Using ethnography to explore causality in mental health policy and practice

Abstract

This article discusses the early findings of an on-going ethnographic study which is exploring the implementation of Community Treatment Orders (CTOs) in English mental health services, a process in which social work practitioners are closely involved. CTOs are present in a number of countries, and most recently in 2008 were enacted in England and Wales with the policy purposes of reducing ‘revolving door’ admissions, increasing the ability of clinicians to manage risk and encouraging recovery. They work by imposing conditions on how mental health service users live in the community as well as providing a mechanism for them to be recalled for treatment in hospital if they fail to meet those conditions. Perhaps unsurprisingly, their introduction has brought with it debate on the ethical implications of extending compulsory treatment into the community. The majority of research on CTOs has tended to ask the question, ‘Do they work?’ In this article I argue that ethnography may help to address a more ethically engaged and pertinent question for social work practice, namely, ‘Who might CTOs work for, in what circumstances and why?’ Immersion in service settings over an extended period enabled the incorporation of contextual factors and causal mechanisms into the analysis, which in turn has led to a consideration of the nature of CTO outcomes. This approach draws upon ideas about the role of qualitative research in exploring causality, and consideration is given to how the research may fit within some form of a realist framework.