Exploring the Experiences of Individuals who are Prescribed Involuntary Community
Treatment in Newfoundland and Labrador

Natasha Tobin
Brandon University Faculty of Health Studies
A Thesis submitted to the Faculty of Graduate Studies in partial fulfillment of the requirement
for the degree of Masters of Psychiatric Nursing

Thesis Advisor: Professor Katherine Pachkowski
Committee Members: Dr. Jane Karpa & Dr. Andrew Latus

Abstract
Community Treatment Orders (CTOs) provide legal means to deliver mental health care to
individuals with serious mental disorders, inclusive of a comprehensive plan of community-based
treatment or care, with supervision that is less restrictive than being detained in a psychiatric
facility (Canadian Mental Health Association, Durham, 2019). CTO’s began in Canada in the
1990’s and became a part of Newfoundland and Labrador’s (NL) Mental Health Care and
Treatment Act in 2008. CTOs are centered around less restrictive care, which is aligned with the
principles of recovery oriented and person-centered care (WHO, 2021). These principles are the
foundation of both the World Health Organization’s focus, and of NL’s strategic plan to address
service gaps. Since their inception, the prescription of CTO’s has risen consistently within NL
each year (Personal Communication, 2021). Most qualitative work involving CTO service user
experience has taken place outside of Canada, and thus this is the first known study to explore the
experiences of individuals who have been prescribed a CTO in the province of NL. This research
employed an interpretive description (ID) approach and blended analysis, to answer the research
question(s): What is the experience of individuals who have been prescribed a CTO; how can these
experiences inform the use of CTOs and; how do the policy structures of CTOs influence the lives
of people who live with them? Interviews were conducted with four participants with three
emerging concepts identified during data analysis: “knowingness”, “confinement”, “engagement”,
and the unique element for one participant: “growth”. The participants’ experiences were
interpreted and discussed within the context of current literature. A phenomenological study was
used to inform policy analysis on the topic. Study findings contribute to understanding the
experiences for individuals prescribed CTOs and add to the growing body of literature surrounding
the topic. Implications for the future of CTOs in NL and areas for future research are provided.

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Acknowledgements

I would like to extend a sincere thank you to the four service users who willingly gave of
their time to share their personal journeys with me. This research would not have been possible
without you.
A special thank you to my thesis advisor professor Katherine Pachkowski, who, despite
the physical miles between us, has been beside me the entire way. You are an exceptional mentor
and role model. Thank you to my committee members Dr. Jane Karpa and Dr. Andrew Latus for
your time and support. It has been a privilege to work with you both in this capacity.
To my parents, you have taught me the value of a strong work ethic and have been my
personal cheerleaders, in all facets of my life, since the beginning. Thank you will never be enough.
To my children, Benjamin and William, you inspire me and fill my bucket, every single
day. “I love you guys”.

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Table of Contents
Abstract ........................................................................................................................................... 1
Acknowledgements ......................................................................................................................... 2
Chapter One: Introduction .......................................................................................................... 5
Research Question(s) .................................................................................................................. 6
Motivation for Study ................................................................................................................... 7
Theoretical Framework ............................................................................................................... 7
Thesis Overview ......................................................................................................................... 8
Chapter Two: Literature Review ................................................................................................ 9
Background ............................................................................................................................... 10
Contextual Information ............................................................................................................. 11
Quantitative studies ................................................................................................................... 11
Qualitative Studies .................................................................................................................... 13
Newfoundland & Labrador CTO Legislation ........................................................................... 15
Intentions of the Study .............................................................................................................. 16
Theoretical Framework ............................................................................................................. 17
Implications for research........................................................................................................... 18
Chapter Three: Research Design .............................................................................................. 19
Methodology ............................................................................................................................. 19
Philosophical underpinnings ................................................................................................. 21
Researcher’s role ................................................................................................................... 21
Analyzing the Legislation ..................................................................................................... 22
Methods..................................................................................................................................... 25
Participant Selection ............................................................................................................. 25
Data collection and protection in participant interviews ...................................................... 27
Data Analysis ........................................................................................................................ 28
Ethical considerations ............................................................................................................... 29
Research Design Summary ....................................................................................................... 31
Chapter Four: Research Findings ............................................................................................. 32
Participants ................................................................................................................................ 32
Emerging Concepts ................................................................................................................... 32
Knowingness ......................................................................................................................... 35
Confinement .......................................................................................................................... 37
Engagement........................................................................................................................... 39

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Growth .................................................................................................................................. 41
Stigma ................................................................................................................................... 43
Summarizing Findings .............................................................................................................. 44
Chapter Five: Discussion............................................................................................................ 45
Discussion of Findings .............................................................................................................. 45
Knowingness ......................................................................................................................... 45
Confinement .......................................................................................................................... 46
Engagement........................................................................................................................... 47
Integrated Discussion of Emerging Concepts ........................................................................... 47
Growth .................................................................................................................................. 48
Reflections on CTO Prescription in NL.................................................................................... 48
Map of Concepts – A Model of Care .................................................................................... 49
Model Analysis ..................................................................................................................... 51
Implications for the future of CTOs in NL ............................................................................... 56
Government of NL ................................................................................................................ 56
CTO Management Teams ..................................................................................................... 57
Service Users ........................................................................................................................ 58
Strengths and Limitations ......................................................................................................... 58
Stigma ................................................................................................................................... 59
Areas for Future Research ........................................................................................................ 59
Chapter Six: Conclusion ............................................................................................................ 61
References .................................................................................................................................... 62
Appendix A: Invitation to Participate ........................................................................................... 71
Appendix B: Informed Consent .................................................................................................... 76
Appendix C: Guided Interview Questions .................................................................................... 80
Appendix D: Confidentiality Agreement ...................................................................................... 81
Appendix E: List of Crisis Supports ............................................................................................. 82
Appendix F: Ethics Certificates .................................................................................................... 83
Appendix G: TCPS 2 .................................................................................................................... 92

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Chapter One: Introduction
Community Treatment Orders (CTOs) provide legal means to deliver mental health care
to individuals with serious mental disorders, inclusive of a comprehensive plan of communitybased treatment or care, with supervision that is less restrictive than being detained in a psychiatric
facility (Canadian Mental Health Association, Durham, 2019). Person centered and human rightsbased approaches in mental health care have been identified by the World Health Organization as
a priority, with a goal of aligning mental health services with a recovery focused approach (WHO,
2021). Recovery oriented care is also identified as a core approach in the provincial government
of Newfoundland and Labrador’s (NL) 2017 document titled “Towards Recovery”, which outlines
54 recommendations to address service gaps within the areas of Mental Health and Addictions
within the province (Government of NL, 2017).
CTOs are designed for those that have had repeated psychiatric admissions and who do not
voluntarily engage in outpatient follow-up (Centre for Addiction & Mental Health, 2019). The use
of CTOs began in Canada in the 1990’s and has been included in the Mental Health Care and
Treatment Act in Newfoundland and Labrador since 2006 (Government of NL, 2007). While
CTOs have been considered controversial since inception, there is literature to support their
benefits, including self-reported increased quality of life for those living with a chronic mental
illness (Ingram, Muirhead & Harvey, 2009). Service users tend to report having contradictory
feelings about being on a CTO with respect to feelings of stigmatization, coercion and
experiencing a lack of control over their lives, while also acknowledging some benefits associated
with the CTO (Mfoafo-M’Carthy et al., 2018).
Quantitative studies have produced some evidence to support their efficacy, but these
studies are limited by their nature and often lack direct service user input. The use of qualitative

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studies however, has allowed for detailed exploration of the use of CTOs, regarding issues such as
positive and negative experiences for individuals who are placed on a CTO. (Corring et al, 2017).
Research within Canada on the subject of individuals’ lived experience of being on a CTO
is limited. While the prescription of CTOs in NL has continued to rise each year since their
implementation (Personal Communication, 2021), it appears no published research involving
qualitative discovery with individuals who are prescribed a CTO has been conducted in the
province. This gap highlights the lack of important contextual understanding of the lived
experience of the individuals who are being prescribed this mandated treatment. The purpose of
this qualitative research project was to better understand the experiences of individuals who have
been prescribed mandatory community treatment and how these experiences can serve to inform
and potentially affect, the future of CTOs in NL.
Research Question(s)
In order to address the identified gap in knowledge, the following research questions were
developed: What is the experience of individuals who have been prescribed a CTO; how can these
experiences inform the use of CTOS and; how do the policy structures of CTOs influence the lives
of people who live with them?
Gaining insight into the experiences of individuals prescribed CTOs is an important step
in understanding and identifying supports that are needed for safe, holistic, integrated, and
recovery-oriented care of individuals with serious mental illness. Research findings may provide
strategies for the government of NL and CTO management teams, regarding CTO development
and support of service users who are prescribed CTOs, along with direction for future areas of
study.

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Phenomenological study is an important tool to gain understanding of the experiences of
people who live with a CTO. ID and blended analysis was used to answer the research questions.
A policy analysis based on the work of Bacchi was incorporated into data analysis, in order to
provide further contextual understanding of the data. The methodology used is discussed in detail
in Chapter 3.
Motivation for Study
The motivation for this study came from several facets of my life, spanning over the last
decade. As a nursing student, I provided care, under the supervision of a preceptor, to individuals
receiving CTO treatment by way of an Assertive Community Treatment (ACT) Team. This gave
me insight into the level of wellness that an individual can maintain, when appropriate services
and supports are in place in the community. As a Registered Nurse (RN), primarily working in an
inpatient environment, I experienced the “other side” of a CTO, when an individual had
deteriorated in the community, to the point that they required an inpatient admission. As a program
manager and policy consultant, who has been removed from frontline care for several years, I can
now acknowledge that all of these experiences lacked any context from a service user perspective.
The culmination of these events has led me to explore the experiences of individuals who are
prescribed a CTO within my province.
Theoretical Framework
The framework that underlies this research is one of recovery-oriented practice and person
centeredness, whereby healthcare providers build on personal strengths and skills to enhance
health outcomes and quality of life. Included in this is a broad range of activities that are personcentered and promote resilience. Research involving service users directly correlates with the

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philosophical tenets of recovery such as empowerment and advocacy, making this the ideal
framework to support this topic.
Thesis Overview
Chapter one provides an introduction to the thesis. In Chapter two, a review of the literature
to identify gaps in knowledge related to the study topic is presented. The literature review provides
context for the study and positions it within the existing literature on the topic. In Chapter three,
the study’s methodology, ID and use of Bacchi’s analysis, is detailed. The research method,
philosophical underpinnings, procedural steps, researcher’s role, and ethical considerations are
summarized. Chapter four provides a detailed description of the study findings. Emergent concepts
are identified and supported by the narrative descriptions given by study participants. In Chapter
five, the findings, implications for the future of CTOs in NL, and the strengths and limitations of
the study are discussed and summarized, and the research is concluded in Chapter six.

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Chapter Two: Literature Review
Conducting a literature review establishes familiarity with and understanding of current
research in a particular field before carrying out a new investigation (IAD, 2022). Randolph (2009)
notes that without establishing the state of previous research, it is impossible to establish how the
new research advances the previous research. Prior to preparing for this study, an extensive
literature review was conducted to identify research that had been published on this topic. The
literature and knowledge regarding the topic served as a contextual framework for analysis of the
data collected.
The data bases used for the literature search included Pubmed, CINAHL, and Google
Scholar. The main search terms were community treatment orders, CTO, mandated community
treatment and, lived experience. Advanced search strategies were also employed for community
treatment orders AND Canada, community treatment orders AND lived experience, community
treatment orders AND ACT Teams, mandated community treatment AND Canada WITH lived
experience AND mental illness. While initially searching for research published within the last five
years, the researcher later broadened the timeframe to have no date restrictions, which garnered a
larger number of results. Only English publications were reviewed and abstracts from all articles
identified in the search were reviewed to determine the most relevant literature. Similarly,
references from the selected articles were reviewed to provide additional context. Almost all the
available literature originated in the United Kingdom and the United States.
The review that follows provides a background of CTOs and summarizes the current
quantitative and qualitative literature that exists regarding experiences of individuals who have
been prescribed CTOs. NL legislation regarding CTOs and intentions of the study is provided, and
implications for research are discussed.

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Initial observations revealed that most literature was quantitative in nature, removing a lot of the
experiential knowledge/understanding, further emphasizing the need to explore the gap in
literature.
Background
CTOs provide a legal means to provide involuntary treatment to individuals with severe
mental illnesses who are assessed to be a risk of deterioration and/or, a risk to themselves or others.
CTOs are designed to balance the rights of the affected individual and the rights of those people
who may be affected by an individual’s actions (Snow, 2016). CTOs are included in many mental
health acts in Canada and in other countries; in NL, the provision of CTOs came into effect as part
of the MHCTA on January 1st 2008 (Government of NL, 2007).

The process for a CTO varies but are primarily, and in NL, issued by a psychiatrist. In NL,
psychiatrists, along with the assistance of other health care providers (for example case manager,
ACT Teams which may include occupational therapists, social workers and peer supporters),
supervise the individual’s care within the community. The treatment plan supports the individual
and assists them with obtaining safe and affordable housing, income support, healthy food,
accessible transportation, and meaningful work. If the required and necessary services are
unavailable, a CTO is not a viable option – that is, the utilization of a CTO is reliant on the presence
of resources. A CTO has a term of six months, and a psychiatrist may renew the order as required
for additional six-month periods. During that time, if an individual fails to meet the conditions of
the order, the supervising psychiatrist may require that the person be returned to a psychiatric
facility for assessment (Government of NL, 2007).

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Much of the support for CTOs comes from the argument that CTOs are less restrictive than
mandatory inpatient admissions and are therefore in accordance with legal and Charter of Rights
and Freedoms principles (Snow, 2016). While many national and provincial associations are
generally supportive of CTOs (E.g.: Schizophrenia Society of Canada), there is varying support
from provincial branches of the Canadian Mental Health Association (CMHA) (Snow, 2016). The
national branch of CMHA has argued that CTOs are a further erosion of individuals’ rights and
diminishes their ability to be in control of their life. CMHA goes on to state that forced treatment
can jeopardize long term relationships with caregivers and, that if adequate mental health services
were in place, community committal would not be needed (Snow, 2016).

The contention within the literature, coupled with the minimal research involving service
users and their perspectives, requires that more research be conducted in the field.

Contextual Information
Person- centered care is not just about giving people information regarding their assumed
wants, but rather sees people who use health and social services as equal partners in planning,
developing, and monitoring care to make sure it meets their needs (HIN, 2023). Implementing a
rights- based approach means taking action to promote individuals’ rights to community
inclusion, dignity, autonomy, empowerment and recovery (WHO, 2021). The interconnected
components of person- centered and rights- based care align with and provide a foundation for
research involving lived experiences.
Quantitative studies
Three randomized controlled studies (RCT’s) (Schwartz, 1999; Steadman 2001; Burns,
2013), have demonstrated that there is little effect between individuals on CTOs compared to

12
control group counterparts who were not on CTOs. The Cochrane collaboration (Kisley, Campbell
& Preston, 2011) also failed to show any significant benefit of CTOs. In their article, Harris et al.,
(2018) specifically focus on the effectiveness of the CTO throughout its duration, as opposed to
observation that went beyond the expiry date (like the three RCT’s noted previously). Their case
control study looked at all persons in New South Wales who received a CTO from 2004-2009.
When compared to matched controls, people on CTOs had a reduced likelihood and extended
periods between readmission, fewer total hospital days and increased use of community care.
There was no significant difference in total hospital days during CTO care.

Nakhost et al., (2012) supports similar findings in their observational study conducted with
patients from two McGill University affiliated hospitals. All patients who had been given a CTO
within a 9-year time frame were included, and the patients served as their own control group.
Patients with frequent readmissions showed a significant reduction in the number of
hospitalizations as well as an increase in the median time to re-hospitalization while the CTO was
in place. Compared to their early admission period, patients stayed out of hospital four times longer
following the initiation of a CTO. This study’s results converged with that of Van Dorn et al.,
(2010) in that the positive effects of CTOs were sustained even after the treatment date expired.
Rugkasa (2016), drew on two systematic literature reviews published before 2013 and
studies found with the same search terms between 2013 and 2015. He purposefully delineated what
the literature says as a whole on CTOs to review strengths and weaknesses of different
methodologies. He concluded that more than 50 non-randomized controlled studies have shown
mixed results, and that the usefulness and ethics of CTOs should be questioned, with any future
studies being designed as RCT. While RCT’s are considered the “gold standard” in quantitative

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research, they can be problematic when evaluating complex interventions, such as CTOs, because
valid acknowledgement of causation is not guaranteed (O’Reilly & Vingilis, 2018).
A large-scale Canadian study by Hunt et al in 2006 revealed that the CTO group had
significantly less readmissions and cumulative days spent in hospital when compared to their
counterparts. In contrast, Kisley and Campbell (2007) note that while CTOs may assist with early
intervention and reduced length of stay, there is evidence to suggest that they do not reduce the
incidence of the “revolving door patient” (p.374).
These quantitative studies highlight the inconsistences that exist regarding positive and
negative aspects of CTOs. They are void of service user input and despite recommendations of
further RCT’s to determine CTO effectiveness, there is no evidence to suggest that RCT’s would
be value added or yield different results.

Qualitative Studies
Most research aimed at exploring the opinions and beliefs of service users about CTOs has
been conducted in the United States and throughout Europe. While there are contextual differences
between Canada and these areas, there are similarities of CTO usage between the countries and
thus there are important lessons and insights to be drawn from these studies about service user
experiences. Qualitative studies have revealed that family members and clinicians were positive
about the effects of CTOs while patients were ambivalent. Stuen et al (2015) conducted qualitative
in-depth interviews with patients on CTOs. Their results showed that when followed by an ACT
Team, patients found that many of their previous/ pre-CTO “unmet needs” were now being met
and they were able to better manage day to day problems and future crises. A 2018 Canadian study
by Mfoafo-M’Carty, echoed the sentiments regarding patient’s reports of improvements in life,

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however the majority of their 11 participants reported negative feelings such as viewing a CTO as
“punishment” (p.654) and “unfair” (p.654).

Schwartz et al (2010) explored the lived experience of CTOs with six willing participants.
Many of the themes that emerged were consistent with other themes seen in the literature which
include feelings of coercion and powerlessness but also recognizing some positive aspects of
CTOs. Unique to their study was the report from the service users that the label of a CTO (and
thus stigma) was worse than the conditions of the CTO itself.

Studies of services users’

perceptions of CTOs reveal ambivalence towards CTOs and their inherent coercion. Corring et
al’s 2010 study of eight participants who have been prescribed a CTO, reflects this ambivalence.
Themes that emerged included feelings of powerlessness, limited symptom management and
understanding of a CTO, as well as increased stability and decreased hospitalizations.

A systematic review by Corring et al (2017), focused on understanding individuals’ CTO
experiences. Their review of 22 papers revealed 10 themes that coincide with previous literature
on the topic, including feelings of powerlessness and coercion, improved medication compliance,
and preference of a CTO over hospitalization. While some papers identified a theme of an
improved patient physician relationship, others reported a negative impact to the relationship with
a CTO in place.
Pridham et al’s 2018 study, reviewed CTO experiences from the perspective of the patient,
family and clinician. Of the nine patients that were interviewed, similar themes of coercion and
altered therapeutic relationships were present. While reflective of input from service users, these
qualitative studies lack Canadian context. Many underpinnings of CTOs can cross borders,
however, there are perspectives, unique to Canada, in need of being explored.

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Newfoundland & Labrador CTO Legislation
CTOs have been included in the Mental Health Care and Treatment Act in Newfoundland
and Labrador since 2008 (Government of NL, 2007). The criteria for a CTO are as follows:


The individual must have a history of mental illness and require ongoing treatment
or supervision in the community



If such care was not provided, there must be an identifiable risk that the person
would deteriorate and may become harmful to self or others



The person, because of their severe mental illness, would have to demonstrate a
lack of insight or understanding into its nature and need for treatment and therefore,
they would be unlikely to voluntarily agree to treatment



As well, if the person does not avail of such services, then their mental status and
level of functioning will continue to deteriorate



To be eligible, a person is required to have at least three involuntary admissions to
a mental health facility in the past two years, or have previously been on a CTO

Currently in NL, the management of CTOs within the capital city is monitored by ACTT
and FACT (Flexible Assertive Community Treatment) Teams. For areas that do not have such
teams, a designate such as a physician or case manager assumes the responsibility. ACT Teams
provide treatment, rehabilitation and supportive services to adults living in the community who
have severe and persistent mental illness. This includes symptom and crisis management,
assistance with finances and transportation, and achievement of personal goals (Eastern Health,
2020). The “F” in FACT stands for “flexible” which means there is variation in how much support

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the team provides (PsychosisNet, 2023). Both teams are staffed with various disciplines including
social workers, RNs, occupational therapists, psychiatrists, and peer support workers.

Intentions of the Study
The purpose of this study is to explore the experience of individuals in NL, who have been
prescribed a CTO. All individuals who have been prescribed a CTO within the capital city and
surrounding area, regardless of diagnosis, were offered the opportunity to participate. Because so
little is known about CTO effectiveness within Canada, this study is designed to increase the
research and knowledge base surrounding the topic. It is expected that this study will make at least
two contributions to the area of Mental Health and Addictions in relation to mandated community
treatment:

First, the study aims to capture the voice/perspectives of those who are being mandated
psychiatric care in the community. Knowing what is beneficial and what is perceived as nonvaluable to the service user provides invaluable information for those developing and revaluating
community service treatments. As more is known about the relationship between CTOs and service
user perspectives on them, it will be possible to more clearly understand the benefits of CTOs in
supporting individuals to live a more independent and rewarding life in the community setting.
Due to the small number of individuals who are prescribed CTOs, this study incorporates user
expertise and policy analysis to enhance understanding of this phenomenon.

Second, this study is the first (known) one to have been conducted within the Atlantic
Canadian Province of NL. Information from the Canadian Institute of Health Information (CIHI)
showed that in 2005-2006 Newfoundland and Labrador had the highest rate of schizophrenic and
psychotic disorders, the highest rate of mood disorders and the third highest rate of substance-

17
related disorders in Canada (Newfoundland & Labrador Medical Association, 2019). The
economic cost associated with Mental Illness within Canada is estimated to be 51 billion dollars
annually (Centre for Addiction & Mental Health, 2019). This study has the ability to contribute to
a better understanding of the needs of the service user population within the province, and can
support further Canadian research into the area of CTO prescription as opposed to hospitalization
and discharge alone.

Theoretical Framework
Theories are formulated to explain, predict, and understand phenomena and, in many
cases, to challenge and extend existing knowledge within the limits of critical bounding
assumptions, with a theoretical framework being a structure that can hold or support a theory
of a research study (USC, 2022). The framework that underlies this research is one of recoveryoriented practice and person centeredness. According to the Mental Health Commission of Canada
(MHCC), recovery-oriented care involves healthcare providers working with individuals and their
families to reach their chosen recovery goals. Healthcare providers build on personal strengths and
skills to enhance health outcomes and quality of life. This includes a broad range of activities that
are person-centered and promote resilience (MHCC, 2021). Philosophical tenets of recovery such
as self-help, empowerment and advocacy, have a history that dates back to the civil rights
movements of the 1960’s and 1970’s (MHCC, 2015). National documents such as “Changing
Directions, Changing Lives: The Mental Health Strategy for Canada” (MHCC, 2012), and
provincial reports including “Towards Recovery: The Mental Health and Addictions Action plan
for Newfoundland and Labrador” (Government of NL, 2017), not only align with the framework
of recovery, but support the research of lived experience.

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Implications for research
The World Health Organization’s “Guidance on community mental health services:
Promoting person-centred and rights-based approaches” (2021), highlights the need to improve
the mental health and well-being of whole communities at the national level. The MHCC’s
“Guidelines for Recovery-Oriented Practice Hope. Dignity. Inclusion” (2015), identifies the
importance of acknowledging, valuing and learning from people’s experiential knowledge.
Nevertheless, current research and knowledge related to the service user experience of being
prescribed mandated community treatment in Canada are lacking. The majority of the current
literature focuses on the need for future quantitative studies, which will not provide space for the
abundant knowledge that service users can provide. Since limited studies were found in Canada
regarding the experiences of individuals who have been prescribed CTOs, along with no known
research regarding the topic in NL, this study aims to provide a more complete, contextualized
understanding of the area of interest. The knowledge gained from this study can potentially
improve the CTO structure in NL, inclusive of the service user’s experience. Similarly, the
information gained may benefit research, policy and legislation within NL and beyond.

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Chapter Three: Research Design
Chapter two provided details on the recovery-oriented practice and person centeredness
framework that underlies this research. Living in and being part of a community is threaded
throughout the CTO process, and each individual prescribed a CTO has their own unique
journey and experience. It is for these reasons that the recovery-oriented practice and person
centeredness framework is the most appropriate theoretical framework for this research.
After several calls for interest, the project secured four willing participants. While ID can
support small sample sizes, the researcher found it prudent to dive deeper and analyze how NL
legislation may guide the living experiences of individuals prescribed a CTO. This was achieved
using Bacchi’s (2016) approach to policy analysis – “What’s the Problem Represented to be
(WPR)?” Both approaches are described in this chapter.
Methodology
Interpretive Description
This study initially employed an ID design. ID was used to answer the research question(s):
what is the experience of individuals who have been prescribed a CTO, and how can these
experiences inform the use of CTOS? Given that the aim of ID is to generate knowledge relevant
for the clinical context of applied health disciplines (Hunt, 2009), it was the most natural and
applicable choice of methodology. Gaining insight into the experiences of individuals prescribed
CTOs is an important step in understanding and identifying supports that are needed for safe,
holistic, integrated, and recovery-oriented care of individuals with serious mental illness. ID also
supports the potential to provide strategies for the government of NL and CTO management teams,
regarding CTO development and support of service users prescribed

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The methodological approach that grew into what is now called interpretive description,
arose from the necessity to find a way to do a kind of qualitative research that could generate the
kinds of understanding of complex experiential clinical phenomena that would be optimally
relevant and useful to the practice of nursing and other professional disciplines concerned with
questions “from the field” (Thorne, 2016).

ID offers a viable alternative to what is sometimes observed as watering down or modifying
of such conventional methods such as phenomenology, ethnography, and grounded theory
(Thorne, 2016). ID was developed to offer a more focused methodology with a more concentrated
range of approaches, with its defining feature resting in its emphasis on the generation of clinically
relevant knowledge (Hyde, 2022). Users of ID are encouraged to “lead their eventual reader toward
a kind of knowing that was not possible prior to their study” (Thorne, 2016, p.181). This approach
has its roots in the methodological traditions of the Social Sciences, although ID differs from them
in terms of its lack of rigidity and essentially theoretical objectives (Teodoro et al, 2018). In
contrast to traditional phenomenological inquiry, nursing’s interpretive description ought to be
located within the existing knowledge so that findings can be constructed on the basis of thoughtful
linkages to the work of others in the field (Mitchell & Cody, 1993 as cited in Thorne, Kirkham &
MacDonald-Emes, 1997). ID responds to the imperative for informed action within the imperfect
scientific foundation that surrounds the human sciences (Thorne, 2016). ID is a qualitative research
approach rooted within nursing science, specifically developed to address limitations within
formally established qualitative traditions, as a means to reliably answer questions about health
and illness experiences from holistic, interpretive, and relational perspectives (Thompson Burdine
et al, 2021). During the 1980s it became apparent that the discipline of nursing needed a research
method distinct from the approach of social science knowledge development (Thorne, 2011).

21
Longstanding attempts to adhere to the rigorous tenants of grounded theory, phenomenology, and
ethnography were creating an increasingly obvious tension associated with the discipline’s
requirement for “useable” knowledge (Thorne, 2014).

Philosophical underpinnings
The philosophical underpinnings of the ID methodology made this a desirable approach to
use when exploring such a topic. For example, the multiple constructed realities that can only be
studied holistically, therefore the reality is considered complex and ultimately subjective (Thorne
et al, 2004), aligns with a CTO being an objective treatment that is subjectively experienced, and
is undoubtedly uniquely complex for each individual. It is these tenets, along with the wide range
of design decisions that ID allows, that aided the writer in answering her proposed research
questions. ID allowed for service user input as a fundamental source of insight and capitalized on
the commonalities of the participants (being prescribed a CTO) while being inclusive of each
user’s individual expression. ID supports that multiple realties may be present for CTO service
users and that at times, these realities may be contradictory (those with a perceived benefit from a
CTO and those with concerns around their prescription).
Researcher’s role
The role of the researcher in ID is delineated by the central place their own reality takes in
the generation of new knowledge, and it is up to the researcher to combine the understanding of
what is known with a desire of new possibilities in the structuring of knowledge (Teodoro et al,
2018). This concept aligns with the researcher’s study of exploring the experiences of individuals
who have been prescribed a CTO.

22
The researcher is an RN with a Bachelor of Nursing degree and is currently enrolled in the
Master of Psychiatric Nursing program at Brandon University. The researcher is certified in
psychiatric and mental health nursing through the Canadian Nurses Association, and holds
Canadian Health Executive status with the Canadian College of Health Leaders. The researcher’s
experience embedded within the healthcare system as a nursing student, RN, acute care mental
health manager, and current consultant with the Department of Health and Community Services
NL, has complimented and motivated this research. The researcher has no associated conflicts of
interest.

Analyzing the Legislation
Saukkko’s (2005) “integrative approach” highlights the complimentary nature of
hermeneutic and critical forms of analysis. The intensive exploration of a phenomenon, such as
experiences of individuals who are prescribed CTOs, will therefore need to examine not only how
CTOs are experienced and perceived by CTO service users who give it meaning, but also the
structural relations, such as legislation, through which those meanings are produced (Hood, 2015).
Thorne (2020) emphasizes that ID offers the invitation to reclaim the foundational intellectual
character of nursing thought – lending the nurse researcher’s expertise as a fundamental data
source. It is through analysis that the researcher answered her third research question: how do the
policy structures of CTOs influence the lives of people who live with them?

While ID can support small sample sizes, the researcher found it pragmatic to go a step
further and analyze how NL legislation may guide the living experiences of individuals prescribed
a CTO. This further step of analysis can support and enhance the analysis of the data from the
interviews. As above, the use of additional sources of knowledge in ID analysis is supported

23
through Thorne’s own arguments regarding the nature of ID (Thorne, et al., 1998). To this end, a
blended analysis using Bacchi’s (2016) approach to policy analysis - “What’s the Problem
Represented to be (WPR)?” was utilized. In this form of analysis, problems are not on the “outside”
of policies but rather within them. That is, contained within every policy (or legislation); there is
representation of what the problem is represented to be. WPR suggests that rather than reacting to
problems, governments are active in the creation (or production) of policy problems (Bacchi,
2009).

In this study, the MHCTA, which provides mandated treatment, care and supervision of
people living with severe and persistent mental illness in NL, represents the problem as the
inability of individuals with severe and persistent mental illness to manage their own treatment
and care. To study this legislation, there is a need to analytically probe how the inability of
individuals with severe and persistent mental illness to manage their own treatment and care, is
problematized. Of the four paradigms in health policy identified by Bacchi, the interpretivism
approach aligns with this area of research. Interpretivists (researchers) see people’s (participants)
self-interpretation as central to understanding social organization (Bacchi, 2016). The following
interrelated questions offer an initial analysis of the WPR approach to CTOs in NL’s MHCTA. A
more fulsome analysis and discussion is found in Chapter five:

Questions

Responses

What is the “problem” represented to be in

Inability of individuals with severe and

NL’s MHCTA?

persistent mental illness to manage their own
treatment and care. Non-management could
lead to harm of themselves or others.

24
What presuppositions underlie this

Individuals with severe and persistent mental

representation of the “problem”?

illness do not have capacity to care for
themselves and maintain wellness
independently. Mandated Community
treatment (a CTO) would alleviate/lessen this
“problem”.

How has this representation of the “problem”

CTOs became a part of the MHCTA in 2008

come about?

as a means to provide care to individuals with
severe and persistent mental illness in a
community setting. Offered an alternative to
hospital based mandatory treatment.

What is left unproblematic in this problem

Individuals managed by a CTO often do not

representation? Where are the silences?

present/get admitted to hospital. It is therefore
assumed that they are “healthy/doing well” on
their CTO. Even though an individual may
meet criteria for a CTO, it is a psychiatrist’s
decision to prescribe or not, potentially
resulting in additional hospital
admissions/further deterioration.

What effects are produced by this

Individuals are required to meet criteria for a

representation of the “problem”?

CTO and a case management team manages
their mental health treatment. This includes
service users having a fixed address and being

25
present for all appointments. A violation of a
CTO could result in apprehension and
conveyance to a psychiatric facility.
How and where has this representation of the

Part IV of the MHCTA (Government of NL,

“problem” been produced, disseminated, and

2006). A quality review of CTOs occurs

defended? How has it been/and or can it be

every five years, most recently in 2022.

questioned, disrupted, and replaced?

Revisions (i.e. change in criteria) are
expected. Since 2017, a provincial recovery
council reviews and advises on such
legislation. The ultimate decision rests with
the Minister of Health.

Methods
Participant Selection
The researcher utilized purposive sampling, targeting individuals who have been
prescribed a CTO within the capital city of St. John’s, NL and its surrounding areas. Purposive
sampling is widely used in qualitative research for the identification and selection of informationrich cases related to the phenomenon of interest (Palinkas et al, 2015). Purposive sampling relies
on the judgement of the researcher when it comes to selecting the units that are to be studied. The
main goal of purposive sampling is to focus on particular characteristics of a population that are
of interest, which will best enable the researcher to answer their research questions (Lund research,
2012). Purposive sampling was chosen for this study as it provided the opportunity for the
researcher to connect with a specific population of individuals who were prescribed a CTO.

26
Furthermore, it facilitated the collection of rich information from individuals within the targeted
population, which aided in answering the research question(s) of this study.

All individuals who have been prescribed a CTO within the capital city of NL and
surrounding areas, regardless of diagnosis, were invited to participate via a written letter of interest
(See Appendix A). This geographic area was chosen due to the proximity to the researcher and
availability of public transit to facilitate in person interviews, where requested.

The researcher connected with the clinical lead and program manager of the ACT Team to
request their assistance in recruiting participants. Only individuals who were deemed to have
capacity/were without a substitute decision maker (SDM), were considered as potential
participants. This was accomplished by requesting that ACTT members only distribute letters of
invitation to individuals without SDMs. Ultimately, at the time at distribution, there were no
potential participants with an SDM. As there were a limited number of active CTOs within the
geographic area (22 at the time of invitation), the researcher planned for three to six participants.
After several calls for participants and rounds of recruitment, the researcher successfully gained
consent from four participants. During the recruitment phase, several unforeseen circumstances
occurred including a higher-than-expected discontinuation of several CTOs (six discontinuations
leaving 16 active at the time of data collection) and staffing difficulties within the ACTT service
that was being used as the venue of recruitment. The result of these difficulties was a decreased
capacity for staff to connect with a similarly decreased participant pool. Ultimately, the researcher
had the opportunity to interview four CTO service users. The notable differences between the
service users has allowed the researcher to delve into unique experiences, as well as common
experiences that were revealed through analysis of emerging concepts. Given that the foundation

27
of ID is the “smaller scale qualitative investigation of a clinical phenomenon” (Thorne et al, 2004,
p.3), the final data set was appropriate and supported by literature. Further, as per Thorne at al.
(1993), the final data analysis was strongly informed by policy analysis.
Data collection and protection in participant interviews
Information about the experiences of individuals who have been prescribed CTOs was
collected using semi-structured interviews, observations, and audio recordings. An interview guide
(see Appendix C) was used so that order and wording of questions could be flexible (Patton, 2003).
Tutty and colleagues (1996) explain that semi-structured interviews, which use predetermined
questions or key words as a guide, are particularly appropriate to compare information between
and among people while at the same time to more fully understand each person’s unique
experience. Semi-structured interviews align with the core concepts of ID in relation to exploring
experiences from holistic, interpretive and relational perspectives. This style of interview allowed
participants to relay their unique experience of CTO prescription, while being guided by key words
and questions, designed by the researcher, to gain an understanding of CTO prescription as a whole
as well as each individual’s experience with them (Thorne, 2016). Interviews were conducted by
telephone, as per each participant’s request, and were audio recorded and transcribed by the
researcher.
All information obtained by the researcher was locked by password on the researcher’s
computer and lock and key in a filing cabinet within the researcher’s locked office. Confidentiality
was maintained through anonymization and ensuring any information containing the participant’s
names did not leave the researcher’s office. Given the population numbers in the area,
demographics were not reported as to not risk indentifying any of the participants and any direct
quotations were attached to pseudonyms. The participant names were not stored with the raw data

28
but rather with the consent forms, in a separate file. All field notes were destroyed once transferred
to the researcher’s password protected computer, with all files being saved by the same manner.
Coding of transcriptions used non identifiable indicators and raw data that was collected
throughout the process will be permanently destroyed after the researcher’s thesis defense and no
later than five years after approval was given to conduct the research. No cloud-based services
were utilized during any part of the study.
Data Analysis
Audio recordings of the interviews were reviewed and transcribed by the researcher and a
thematic analysis approach, as described below, was used. Thematic analysis is useful in analyzing
narrative material from in depth interviews and focus groups (Dudley, 2009). An etic perspective
was employed with research categories being identified by the researcher. This perspective is that
of an observer or outsider looking in (Lumen Learning, 2021). Given that the researcher was not
immersed within a CTO prescription experience but rather observed and engaged those that are,
this approach was most appropriate. In contrast, an emic perspective would have the researcher
engaged as an insider, providing viewpoints as part of the CTO culture (AU, 2022).
The primary purpose of an inductive approach is to allow research findings to emerge from
the frequent or significant themes inherent in raw data, without the restraints imposed by structured
methodologies (Thomas, 2006). Through use of this approach, the researcher began with specific
observations of CTO service users and then moved to detecting themes and patterns in the data
that was collected. The researcher organized the raw data into categories in order to create concepts
to analyze the data (Neuman & Kreuger, 2003). The researcher looked for common elements or
patterns presented in the transcribed notes of the interviews. Given the natural inquiry of
qualitative research and the researcher’s experiences with CTOs, theme checking and reaffirming

29
also occurred deductively. Using open coding, initial labels were assigned in a first attempt to
condense the data into categories. To ensure reliability, the researcher reviewed the concepts with
her supervisor to ensure important information was not being missed and that potential biases were
being revealed. Given the innate nature of qualitative inquiry, an inherent subjectiveness
accompanies it. The researcher practiced ongoing reflection as well as bracketing throughout the
research process, to support the highest level of feasible objectivity. The researcher regularly
challenged herself to identify held beliefs about the data and regularly checked in with their thesis
advisor to explore same. Tufford and Newman (2012) note bracketing as a method used in
qualitative research to mitigate the potentially detrimental effects of preconceptions that may taint
the research process. Reflection and bracketing occurred by way of journaling by the researcher.
Reflection was an ongoing process throughout the duration of the study, with journaling occurring
robustly during the data collection phase. The researcher’s journal was contained on their password
protected computer and the entries were reflective of feelings, emotions and questions that were
evoked during participant interviews. Reviewing the entries at various stages throughout the study
supported the researcher’s ability to reflect and broaden their scope of consideration regarding the
effects of CTO prescription on individuals. Journal entries also included future potential research
ideas, which will be discussed later in the study.
Ethical considerations
No foreseeable risks or potential harms were anticipated for the participants, however given
that CTOs are prescribed to individuals with mental illnesses significant enough to require
mandated treatment, the population of study is inheretly known to be at a heightened level of
vulnerability. With this in mind, pre-emptive planning occurred in the event that a participant had
feelings of distress during the interview process. As part of the invitation to participate, individuals

30
were offered to bring a support person to the interview (though none opted to) and, throughout the
interview process, the researcher had a list of crisis supports available should they be needed
(Appendix E). The aim throughout the study was to maintain ethical principles while protecting
the participants (Streubert & Carpenter, 2011). Research ethics approval was obtained from
Brandon University Research Ethics Committee (BUREC), the Health Research Ethics Board
(HREB) and the Eastern Health Ethics Review board, prior to commencement of the study (See
Appendix F for Ethics Certificates).
Participants were informed of the purpose of the research and consent was obtained prior
to involvement. Participants signed a consent form (Appendix B), which informed that
participation was voluntary, and that they could withdraw from the study at any time before
September 30th 2022 (when data analysis began), and that this research would in no way, affect
their treatment plan. To protect the participants’ privacy and ensure confidentiality, the researcher
was the only person aware of the participants’ identities. Interviews were audio-recorded, and only
first names were used during the interview. All identifying information in narrative descriptions
of experiences was removed before the dissemination of findings. All files containing identifying
information, e.g., consent forms, were securely stored in a locked cabinet. All data were stored in
password-protected files and will be destroyed five years following the study completion and thesis
defense, in accordance with Brandon University research ethics policies. Participant names were
removed from transcribed interviews. The researcher used “W”, “R1”, “R2”, “R3” and “R4” to
indicate the researcher and participant’s respective contributions. At the end of data analysis, the
researcher selected gender neutral pseudonyms for each participant that were used to report
findings. Pseudonyms cannot be contextually connected with unique participants.

31
Research Design Summary
ID was selected as the methodology for this study as it aligns with the exploration of
complex experiences of individuals who have been prescribed CTOs and, lends itself to the
generation of rich information within a small data set. Given this small data set, the researcher
utilized Bacchi’s WRP approach to go a step further and analyze how the MHCTA affects the
experiences of individuals prescribed a CTO. Data collection and analysis fit within the
philosophical tenets of ID and choices made by the researcher maintained the ethical principles of
protecting and respecting participants. Research findings that include emerging concepts
uncovered during data analysis are described in the next chapter.

32
Chapter Four: Research Findings
The purpose of this study was to explore the experiences of individuals who are
prescribed involuntary community treatment in NL. This was accomplished through use of semistructured interviews and a series of guided interview questions. The research findings include
excerpts from individual interview transcripts, observations made by the researcher during the
interviews, and emerging concepts that were identified during data analysis.
Participants
Four service users with active CTOs participated in the study. All met the inclusion
criteria and agreed to participate in the research project. Thorne et al (2004) note the foundation
of ID is the smaller scale qualitative investigation of a clinical phenomenon with studies often
building upon relatively small samples. This foundation coupled with the in-depth qualitative
inquiry of the topic, supported a small sample size while acknowledging that highly informative
and meaningful contributions could be made (Boddy, 2016). Telephone interview was the
indicated preferred method for all service users and interviews proceeded as mutually agreed
upon with all participants engaged in the process. Given the small geographic area and
participant pool, no demographic data outside of the inclusion criteria was collected and
participants were assigned pseudonyms to protect their identities on transcripts.
Emerging Concepts
There was a stark contrast in experiences between service users, which led the researcher
to explore differences between the following three emerging concepts; “knowingness”,
“confinement”, and “engagement”. While the delineation of themes and concepts, are not well
defined in nursing science, DeSantis and Ugarriza (2000), note that a theme is an abstract entity
that brings meaning and identity to a recurrent experience, capturing and unifying the nature or

33
basis of the experience into a meaningful whole. Given the divergence in experiences reported
by each of the service users, the term concept was deemed to more accurately reflect and
categorize the research findings. The term concept is used here to allow each category to
encompass a broader array of experiences. This becomes important in the conceptual framework
provided in chapter five. Underlying each of the concepts are the elements of comprehension and
perspective.
These concepts are overarching and do not represent themes in the sense of commonly
held experiences. Rather, they are higher level, broader concepts that create a framework that
helps contextualize the experiences of each user on a CTO. Each concept (knowingness,
confinement, engagement) is experienced differently by each participant. Learning precisely how
each individual participant experiences each of these concepts is vital to understanding their
experiences with a CTO. Thus, it is important to understand that while each participant may
experience each concept in a different way (in some cases, in exactly opposing ways), each
concept is experienced by each user. The elements of “comprehension” and “perspective”
capture the complexities of how each participant experiences the elements. These concepts will
be presented in a diagram in the section titled “Implication for the future of CTOs in NL”.
The literature supports the researcher’s experience of each service user having their own
understanding and interpretation of the questions being asked (WETA, 2023) as well as their
own particular way of thinking about a CTO (Collins, 2023). As will be described in Chapter
five, there may be various reasons for such disparities in responses; however, each service user’s
level of comprehension and their individual perspective (optimism, pessimism, realism)
ultimately affects their experience of knowingness, confinement and engagement. While
information related to the participants’ diagnosis was not collected for each service user, Burns

34
& Molodynski (2014), note that the most common diagnosis associated with a CTO is
Schizophrenia. Given the symptoms associated with serious mental illnesses, including confused
thinking, reduced ability to concentrate and withdrawal from others, it was expected and
understood by the researcher that service users may not provide a substantial amount of verbal
detail in their responses. It should be noted that the researcher thus paid close attention to
paraverbal cues such as pauses, inflection, emphasis, and so on, as such cues can provide rich
insight into meaning. Paraverbal communication is often an overlooked form of communication
that speaks volumes when relaying messages. Put simply, it is not just the words said but rather
how the message(s) is portrayed (Bennett, 2023).
The data collected revealed a map of concepts that are relevant to the lived experiences of
individuals who are prescribed a CTO. These findings acknowledge the importance of the
concepts themselves, while respecting that the lived experiences of these concepts vary between
the four individuals, with both elements equally important. The level of participant knowledge
surrounding what a CTO is, why they were prescribed one, details of the plan and how to have a
CTO discontinued, led the researcher to develop the first concept; “knowingness”. As this
chapter will detail, Some participants had more awareness and thus more fulsome responses
regarding CTOs. Statements regarding the inability for participants to be able to leave their
residence at their leisure, and comparisons between a hospital stay and a CTO, resulted in the
concept of “confinement”. Participants acknowledged varying levels of emotions related to
feeling confined. Connection or lack thereof, is how the concept of “engagement” was
developed. Three participants identified as being connected to their treatment team and feeling
involved with decisions, with the other participant appearing more ambivalent regarding their
level of involvement.

35
The literature acknowledges conflicting views of individuals prescribed CTOs, including
about coercion, trust and independence (McMillian et al, 2019). This existing knowledge aligns
with the discovery of these sundry concepts and is where the researcher obtained meaningful
data. The notion of growth was unique to only one of the four participants and is explored further
as its own element. Given its significance within the literature, the researcher will also touch on
how stigma affected each service user.
The underlying essence to the experience of individuals who have been prescribed
mandatory community treatment was the preference of this option when compared to the
alternative of being involuntarily admitted to an inpatient mental health unit. There was a clear
distinction between service users when it came to the level of detail they provided during their
interviews and while all consented to the process, the researcher observed that “Jesse”, “Alex”
and “Jamie” appeared more engaged and verbose than “Taylor”.
Knowingness
Knowingness represents each service user’s level of understanding of their mandated
community treatment including what a CTO is, why they were prescribed one, details of the
plan, and how to have a CTO discontinued. When searching for patterns within the data, the
overarching question “what do these service users know about their own CTO?” became a
thought that the researcher continued to come back to. Upon deeper reflection into the service
user’s responses and the researcher’s own journaling, the concept of “knowingness” emerged. As
is evident by the transcripts below, there are significant differences between each participant’s
responses. Both Taylor and Alex were unaware of what a CTO was or why they were on one.
They could not remember if the parameters of the CTO were discussed with them nor what
would be required for their CTO to be discontinued. Jesse, however, was able to identify what

36
the acronym stood for and why they were prescribed one. Jamie also identified why they were on
a CTO, confirmed they received a copy of their CTO and had an idea of how to eventually come
off a CTO. Whilst two of the four participants expressed vastly different levels of
“knowingness”, the knowingness itself is of value and has meaning. This is deduced not only
because of the participant’s contributions, but also of emphasis placed, and the researcher’s own
experiences (Thorne, 2016).
When asked if they knew what a CTO was and why they were prescribed one:
I don’t know (Taylor)
I don’t know what it is (Alex)
A community treatment order….due to my mental illness (Jesse)
It’s forced treatment so that I can stay better and out of hospital. If I don’t follow it, the
cops can bring me back to hospital (Jamie)
Further prompting and exploration with Taylor and Alex did not yield any additional
information.
You don’t know what a CTO is? (Researcher)
No (Taylor)
No I don’t (Alex)
Ok, do you know why you were put on one? (Researcher)
No (Taylor)
No I’m not sure (Alex)
Where the rules of the CTO ever explained to you? (Researcher)
I don’t remember (Taylor)
I don’t think so, no (Alex)

37
Oh yes, before I left hospital (Jesse)
Yes, they did that before I left the hospital and they gave me my patient copy and the copy
for my patient rep (Jamie)
How do you see yourself getting off a CTO, do you know what you have to do for the
CTO to end? (Researcher)

No (Taylor)
I’m not sure (Alex)
Take my meds and go to my appointments (Jesse)
Well they are supposed to be for 6 months. I don’t want to be on one forever. I just need
to keep taking my medication (Jamie)
What do you feel you know about your CTO? (Researcher)
Uh, nothing really (Taylor)
That it gives me support (Alex)
Objectively, the researcher noted both Jesse and Jamie, who appeared more engaged in
the interview, demonstrated a higher level of knowingness than Taylor or Alex. Jesse and
Jamie’s tone of voice was friendly, and their responses were more indicative of an optimistic
perspective, thus potentially explaining their increased level of knowingness. Conversely,
Taylor’s voice was more monotone when giving concrete responses and less detail than Jesse
and Jamie. Alex appeared both friendly and ambivalent during the discussion. It is possible that
this detail may reflect the current state of their illness.

Confinement

38
The Oxford dictionary defines confinement as “the state of being forced to stay in a
closed space; the act of putting somebody there” (Oxford Leaner’s Dictionary, 2022). While all
four service users identified the need to be at their residences on the multiple days per week that
ACTT would visit, their reported feelings regarding this differed. Perceived level of restriction
with a CTO, is one of the main areas of interest that led the researcher to delve into this research.
Much of the researcher’s own journaling revolved around this area and became a means to
bracket her own views and perceptions regarding restrictions in the community compared to
those within a hospital. Given that all service users identified the need to be at their residences,
and that to be prescribed a CTO, the service user must have a fixed address, “confinement”, by
definition, surfaced as an emerging concept. Taylor appeared to have negative feelings regarding
the need to be at their residence awaiting their ACTT member, whereas Jesse and Jamie
appeared to focus less on the requirement to be at their home and rather welcomed the structure
that this provided them. Different again, Alex voiced that they preferred to stay close to home
and that even with encouragement from their treatment team; they did not like to leave their
home. Once again, the following responses identify contrasting experiences for each service
user, with the value and meaning reckoned within the experience of “confinement” itself:
When asked about any impacts that the CTO has had on their life:
You have to be home all the time, waiting around for them to come, so you can’t go out
nowhere and that’s, I knows sometimes they come early, sometimes they comes late (Taylor)
Every second or third day they’ll come by and drop off my medications and see how I’m
doing and help me with like, recently I told them I’m looking at trying to find employment and
they’re trying to help me find employment now (Jesse)
Nothing bad. It’s helping me. It’s making me better (Alex)
It’s way better than being in hospital, that place is a hell hole. I feel like now I can
appreciate the fact that I need to take my medication (name was identified but omitted as not to
potentially identify participant), and taking it is what keeps me better, not stopping it (Jamie)

39

When asked about words that come to mind when they think of a CTO:
Trapped, like stuck on a fucking, like I’m supposed to be in jail or something. Makes me
feel like I’m a danger to society (Taylor)
It’s good to be on one (Jesse)
Support (Alex)
Prevention, healing, support (Jamie)
Taylor’s response and tone of voice indicated a level of frustration. It was of interest to
the researcher that even though literature highlights one of the benefits of a CTO is that
individuals are less restricted than when in hospital, Taylor still felt confined within the realm of
their CTO and did not identify a CTO being beneficial for this reason.
Jesse however, expressed their satisfaction with being on a CTO and through their
responses, indicated that the need to be at their residence at certain times was more of a
supportive experience as opposed to a hindrance. Jesse’s responses in this area align with the
research that supports a CTO being less restrictive than an inpatient stay. Jamie voiced clear
distain for the hospital environment and a preference for mandated treatment in the community.
Objectively, Jamie appeared to have insight into the benefits of adhering to their medication
regime. For Alex, the CTO parameters and expectations to be at home during a certain time were
not an issue as they were home most of the day by choice.
Engagement
Engagement represents the level of involvement with ACTT and their CTO treatment
plan that the service user’s perceived to have. On one hand, Taylor expressed ambivalence about
their engagement with the service team, indicating that engagement is “good”, and had nothing
directly negative to say about the level of engagement. However, when pressed, they were

40
unable to expand upon what is or isn’t positive or helpful about the level of engagement. Jesse,
Jamie and Alex on the other hand, had a more positive response to the level of engagement that
was present. It is the content within the concept of “engagement” where rich data was obtained.
The researcher would be remiss if they did not acknowledge that engagement is a two-way
communication and not something that can be forced. While mandatory components of a CTO
include medication adherence and attending appointments with their team, refusing to engage in
an outing to a social setting, would not be grounds for violating a CTO. Data revealed layers of
engagement which included not only Taylor, Jesse, Jamie and Alex, but their accounts of the
level of engagement provided by their ACTT members.
When asked about the level of support provided by the team:
Well, the doctor just comes to my house (Taylor)
And how does that go? (Researcher)
Good (Taylor)
You mentioned the doctor comes to your house, is there any other support that they offer
you? (Researcher)
Well, they ask me if I want to go to coffees and stuff like that, I don’t really go (Taylor)
Do you ever go into their offices? (Researcher)
No (Taylor)
How would you like to interact with the team? (Researcher)
I don’t know really, do what I’m supposed to (Taylor)
They drop off my medication daily, …..they’re a great team (Jesse)
I see them almost every day. They’re such a support. (Alex)
They check in on my every other day and I see them every couple of weeks for my
injection (Jamie)

41
When asked if they are involved in decisions regarding their treatment plans:
Ah yeah, sometimes (Taylor)
Do you have any examples that you would be willing to share? (Researcher)
Well, the doctor just comes to the house (Taylor)
So when the doctor comes to your house, how does that go? (Researcher)
Good (Taylor)
Good, ok so you find your interactions are good, the treatment is going good for you?
(Researcher)
Yes (Taylor)
Ah I went through a medication change and I had to go back to the hospital and I had to
go through a medication change and be monitored and come back out into the community
and I found that was a great help (Jesse)
Yes, they asked me about my housing and helped me with that (Alex)
Yeah, I asked about having a calm down pill available to me once a day if I needed it and
the doctor did that for me (Jamie)
As noted earlier in this chapter, it is possible that Taylor’s ambivalence regarding
engagement could be related to symptoms of their mental illness. Their responses are indicative
of attempts to engage by his treatment team with reluctance on their part. Jesse and Jamie credit
their level of engagement along with that of their team, for improving their mental health. Alex
regularly incorporated the word “support” in reference to their CTO.
Growth
As mentioned in the introduction to this chapter, the element of growth was distinctly
expressed by one of the four service users: Jesse. One definition of growth is a gradual increase
in development (Oxford Dictionary, 2022). In this context, growth is represented by the

42
development that Jesse identified in terms of positive life changes that occurred since being
prescribed a CTO.
When asked questions regarding life before a CTO:
I was living at home with my parents, and ah, yeah I lived at home with my parents, I
didn’t work
When asked about the transition from hospital to the community and what that felt like for them:
Like when I was in hospital, they were basically rehabilitating me and getting me ready
for like to go out in the community so when I went out in the community, I felt great I felt good to
go out in the community

Since being prescribed a CTO:
I did a work term, it was 8 weeks……I’m living on my own now
Jesse identified that prior to being prescribed a CTO, they had repeated hospital
admissions, were unable to live on their own, despite not wanting to live with their parents and
the inability to gain employment. They credit the changes in all three areas to the CTO
prescription while also acknowledging that taking their medication as prescribed and attending
scheduled appointments will result in the CTO eventually being discontinued.
I got everything, like everything I’m going through, like I’m going through counselling
and everything so like, everything, everything that was like I’m getting everything like basically
like years of struggling with mental illness like I didn’t know how to get help or nothing and I
finally got help, like I finally got help when I got put on this CTO pretty much, cause I was able
to get my life in order and back on track and everything.
The unique element of growth that was reflected in Jesse’s responses align with the
characteristics of an optimistic perspective. Optimism is sometimes referred to as a self-fulfilling
prophecy (GMAC, 2023) and Jesse’s responses are indicative of this. They understand the
benefits of their counselling and adhering to their medication regime and that continuing to do
this will foster continued successes.

43
Stigma
Stigma did not emerge as a concept from the interview data. Questions related to stigma
were asked of each participant due to knowledge gained from both the literature review and from
the researcher’s knowledge and experience. Stigma is when someone is viewed in a negative
way because they have a distinguishing characteristic or personal trait that is thought to be a
disadvantage (Mayo Clinic, 2017). CMHA notes that stigma originally meant a physical mark of
shame. Now, it’s an invisible mark that sets a person apart from others (CMHA, 2022). Stigma is
known to have strong influences on the lived experiences of people with mental illness, in nearly
every aspect of their lives. As such, it was expected by the researcher that interview participants
would report stigma and the effects of stigma on their lived experience with CTO.
It was admittedly unexpected to the researcher to find that neither service user reported
feeling stigmatized because of their CTO, thus contradicting much of what exists in the current
literature.
When asked specifically if there has been stigma or judgement experienced while being
on a CTO or if they felt they were being treated unfairly:
No (Taylor)
No (Jesse)
No (Alex)
No, I don’t feel stigma or like I’m being judged, when you’re that sick you don’t even
care about those things (Jamie)
At no point in the rest of the interviews did Taylor, Jesse, Jamie, or Alex indicate feelings
or perceptions that could be interpreted as being related to stigma. Thorough examination of the
data showed that neither mentioned concerns of others knowing their CTO status or reported

44
feeling that they were treated differently because of their CTO. Taylor’s comments of feeling
“trapped, like stuck on a fucking, like I’m supposed to be in jail or something. Makes me feel
like I’m a danger to society” are interpreted by the researcher as indicative of their personal
feelings about a CTO, rather than how they perceive others to treat them because of it.
Due to the fact that stigma was not reported in a meaningful way by any of the
participants, it was not included as a concept. However, it is worth noting that this is exceptional
in how strongly it diverges from what would be expected from the literature.
Summarizing Findings
Participants shared their experiences of being prescribed a CTO. The elements that
emerged were: “knowingness”, “confinement”, and “engagement”, with “growth” being unique
to one of the four participants. The unexpected finding of participants’ not experiencing stigma
because of their CTO was also noteworthy.
The findings from this study further highlight the differences that exist for an objective
treatment that is subjectively experienced. The potential rationale for the differences amongst
these participants, along with implications for the future of CTOs in NL are discussed in the next
chapter.

45
Chapter Five: Discussion
ID was employed to document the experiences of individuals who are prescribed
involuntary community treatment in NL. This study explored the experiences of four service
users with active community treatment orders and is the first known study of its kind to have
occurred within the province of NL. While overlapping of experiences were present, they were
minimal and highlighted the stark contrast between each individual’s experiences of their
community treatment journey. Three concepts emerged through data analysis: “knowingness”,
“confinement”, and “engagement”, along with an element unique to one of the service users;
“growth”.
This chapter begins with an integrated discussion of study findings and themes in the
context of current literature, followed by a reflection on the prescription of CTOs in NL. Next,
key considerations will be reviewed regarding implications for the future of CTOs in NL, and
finally, the strengths and limitations of the study and areas for future research are discussed.

Discussion of Findings
As discussed in Chapter two, most of the current literature is quantitative in nature and
existing qualitative studies, inclusive of service user input, lack Canadian context. Overall, many
aspects of the study’s findings are consistent with the literature with the added benefit of a
Canadian setting.
Knowingness
As noted in the introduction to this chapter, each service user’s experience of a CTO was
unique, aligning with Sheehan’s (2009) findings that compulsory treatment is an objective event
which is subjectively experienced by patients, families, and clinicians. Two of the service users
expressed not knowing why or how long they would be on a CTO, along with uncertainty of what

46
a CTO is and uncertainty if they received a copy of their treatment order. The NL MHCTA (2006)
states that individuals will receive a copy of their community treatment order as part of the
legislative commitment to ensuring their rights are upheld. These rights include access to a rights
advisor who in addition to explaining the rights of the person, may also provide the individual with
assistance in requesting a review of his or her community treatment order by the Mental Health
Care and Treatment Review Board (Government of NL, 2006).
Conversely, the third service user defined what a CTO is and along with the fourth service
user, provided an explanation of the circumstances surrounding their prescription, while also
confirming they received a copy of the plan. While this aligns with provincial legislation, I could
not find any research to date to support this level of knowingness in other service users of CTOs.
Lawn et al (2015) did conclude that most service users appeared to use moral framing to: try to
understand why they were placed on a CTO; make sense of the experience of being on a CTO; and
convey the lessons they have learnt.
Confinement
Swartz & Swanson (2019) note that if properly targeted and resourced, mandated
community treatment can offer a less-restrictive alternative to hospitalization with the goal of
ensuring that beneficial treatment is consistently maintained, rather than delaying intervention
until confinement is required. All service users reported being given a timeframe of when they
could expect their case manager to arrive, yet each described different feelings regarding this. The
perspective of the participant who felt “trapped”, gives a unique lens to confinement and its ability
to span outside of a locked facility. The preference of one service user to remain at home regardless
of CTO parameters is noteworthy as well.

47
While the concept of confinement is reflected in most of the current literature, it is primarily
from the query; should mandated community treatment exist? This often leaves a void in the
service user’s perspective regarding their own personal confliction when being faced with either
the prescription of a CTO or being admitted involuntarily to a mental health facility. Ridley and
Hunter (2013) and McMillian et al (2019) are some of the many researchers who have noted
conflicting views and sometimes highly contested beliefs regarding mandated community
treatment, while also acknowledging that little has been done in researching the direct experiences.
Engagement
In the context of this study, engagement referred to the level of involvement with ACTT
and their CTO treatment plan, the service users perceived to have. A 2019 mixed method study
from England concluded that individuals prescribed CTOs who are experiencing recovery, tend
to be less engaged in care plans (Haynes & Stroud, 2019). A 2015 study also from England
reported service user’s attempting to be engaged with their care team and treatment plan to avoid
hospitalization (Stroud et al, 2015). Both articles conclude that the perceptions of service users
have an important role in determining the value and potential effectiveness of CTOs.
Integrated Discussion of Emerging Concepts
These concepts reflect the high level of subjectivity that exist for CTO service users. While
there is overlap in the area of confinement, there are distinctions amongst levels of knowingness
and engagement. While the rationale for this is unknown at this time, potential reasoning may
include differences in individual literacy levels, varying levels of interest/feeling of importance of
engagement, therapeutic relationships within and outside of the care team, and other factors
affecting a person’s determinants of health at the time of and throughout their CTO prescription.

48
The potential to explore these areas will be discussed later in this chapter when reviewing
implications for the future of CTOs in NL.
While each participant’s outlook is unique, the majority of the findings within each of the
emerging concepts can be found within the current literature. The exception is the distinctive
element reported by one service user in terms of their growth since beginning their CTO journey.
This perspective has yet to be captured in any known literature and provides a platform for further
exploration into this area. Utilizing the ID approach, the researcher explores the concept of growth
in more detail.
Growth
Examples of growth since being prescribed a CTO, were notable during one service user’s
interview. This individual highlighted specific differences between their access to resources while
an inpatient in a hospital setting, compared to being in a home like community environment. This
perspective is supported by Mfoafo-M’Carthy’s 2014 research where individuals reported to have
an increased rapport with their clinical team, along with a sense of empowerment while on a CTO,
compared to an inpatient stay. Furthermore, Lofthus et al (2016) note that ACTT models focusing
on assertiveness, empowerment, and therapy relations result in increased satisfaction from CTO
service users.
Reflections on CTO Prescription in NL
CTOs became a part of NL’s MHCTA in 2008 and since their inception, the prescription
of CTO’s has risen consistently each year (Personal Communication, 2021). To be eligible for a
CTO in NL, a person is required to have at least three involuntary admissions to a mental health
facility in the past two years or have previously been on a CTO. Along with the risk of harming
self or others if care was not provided, other criteria for a CTO in NL includes the demonstration

49
of a lack of insight or understanding into the nature of one’s illness and need for treatment and
therefore, the individual would be unlikely to voluntarily agree to treatment. As well, if the person
does not avail of such services, then their mental status and level of functioning would continue to
deteriorate (Government of NL, 2007).
This was the first CTO for three of the four service users, with two of the four participants
acknowledging that prior to their CTO, they had repeated hospital admissions and did not fully
understand or appreciate the severity of their illness. From these service user’s viewpoint, the
prescription and management of CTOs in NL is appropriate and neither participant identified
suggestions for changes or improvements.
Map of Concepts – A Model of Care
As discussed in Chapter four, the data collected revealed a map of concepts that are relevant
to the lived experiences of individuals who are prescribed a CTO. This is evident by the conflicts
that exist between the service users within several of the concepts, while acknowledging that there
is equal importance for both the concepts themselves and the unique lived experience of them.
This led the researcher to consider a model for healthcare providers when they are working with
individuals prescribed a CTO. Broadly defined, a model of care refers to the way that health care
services are organized and delivered for a person as they progress through the stages of a condition,
injury, or event (May, 2013). The proposed Map of Concepts Model of Care provides a concept
map of the different areas that are important for healthcare providers to assess when they are
working with individuals who have been prescribed a CTO. Exploring these different areas with
an individual on a CTO will assist the provider in understanding what that individual is
experiencing with their prescribed CTO, and therefore, assist them to work with that individual.
For example, the contrasting views regarding the concept of “knowingness” could be used to

50
further explore and inform plans of care that are inclusive of each service user’s own unique
experiences, given their understanding of CTOs at this juncture. The series of guided interview
questions (Appendix C) has the potential to inform this model, while remaining within the
parameters of CTO prescription. This proposed model is applicable to the ACT and FACT Teams,
along with any other healthcare provider who would be involved in the care of an individual on a
CTO.

Care
Provider

Care
Provider

Confinement
Knowingness

Service User
Experiences

Engagement

Stigma

Growth
Care
Provider

Care
Provider

Community/
Other Sources

51

Model Analysis
The following is an analysis of the data collected, using Bacchi’s WPR approach and
Foucault’s (1988) concept of “governmentality” which accepts that rule develops in order to
maintain order within a population:
Questions

Responses

Analysis

What is the “problem”

Inability of individuals with

Jesse and Jamie

represented to be in NL’s

severe and persistent mental

recognized this inability

MHCTA?

illness to manage their own

within themselves.

treatment and care. Non-

Taylor and Alex did not

management could lead to harm

appear to. This

of themselves or others

intention/rule is stated
within the MHCTA.

What presuppositions underlie

Individuals with severe and

Jesse, Jamie, and Alex

this representation of the

persistent mental illness do not

acknowledged positive

“problem”?

have capacity to care for

life changes since their

themselves and maintain

CTO prescription. The

wellness independently.

MHCTA states the

Mandated Community

person must be capable

treatment (a CTO) would

of complying with the

alleviate/lessen this “problem”.

requirements for
treatment/care and
supervision set out in the

52
CTO. This rule therefore
suggests that an
individual must not have
enough capacity to
appreciate the nature of
their illness, but enough
to agree to follow the
terms of a CTO.
How has this representation of

CTOs became a part of the

Despite legislative

the “problem” come about?

MHCTA in 2006 as a means to

assumption that the

provide care to individuals with

community is less

severe and persistent mental

restrictive than hospital,

illness in a community setting.

Taylor felt confined in

Offered an alternative to

their community home.

hospital based mandatory

The MHCTA states that

treatment.

failure to comply with a
CTO can result in
apprehension and
conveyance to a
psychiatric facility.
While implemented as a
less restrictive means of
mental health care, this

53
research reveals levels of
restriction within the
CTO itself.
What is left unproblematic in

Individuals managed by a CTO

Two participants would

this problem representation?

often do not present/get

fall under this

Where are the silences?

admitted to hospital. It is

assumption while the

therefore assumed that they are

individual who has had

“healthy/doing well” on their

more than one CTO

CTO. Even though an

along with one other

individual may meet criteria for

participant’s experience

a CTO, it is the psychiatrist’s

reveals otherwise

decision to prescribe or not,

(pseudonyms not used here

potentially resulting in

to avoid possible

additional hospital

identification of participant

admissions/further
deterioration.

with previous CTOs). As

per the MHCTA,
treatment details for each
care provider shall be
stated in the treatment
plan, thus a presentation
to hospital should not be
the only sign that a CTO
service user is unwell.

54
Likewise, the question
arises; should a
psychiatrist’s preference
be a deciding factor for
an individual not to be
prescribed a CTO/the
ability to live in the
community setting and
receive intense
treatment?
What effects are produced by

Individuals are required to meet

All participants

this representation of the

criteria for a CTO and a case

identified having case

“problem”?

management team manages

management teams but

their mental health. This

with varying levels of

includes service users having a

involvement. CTO

fixed address and being present

criteria and treatment

for all appointments. A

plan management are

violation of a CTO could result

identified in the

in apprehension and

MHCTA. Only audits,

conveyance to a psychiatric

review board hearings,

facility.

(and potentially five-year
quality reviews), would
reveal the level of

55
involvement/treatment
carried out in the plan.
How and where has this

Part IV of the MHCTA

While none of the

representation of the “problem”

(Government of NL, 2006). A

participants identified

been produced, disseminated,

quality review of CTOs occurs

possible revisions for

and defended? How has it

every five years, most recently

CTOs, it is anticipated

been/and or can it be

in 2022. Revisions (i.e., change

that the 2022 report will

questioned, disrupted, and

in criteria) are expected. Since

yield changes in at least

replaced?

2017, a provincial recovery

one area. Additional

council reviews and advises on

research involving

such legislation. The ultimate

service users,

decision rests with the Minister.

ACT/FACT teams and
CTO prescribers, along
with public
consultations, could
delineate the “problem”
and CTO process further.

An analysis of Bacchi’s WPR approach, the Map of Concepts Model, Foucault’s idea of
“governmentality”, participant interviews, and the CTO legislation and resource material for
service users, yields several research findings. Firstly, the language in the CTO legislation, while
dated, accurately reflects a CTO prescription and therefore “rule” for the (CTO) “population
(echoed in Jesse’s and Jamie’s responses, only partially in Alex’s and, not in Taylor’s). Secondly,

56
the legislation itself does not accurately capture how each individual lives while on a CTO. While
the intention of a CTO treatment plan is the same for everyone (obtain safe affordable housing,
income support, social and community participation, accessible transportation, find meaningful
employment/volunteer work), only Jesse’s experience is fully reflective of a CTO doing what it is
“supposed” to do. Next, it is imperative that the researcher acknowledged the confines of finances
and availability while recognizing that safe and affordable housing provided as part of the plan,
may not be in an environment or geographical location conducive to a service user’s recovery (i.e.,
they may be placed somewhere that is available but not desirable to them). Finally, reviewing and
analyzing the MHCTA and resource materials alone, would not give full appreciation to the
experience of living on a CTO. Legislation is law (Oxford Dictionary, 2023), and void of any
individual context. Without Jesse, Jamie, Alex, and Taylor’s involvement in this research, it would
be reasonable to conclude that CTOs produce the same results for all those prescribed when all
steps of the MHCTA are followed.

Implications for the future of CTOs in NL
Government of NL
To ensure CTOs are implemented in accordance with service user needs and the
provisions in the MHCTA, in 2017, the Department of Health and Community Services initiated
a provincial quality assurance review of the processes surrounding the issuance, administration,
monitoring, and oversight of CTOs (Government of NL, 2017). This review has since been
established to occur every five years as a measure of quality improvement. One element of this
2017 review included interviews and focus groups with CTO service users, clinicians, and CTO
treatment team members. A significant finding from this review was the need for provincial

57
education regarding CTOs for both healthcare staff and service users. This ranged from staff
needs related to completing CTO documentation to service users needing education to better
understand the CTO legislation. This, and any future similar studies, will support these quality
assurance reviews as they add to the growing body of knowledge of the CTO service user’s
perspectives. This research is also timely in that the next review (2022) is due to be released in
2023 and it will be beneficial to determine if any changes in the review directly relate to the
service user’s experiences or if this research can, in part, guide the 2027 review. The
Government of NL’s website states that the Mental Health and Addictions Division is
responsible for providing leadership in the planning, development, implementation and
evaluation of provincial policies and programs related to mental health and addiction in NL. The
division works in partnership with the four regional health authorities, community groups, the
provincial Mental Health and Addiction Advisory Council and Recovery Council, family
members and individuals with lived experience, as well as other stakeholders in NL
(Government of NL, 2022). With this level of commitment, it is imperative that the lived
experience of CTO service users be embedded in all future provincial CTO planning.
CTO Management Teams
FACT and ACT teams provide intensive case management services to individuals with
severe mental illness, including those who have been prescribed a CTO (Train et al, 2021).
Chapter 2 described the limited literature reflective of service user’s experiences within Canada.
There is even less literature that explores the functioning of FACT and ACT teams in relation to
CTO management, however, such knowledge is important for future adjustments of innovation
processes and service systems. Since NL’s 2017 quality assurance review, there has been an
additional ACT Team developed along with 13 FACT teams implemented across the province,

58
therefore, given the immediate role of these interprofessional teams in a CTO plan, which is
reflective of a service user’s determinants of health, it is recommended that the future of CTOs
within this target group be reflective of an increase in contributions from these fields.
Service Users
This study gives written voice to those who are being mandated mental health care in the
community and provides invaluable information for those developing and revaluating community
service treatments. The experiences of this study’s service users, while vastly different from one
another, reflect what has been seen in the literature over the last decade. As more is known about
the relationship between CTOs and service user perspectives on them, it will be possible to
understand the benefits of CTOs more clearly in supporting individuals to live a more independent
and rewarding life in the community setting.

Strengths and Limitations
A review of the literature identified gaps regarding service user perspectives, most notably
within Canada. This research project explored the space where the service user’s viewpoints reside
and has provided a platform to incorporate these experiences into future decision-making
regarding CTO use. This study is also the first of its kind known to have occurred in the province
of NL, thus adding to the growing body of knowledge and literature surrounding the experiences
of service users who are prescribed CTOs. This project has laid the groundwork for future research
in this area, which will be explored further in the next section.

While this work holds significance, it is not without its limitations. While it was
anticipated that the uptake would not be high given the number of CTOs at the time of proposing
this project (22), several unforeseen circumstances occurred. These included a higher-than-

59
expected discontinuation of several CTOs (six discontinuations leaving 16 active at the time of
data collection) and staffing difficulties within the CTO management team that was used as the
gatekeeper. This resulted in a decreased capacity for staff to connect with an already decreased
participant pool. As such, generalizability of the study is limited, with four service users
consenting to participate. It is also noteworthy that all participants resided in the most CTO
resourced area of the province with access to ACTT, public transit, grocery, and social centres,
most of which is limited or non- existent in areas outside the province’s capital city. Finally,
even though these four service users met the legislative requirements for prescription of a CTO,
it was ultimately the decision of their prescribing psychiatrist of whether they were placed on
one or not, therefore, it is possible that the sample may reflect the opinions of only a few
psychiatrists who support CTO use.

Stigma
Given its strong reference in the literature, it was expected that the concept of stigma
would emerge from the data. Despite probing attempts with each of the participants, tangentially,
nothing alluded to stigma in a strong enough way to call it a concept. At this time, there is not
enough information to explain why stigma was absent and additional research is needed in this
area. Its dearth was unexpected and therefore noteworthy.
Areas for Future Research
In many developed areas of the world, including Canada, it remains unclear if CTOs can
reduce health service use, or improve clinical and social outcomes (Kisely, 2016). As such, it
would be beneficial to continue to seek the perspectives of CTO service users along with other
populations who are directly or indirectly involved with these treatment plans. Future areas for
research may include exploring experiences of psychiatrists who prescribe CTOs, members of

60
ACTT and FACTT who case manage these treatment plans, and experiences of family
members/caregivers of individuals who have been prescribed a CTO. Focus in these areas from a
Canadian context is preferable.

61
Chapter Six: Conclusion
Using ID and analysis, the researcher explored the lived experience of four
individuals who have been prescribed a CTO in NL. The findings demonstrate that a CTO is an
objective treatment that is subjectively experienced. The emerging concepts of “knowingness”,
“confinement”, “engagement”, and “growth” were explored, and comparisons and considerations
were drawn. Bacchi’s WPR approach was used to analyze the legislation and explore how the
structure of the MHCTA influence the lives of CTO service users.

The results of this research has the potential to inform future CTO use, as well as policy
development and decision making, regarding this mandated form of community treatment. This
research captured the perspectives of four service users and has provided invaluable information
for those developing and revaluating CTOs. This is the first known ID qualitative study to occur
within one of the Atlantic Canadian provinces and will add to the growing body of literature
surrounding service users’ experiences with CTOs.

In 2005-2006 NL had the highest rate of schizophrenic and psychotic disorders, the
highest rate of mood disorders and the third highest rate of substance-related disorders
(Newfoundland & Labrador Medical Association, 2019). In Canada, economic costs associated
with Mental Illness are estimated to be 51 billion dollars annually (Centre for Addiction &
Mental Health, 2019), and there is no indication that these costs will decrease in the coming
years. This research has the ability to contribute to a better understanding of the needs of the
service user population within the province and can support further Canadian research into the
area of CTO prescription.

62
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Appendix A: Invitation to Participate
Hello,
My name is Natasha Tobin and I am a Graduate Student at Brandon University. My background
is as a psychiatric registered nurse and I am currently working in a management role. I am reaching
out to you today by way of your ACT/FACT team, to invite you to take part in a research study
that I wish to conduct. This research is being undertaken in fulfillment of a masters program and
looks to explore an area that I have great interest in and to date, has not been well studied in NL.
Before you decide, I would like you to understand why the research is being done and what it
would involve for you. Please take the time to read the below information carefully and discuss it
with others if you wish. When you have read the information provided, you can contact me with
any questions you may have. It is your decision if you wish to participate in the study or not, but
please sign and return this letter to your case manager either way.

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As a token of thanks for your consideration and time, please accept this $5 Tim Horton’s Card. If
you decide to take part in this study, you will receive an additional $5 prepaid gift card at our
interview. This is to recognize your valuable time and contributions.
Purpose of the study
This is a study about the experiences of individuals who have been prescribed a community
treatment order (CTO). In an effort to explore this, I would like to meet with you in person and
ask a series of questions that will guide our discussion. In the event that pandemic restrictions
affect this, we can mutually agree on an alternative way to meet.
You have been invited to take part in the study as you are currently under the care of a CTO.
If you do not wish to participate in this research, you can sign and date the attached form and return
to your ACT/FACT team member. If you decide that you will participate, please sign and date the
attached form and once returned to your ACT/FACT team member, I will meet with you to review
and sign a letter of informed consent. This is needed for the purpose of accessing your health
record in relation to your CTO treatment plan. The only information that I require access to is the
physician order for your CTO and your name/MCP to confirm your identity. Even if you agree to
meet with me, you can still decide not to participate.
What is expected of me?
Once I receive your signature of participation and your informed consent, we will arrange a time
and location to meet and conduct the interview. During the interview, I will ask you questions
about what your life is like under a CTO, your thoughts and opinions about the CTO, and how it
has affected you. It is possible that this discussion may bring about emotions for you and
therefore I would like to offer the opportunity for you to bring a support person to the interview
if you’d like. The process will require approximately 2 hours of your time. There is no obligation
to take part in this study and if you change your mind and wish to withdraw, you may do so at
any point during the data collection process. Any requests to withdraw after September 30th
2022, will not be guaranteed as the research will be in its submission stage. If you withdraw
before this date, I will destroy all information that had been collected up to that point. Your
choice to participate, will in not affect your treatment plan in any way and your ACT/FACT
team will not be aware if you choose to participate or not.

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Confidentiality
Any information that I collect during the course of the study will be maintained on a confidential
basis and access will be restricted to myself and my thesis advisor, Katherine Pachkowski (she
will have access to coded information only). Your name will not be disclosed, nor will your details
be given to anyone. Your information will be secured electronically on a password protected USB
drive and in a locked filing cabinet in a secured office and will be permanently deleted and/or
shredded by the researcher upon thesis completion/publication. Should you wish to bring a support
person to your interview, they will be asked to sign a confidentiality agreement
What will happen to the results of the research study?
The overall findings of the study will be used to write my thesis and will be included in its
publication. They may also be published in a nursing journal, but these publications will not
mention individual people in any way. You will have the opportunity to review the results of the
study should you wish.

Concerns or complaints about the research
If you have a concern about any aspect of this study, please first reach out to your case manager,
who will then get in contact with me and I will do my best to answer your questions.
At any time, you may reach out to the Brandon University Research Ethics Committee at
burec@brandonu.ca.
If you have questions regarding your rights as a research participant please contact the Health
Research Ethics Authority at 709-777-6974 or info@hrea.ca.

Thank you for taking the time to read this information and for your consideration.

74

Exploring the Experiences of Individuals who are Prescribed
Involuntary Community Treatment In Newfoundland and Labrador
Researcher: Natasha Tobin

I _________________________ wish to participate in this research study. I understand that I may
withdraw at any time during the data collection process. I cannot be guaranteed withdrawal after
September 30th 2022.

__________________________

__________________________

75
(please print name)

(Date)

___________________________
(please sign name here)

Please return to your ACT/FACT team member during your next visit

Exploring the Experiences of Individuals who are Prescribed
Involuntary Community Treatment In Newfoundland and Labrador
Researcher: Natasha Tobin

I _________________________ do not wish to participate in this research study.

__________________________

__________________________

(please print name)

(Date)

76
___________________________
(please sign name here)

Please return to your ACT/FACT team member during your next visit

Appendix B: Informed Consent
Exploring the Experiences of Individuals who are Prescribed Involuntary Community
Treatment
Informed Consent
You have been invited to participate in a research study related to the experiences of individuals
who have been prescribed a community treatment order (CTO). You have already provided signed
consent of your willingness to voluntarily participate. At this stage, I will be gathering your
informed consent. If you have since changed your mind and no longer wish to participate, you may
withdraw from the study without judgement or penalty. You can still keep the $5 Tim Horton’s
card that you received in your letter of invitation to participate.
Purpose of the study
This is a study about the experiences of individuals who have been prescribed a community
treatment order (CTO). In an effort to explore this, I would like to meet with you face to face and

77
ask a series of questions that will guide our discussion. I will take notes during our session and it
will also be audio recorded. I will be the only one to transcribe the information collected.
What is expected of me?
Once I have your signature of participation and your informed consent, we will arrange a time and
location to meet and conduct the interview. This entire process will require approximately 2 hours
of your time. The questions will ask about your CTO experience and any challenges or
recommendations you may have in relation to this treatment. There is no obligation to take part in
this study and if you change your mind and wish to withdraw, you may do so at any point during
the data collection process. Any requests to withdraw after September 30th 2022, will not be
guaranteed as the research will be in its submission stage. If you withdraw before this date, I will
destroy all information that had been collected up to that point. Your choice to participate, will in
no way affect your treatment plan.
What are the risks/benefits of this study?
It is possible that these discussions may bring about emotions for you and therefore I would like
to offer the opportunity for you to bring a support person to the interview if you’d like. I will also
have a list of crisis supports immediately available should you need them. Potential privacy risks
that may be associated with the fact that I will be collecting directly identifying information, will
be mitigated this in the following ways:


I will only obtain the information noted in the participant invite and informed consent;



All information collected will be securely stored and destroyed after my thesis publication;



All publication information will be coded and anonymized as to not risk identification of
you or any other participants

The benefit of this study is that it will contribute to the growing knowledge base surrounding the
use of CTO’s and has the potential to inform future decisions regarding CTO use in the province
of NL.
Confidentiality

78
Any information I collect during the course of the study will be maintained on a confidential basis
and access will be restricted to myself and my thesis advisor, Katherine Pachkowski. Your name
will not be disclosed, nor will your details be given to anyone. Your information will be secured
electronically on a password protected USB drive and in a locked filing cabinet in the researcher’s
secured office. Should you wish to bring a support person to your interview they will be asked to
sign a confidentiality agreement.
Representatives from the Health Research Ethics Board may come to look at the study records and
your personal health information under the supervision of study staff to check that the information
collected for the study is correct and to make sure the study followed the required laws and
guidelines.
What will happen to the results of the research study?
The overall findings of the study will be used to write my thesis and included in its publication.
They may also be published in a nursing journal or submitted as a policy brief to the provincial
government. These documents will not mention individual people in any way. You will have the
opportunity to review the results of the study should you wish. This can be facilitated if you choose
to share a way that I can contact you once this research has concluded. Any information collected
will

be permanently deleted and/or shredded by the researcher following thesis

completion/publication.
Concerns or complaints about the research
If you have a concern about any aspect of this study, please first reach out to your case manager,
who will then get in contact with me and I will do my best to answer your questions.
At any time, you may reach out to the Brandon University Research Ethics Committee at
burec@brandonu.ca and or my thesis advisor Katherine Pachkowski at
pachkowskik@brandonu.ca.
If you have questions regarding your rights as a research participant please contact the Health
Research Ethics Authority at 709-777-6974 or info@hrea.ca.
The researcher will not commercialize any research findings, and there is no potential or perceived
conflicts of interest on the part of the researcher or their institutions. By consenting to participate

79
in this study, you have not waived any legal rights to legal recourse in the event of research related
harm.
In the event that you experience emotional distress during our time together, access to the NL
HealthLine (811) will be immediately available.
If you wish to review the results of this study, please provide a method of contact:
________________________________

I have read and I understand the provided information and have had the opportunity to
ask questions. I understand that my participation is voluntary and that I am free to
withdraw at any time prior to September 30th 2022, without giving a reason and without
penalty. I understand that I will be given a copy of this consent form. I voluntarily agree to
take part in this study.
Participant's signature ______________________________ Date __________
Researcher’s signature _____________________________ Date ___________

80

Appendix C: Guided Interview Questions
1. What is your understanding of what a CTO is?
2. What is your understanding of why you were placed on a CTO? How did it feel to go
from the hospital to mandated treatment in the community? How do you see yourself
getting “off” of the CTO?
3. Were the rules of the CTO explained to you before you were placed on it and did you
understand them? Were you given a copy of it?
4. How involved are you in making decisions about your treatment since being on a CTO?
Can you share some examples? How do you feel about this?

81
5. What support does ACTT/case manager/physician provide to you as part of their contact
with you?
6. How has being on a CTO impacted your life? Do you feel like you have choices? What if
any, is the stigma like for you?
7. Do you feel that life has changed since being on a CTO? If so, how?
8. When you think about the CTO, what words come to mind?
9. How could mental health services improve how they provide support to people on a
CTO?
10. Do you have any other comments to share about your experience of being on a CTO?

Appendix D: Confidentiality Agreement
Exploring the Experiences of Individuals who are Prescribed Involuntary Community
Treatment
Confidentiality Agreement – Support Person

I, ____________________, support person, for ___________________who is participating in
the research project titled “Exploring the Experiences of Individuals who are Prescribed
Involuntary Community Treatment in Newfoundland and Labrador”, agree to:

82
Not disclose information about the participation of the individual in the research study or what
was discussed during the interview, with anyone other than the participant.

Support Person's signature ______________________________ Date __________
Researcher’s signature _____________________________

Date ___________

Appendix E: List of Crisis Supports
Exploring the Experiences of Individuals who are Prescribed Involuntary Community
Treatment
Crisis Supports



NL HealthLine



Lifewise Peer Support Line



Mental Health and Addictions System Navigator

811
753-2560/ 1-855-753-2560
752-3916 /1-877-999-7598

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Appendix F: Ethics Certificates

Ethics Certificate for Research Involving Human Participants
Brandon University Research Ethics Committee (BUREC)

The Brandon University Research Ethics Committee (BUREC) has reviewed and approved the
following ethics proposal in accordance with the current Tri-Council Policy Statement: Ethical
Conduct for Research Involving Humans (TCPS2-2018), the Brandon University Policy on
Research Involving Humans, and the Brandon University Research Ethics Committee (BUREC)
Policies and Procedures.

84

Title of Project:

Principal Investigator:

Exploring the Experiences of Individuals who are Prescribed
Involuntary Community Treatment in Newfoundland and
Labrador
Ms. Natasha Tobin, Brandon University

Co-investigators:

n/a

Faculty Supervisor:

Prof. Katherine Pachkowski, Brandon University

Research Ethics File #:

22963

Date of Approval:

March 21, 2027

Ethics Expiry Date:

March 21, 2027

Conditions of Approval:
This approval is subject to adherence to the Brandon University Research Ethics Committee
(BUREC) Policies and Procedures, including the following conditions:
1.

Approval is granted only for the research and purposes as described in the ethics
application.

2.

Ethics Certification is valid for up to five (5) years from the date approved, pending receipt
of Annual Progress Reports and a Final Report at the conclusion of the project. Failure to
fulfill the continuing research ethics review requirements is considered an act of noncompliance and may result in the suspension of active ethics certification and/or refusal to
review and approve any new research ethics submission. For more information, please
refer to the Brandon University Research Ethics Committee (BUREC) Policies and
Procedures, and the Brandon University Research Ethics Committee (BUREC) NonCompliance Policy and Procedures.

3.

All changes made to the approved protocol must be reported to the BUREC and an
Amendment Application may be required prior to implementation. See Brandon University
Research Ethics Committee (BUREC) Policies and Procedures for more detail.

4.

Any deviations to the research or unanticipated issues/events must be reported to the
BUREC as soon as possible. For more information, please refer to the BUREC Reporting
Unanticipated and Events Issues Standard Operating Procedure.

For information about Brandon University Research Ethics policies and procedures in relation to this project or in
general, please visit www.brandonu.ca/burec or email burec@brandonu.ca.

85
Acting Chair, Brandon University Research Ethics Committee (BUREC)

270 18th Street, Brandon MB, Canada R7A 6A9

HREB
March 31, 2022

20 Brad Gushue Crescent
St. John's NL AIH OA4
Dear Ms Tobin:

Researcher Portal File # 20222586
Reference # 2022.036
Research Ethics Office
Suite 200, Eastern Trust Building

204.727.9712

BrandonU.ca

86
95 Bonaventure Avenue
St. John's, NL

AIB

84

RE: The Lived Experience of Community Treatment Orders
Your application was reviewed by [the Health Research Ethics Board (HREB) at the meeting
held on March 10, 2022 and your response was reviewed by the Acting Chair and the following
decision was rendered:

X Approval
Approval subject to changes

Rejection
Ethics approval is granted for one year effective March 30, 2022. This ethics approval will be
reported to the board at the next scheduled HREB meeting.
This is to confirm that the HREB reviewed and approved or acknowledged the following
documents (as indicated):
Application, approved
Research proposal, approved
Informed Consent (Final), approved
Letter of Invitation, approved
Confidentiality agreement - Support person, approved
List of crisis supports , approved Invite to participate (final), approved

Signed variable list, approved
Guided Interview Questions, approved
Please note the following:
This ethics approval witl lapse on March 30, 2023. It is your responsibility to ensure that the
Ethics Renewal form is submitted prior to the renewal date. This is your ethics approval
only. Organizational approval may also be required. It is your responsibility to seek the
necessary organizational approvals.
Modifications of the study are not permitted without prior approval from the HREB. Request
for modification to the study must be outlined on the relevant Event Form available on the
Researcher Portal website.

Though this research has received HREB approval, you are responsible for the ethical
conduct of this research.
If you have any questions please contact info@hrea.ca or 709 777 6974.
The HREB operates according to the Tri-Council Policy Statement: Ethical Conduct for
Research Involving Humans (TCPS2), ICH Guidance E6: Good Clinical Practice
Guidelines (GCP), the Health Research Ethics Authority Act (HREA Act) and applicable
laws and regulations.

88
We wish you every success with your study.

Sincerely,

Dr Naomi Ml en-Anderson
Acting Chair Non-Clinical Trials Committee
Health Research Ethics Board

You Have Received Ethics Approval. Now What?: HREB Reporting
Requirements
Once a study has received ethics approval from the Health Research Ethics Board (HREB), there
are still associated reporting requirements. In the conduct of approved research researchers are
required to report to the HREB, in a timely manner, proposed changes from approved research
that affect participants at any stage of the process. This includes, but is not limited to, changes to
the consent form, changes to the tasks or interventions involved in the research, or changes to
measures to protect privacy and confidentiality.

Any substantive change to the research should not be implemented prior to
documented approval by the HREB, except when necessary to eliminate an immediate
risk(s) to the participants. Below are examples of post approval documentation that
must be submitted to the HREB:
Amendments
Any proposed change in the conduct of a study must be submitted to the HREB, and approved,
before the change may be implemented. Such changes might include modification of recruitment
procedures, inclusion or exclusion criteria, revised sample size, addition or deletion of study sites,
changes to an intervention, consent forms, questionnaires or scripts, etc. If there are changes in
project team members or changes to funding source(s)/sponsor(s), there are specific forms to
complete to report this to the HREB.

Adverse Events
Serious and unanticipated adverse events that occur within Newfoundland and Labrador are
required to be reported to the HREB. Such events may occur in both clinical trials and in other
types of research, e.g. collapse during a rehabilitation program, emotional breakdown requiring
follow up care during an interview, or breach of privacy during correspondence. Serious
adverse events that are fatal or life-threatening are required to be reported to the HREB as soon
as the research team is aware of the event.

89

Protocol Deviations
Deviations from an approved study protocol must be reported to the HREB. Changes that
eliminate immediate hazards to participants do not require prior approval, but must be reported
soon as reasonably possible.

Safety Reports
Safety reports providing information on all serious adverse events (SAEs) occurring in a clinical
trial must be provided by the sponsor to the HREB, normally on a three or six monthly basis (i.e.
in accordance with the specified reporting timelines that were outlined in the approved ethics
application).

Investigator Brochure (1B) and Product Monograph (PM)
Throughout the course of a clinical trial, changes may be implemented to study documents. Al
revisions to approved study documents must be submitted to the HREB to ensure the record is up
to date. If the revisions include new risk or safety information there may be a requirement to
notify research participants.

Ethics Renewal/Study Closure
Ethics approval lasts for one year. Ethics renewal is required annually, on the anniversary of the
date of the HREB notification of approval. Once data collection is no longer ongoing, a study
closure form is required to be submitted to the HREB for the study to remain active or to be
closed in good standing.

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Department of Research
5th Floor Janeway Hostel
Health Sciences Centre
300 Prince Philip Drive
St. John’s, NL A1B 3V6
Tel: (709) 752-4636
Fax: (709) 752-3591

May 5, 2022

Ms. Natasha Tobin
20 Brad Gushue Crest
St. John’s, NL
A1H 0A4
Dear Ms. Tobin,
Your research proposal HREB Reference #: 2022.036 “The Lived Experience of
Community
Treatment Orders” was reviewed by the Research Proposals Approval Committee (RPAC) of
Eastern Health May 3rd, 2022, and we are pleased to inform you that the proposal has been
granted full approval.
The approval of this project is subject to the following conditions:
• The project is conducted as outlined in the HREB approved protocol;
• Adequate funding is secured to support the project;
• In the case of Health Records, efforts will be made to accommodate requests based
upon available resources. If you require access to records that cannot be
accommodated, then additional fees may be levied to cover the cost;
• A progress report being provided upon request.
If you have any questions or comments, please contact Krista Rideout, Manager of the Patient
Research Centre at 777-7283 or by email at krista.rideout@easternhealth.ca.
Sincerely,

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Krista Rideout
Manager, Patient Research Centre
Co-Chair, RPAC
KR/rg

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Appendix G: TCPS 2

PANEL ON
RESEARCH ETHICS

TCPS 2: CORE 2022

Navigating the ethics of human research

Certificate of Completion
This document certifies that

Natasha Renouf
successfully completed the Course on Research Ethics based on
the Tri-Council Policy Statement: Ethical Conduct for Research
Involving Humans (TCPS 2: CORE 2022)
Certificate # 0000443926

11 September, 2018