title: Examining the use of metaphors to understand the experience of community treatment orders for patients and mental health workers.
abstract: BACKGROUND
  Community Treatment Orders (CTOs) are often complex because of the ethical tensions created by an intervention that aims at promoting the patient's good through an inherently coercive process. There is limited research that examines the complexity of CTOs and how patients on CTOs and workers administering CTOs make sense of their experiences.
  
  
  METHODS
  The study involved in-depth interviews with 8 patients on CTOs and 10 community mental health workers in South Australia, to explore how they constructed their experiences of CTOs. Critical discourse analysis (CDA) was used to analyse the data, supported by NVIVO software.
  
  
  RESULTS
  Analysis of the interviews revealed that patients and workers experienced the CTO process as multi-dimensional, including some positive as well as more negative constructions. The positive metaphor of CTOs as a safety net is described, followed by a more detailed description of the metaphors of power and control as the dominant themes, with five sub-themes of the CTO as control, wake-up, punishment, surveillance, and tranquiliser.
  
  
  CONCLUSIONS
  Metaphors are a way that mental health patients and mental health workers articulate the nature of CTOs. The language used to construct these metaphors was quite different, with patients overwhelmingly experiencing and perceiving CTOs as coercive (that is, punishing, controlling and scrutinizing), whereas workers tended to perceive them as necessary, beneficial and supportive, despite their coerciveness.
  
  
  CONCLUSIONS
  By acknowledging the role of metaphors in these patients' lives, workers could enhance opportunities to engage these patients in more meaningful dialogue about their personal experiences as an alternative to practice predominantly focused on risk. Such a dialogue could enhance workers' reflection on their work and promote recovery-based practice. More understanding of how to promote autonomy, capacity and supported decision-making, and how to address the impacts of coercion within care, is needed.
authors.affiliation: Flinders Human Behaviour and Health Research Unit, Department of Psychiatry, Flinders University, Room 4 T306 Margaret Tobin Centre, PO Box 2100, Adelaide, South Australia, 5001, Australia. sharon.lawn@flinders.edu.au.
authors.forename: Sharon
authors.initials: S
authors.lastname: Lawn
authors.affiliation: Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, South Australia, Australia.
authors.forename: Toni
authors.initials: T
authors.lastname: Delany
authors.affiliation: Discipline of Public Health, Flinders University, Adelaide, South Australia, Australia.
authors.forename: Mariastella
authors.initials: M
authors.lastname: Pulvirenti
authors.affiliation: C/o Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia.
authors.forename: Ann
authors.initials: A
authors.lastname: Smith
authors.affiliation: The Bioethics Centre, University of Otago, Dunedin, New Zealand.
authors.forename: John
authors.initials: J
authors.lastname: McMillan
mesh_terms: D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D001315:Australia; D003156:Community Mental Health Services / Q000379:methods* / Q000706:statistics & numerical data; D005069:Evaluation Studies as Topic; D005260:Female; D006282:Health Personnel / Q000523:psychology* / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D001523:Mental Disorders / Q000523:psychology / Q000628:therapy*; D028642:Persons with Psychiatric Disorders / Q000523:psychology* / Q000706:statistics & numerical data; D019365:Metaphor; D055815:Young Adult
keywords: Coercion; Community mental health; Community treatment orders; Control; Metaphors; Patients’ perspectives