. This thesis aims to get beyond such dichotomous positioning to uncover the potentially multiple and complex ways CTOs are conceptualised, interpreted and used by practitioners and service users, and with what consequences. An ethnographic approach is taken to explore ‘inside’ CTO practice within two Mental Health Trusts, through observations of everyday CTO processes, interviews with practitioners and service users, and document analysis of policy and practice-related sources. In this way a dual analysis is formed which gives a generative explanation of the pathways a CTO might take, and describes how service users and practitioners experience and respond to CTOs as a compulsory intervention. This analysis is guided and deepened by a combined critical realist-governmentality framework, which informs an understanding of why it is CTOs unfold as they do, and how they regulate conduct and encourage self-regulation through assemblages of coercive, disciplinary and reflexive forms of power. As will be shown, a number of distinctive conclusions can be drawn about CTO policy and practice relating to: the gaps and continuities between policy theorisation, practice-level conceptualisation and CTOs in action; the constituting power of agency and interaction alongside institutional and cultural factors in shaping various CTO outcomes; the complex and often ambiguous reactions of practitioners and service users to CTO ends and means as connected to ethical self-work; and the mixed, sometimes unexpected and unintended consequences of CTO use.