Hannah Jobling. 'Policy Ethnography: Creating Stories of Causality', Mental Health Qualitative Research Network, Rethink, London, 11 March 2013.

1. Policy Ethnography:
Creating Stories of
Causality
Hannah Jobling, PhD student
Department of Social Policy and Social Work, University of
York

2. Overview
• Community Treatment Orders (CTOs) in England
and Wales
• Ethnography as the methodological approach
• Findings – CTOs in practice: The creation of a
typology
• Stories of causality: How we can ‘read’ these
findings to help develop an understanding of
who CTOs work for in what circumstances
(context), why (mechanisms) and with what
consequences (outcomes)
• Realism and ethnography

3. CTOs: Background
• Enacted in around 70 jurisdictions worldwide, including USA,
Canada, Australia, New Zealand
• Introduced in England and Wales under the Mental Health Act 2007,
became ‘live’ in late 2008.
• Allow for conditions to be imposed on how mental health service
users live in the community
• Provide a mechanism for detention and treatment enforcement if
conditions are not met, or health & safety concerns
• CTOs “enforce community treatment outside (and independently) of
the hospital, contain specific mechanisms for enforcement and/or
revocation and are authorised by statute” (Churchill et al, 2007, 20)
• Three drivers highlighted in policy and research literature:
• Revolving door (resources)
• Risk management
• Rehabilitation and recovery

4. CTOs: Research Responses to
Policy Problems
• CTOs probably the most controversial aspect of new Act:
• On one hand – help to engage service users, reduce rates of
hospitalisation, improve clinical outcomes and promote stability
• On the other – extend compulsion, result in unnecessary
coercion, loss of rights and neglect of alternative options
• A lot of research (mainly outside the UK):
• (Quasi) experimental > Outcomes > Hospitalisation rates,
treatment compliance etc. Methodological difficulties and
equivocal findings (Churchill et al, 2007).
• Surveys > mostly psychiatrists > mostly positive
• Qualitative research > Focus groups and interviews > families
(mostly positive) and service users (ambivalence)

5. An Ethnography of CTOs
• Considerable scope for finding out how CTOs are
practiced and what that might mean
• A CTO ethnography:
• Enables “the particular context of social actors and groups
and the social matrices of their thoughts and behaviour”
(Swanson, 2010, 185) to be accounted for
• Connects stakeholder experiences to CTO-related events as
they occur
• Allows for CTOs to be viewed as a process, unfolding over
time, mediated by contextual factors
• Illuminates what CTO practice looks and feels like – joins
abstract political concerns with concrete ethical dilemmas
• And by doing all this, enables why, for who and when
questions to be asked about CTO outcomes

6. The Study
• Aim: To find out in what ways CTOs are being implemented
and with what implications for the practice and experiences of
service users and practitioners.
• Case study design: Two Trusts > One AOT in each Trust > 18
CTO cases across the field sites
• Fieldwork took place over 8 months and tracked the progress
of the 18 cases:
• Interviews (some repeat) with 18 service users and 20
practitioners
• Observation of key meetings, daily practice and informal
interactions
• Content analysis of case files
• Additional research activities:
• Key informant interviews with 16 practitioners
• Content analysis of Trust policy

7. Analysis
• Combination of narrative and thematic approaches:
• Progress over time in cases – looking backwards and
forwards
• Conceptual patterns across cases
• Observations and interviews – narratives as making agency (or
lack of) meaningful – interplay of context and action
• Formation of CTO pathways by using ‘configurational’ maps
(Sayer, 2000) to cluster narratives
• Development of a CTO typology: Active/Passive,
Acceptance/Resistance, plus additional categories of
Subversion and Ambivalence
• Institutional means and societal goals (Merton)plus actions
individuals take in response to these

8. Case study: Active acceptance
• James
• Active acceptance something to be worked at from initial discharge
• Taking ownership – ‘it belongs to me’
• Taking control - ‘I felt that part of my Community Treatment Order and
part of my injections were in conflict because I didn’t feel in control of
my injections. I was being told you’ve got to have them. It felt like the
responsibility had been taken out of my hands. It was in the hands of the
nurses here and the doctors here and I thought, well, that’s not fair
because my CTO says I’ve got to be responsible; I’ve got to be in charge
and then, when I went up to the medical centre and they started doing it,
I settled down a bit better.’
• Key factors:
•
•
•
•
Negotiation of medication
Collaborative work – ‘mutuality of accounts’
Making sense of the CTO – developing purpose
On-going explanation and development of legal consciousness

9. Case study: Active Resistance
• Active resistance either through use of legal mechanisms or
avoidance
• Sheila
• Bioethical balancing act – ‘she’s not a risk to others or really to
herself, but It’s a really tight-knit community where she lives and
everyone knows her. She’d only just built up trust again there and
now…So I think it’s about supporting her in the community really’
• Reinforcement of barriers to care and support – ‘she’s not on my
side’
• No hope of discharge by either Sheila or her care coordinator
• Key factors:
• Repeat recalls – reinforcing cycles of resistance
• ‘Surface’ work
• Making sense of the CTO – previous difficult experiences

10. Stories of Causality
• Context affects the way individuals respond to the programme
concept, which in turn influences the ways they interact with
programme intervention strategies, which then form outcomes.
• Context
• Refers both to the characteristics of those individuals made subject
to a policy programme and the institutional and micro-social factors
that mediate their experiences.
• Complex interactions between personal values and beliefs, and past
and present experiences of services, medication and relationships
with professionals.
• Mechanisms
• Refers to the “process of how individuals interpret and act upon the
intervention strategies” (Pawson and Tilley, 2004, 6).
• Recall as an intervention paradox
• Outcomes
• Multiple intended and unintended consequences of relationship
between mechanisms and context.
• Judging ‘success’ or ‘failure’
• Moving beyond ‘effectiveness = ethically sound’

11. Realism and ethnography
• Realism:
• Bridge between positivism and interpretivism
• Generative rather than predictive explanation of
causality
• Mid-range theory and generalisation
• In policy arena, associated with mixed methods
• Sayer (2000) – ‘intensive designs’
• Hammersley and Atkinson (2007) – ethnography and
subtle realism
• Thick description and developing a sense of
verisimilitude - ‘saying something of something’

12. References
• Churchill, R, Owen, G, Singh, S & Hotopf, M, (2007), International
Experiences of Using Community Treatment Orders, London:
Institute of Psychiatry, Kings College London.
• Hammersley, M. and Atkinson, P. (2007), Ethnography: Principles in
Practice, (3rd Ed.) London: Routledge.
• Pawson, R. and Tilly, N. (2004), Realist Evaluation, London: Cabinet
Office
• Sayer, A. (2000), Realism and Social Science, London: Sage
• Swanson, J. (2010), ‘What would Mary Douglas do? A commentary
on Kahan et al., “Cultural cognition and public policy: The case of
outpatient commitment laws”’, Law and Human Behaviour, 34, 176185.
• This paper is under review for a special issue of the Journal
Qualitative Social Work: ‘Ethnography – Practice and Theory in Social
Work Research’.