Ambivalence about community treatment orders

Recovery of Offenders Formerly Labeled as Not Criminally Responsible: Uncovering the Ambiguity From First-Person Narratives

The recovery paradigm is a widely accepted strength-based approach in general mental health care. Particular challenges arise when applying this paradigm in a forensic context. To address these issues, the present study examined recovery based on first-person narratives of offenders formerly labeled as not criminally responsible of whom the judicial measure was abrogated. Eleven in-depth interviews were conducted to obtain information on lived experiences and recovery resources of this hard-to-reach and understudied population. The interviews focused on recovery and elements that indicated a sense of progress in life. Key themes were derived from the collected data. Descriptions of recovery resources followed recurrent themes, including clinical, functional, social, and personal resources. Participants also reported ambiguous experiences related to features of the judicial trajectory. This was defined as forensic recovery and can be seen as an additional mechanism, besides more established recovery dimensions, that is unique to mentally ill offenders.

Community treatment orders in England and Wales: national survey of clinicians' views and use

Aims and method

To ascertain the views and experiences of psychiatrists in England and Wales regarding community treatment orders (CTOs). We mailed 1928 questionnaires to members of the Royal College of Psychiatrists.

Results

In total, 566 usable surveys were returned, providing a 29% response rate. Respondents were generally positive about the introduction of the new powers, more so than in previous UK studies. They reported that their decision-making regarding compulsion was based largely on clinical grounds.

Clinical implications

In the absence of research evidence or a professional consensus about the use of CTOs, multidisciplinary input in decision-making is essential. Further research and training are urgently needed.

Coercion in mental health: a trial of the effectiveness of community treatment orders and an investigation of informal coercion in community mental health care

Background

Coercion comprisesformal coercionorcompulsion[treatment under a section of the Mental Health Act (MHA)] andinformal coercion(a range of treatment pressures, includingleverage). Community compulsion was introduced in England and Wales as community treatment orders (CTOs) in 2008, despite equivocal evidence of effectiveness. Little is known about the nature and operation of informal coercion.

Design

The programme comprised three studies, with associated substudies: Oxford Community Treatment Order Evaluation Trial (OCTET) – a study of CTOs comprising a randomised controlled trial comparing treatment on CTO to voluntary treatment via Section 17 Leave (leave of absence during treatment under section of the MHA), with 12-month follow-up, an economic evaluation, a qualitative study, an ethical analysis, the development of a new measure of capabilities and a detailed legal analysis of the trial design; OCTET Follow-up Study – a follow-up at 36 months; and Use of Leverage Tools to Improve Adherence in community Mental Health care (ULTIMA) – a study of informal coercion comprising a quantitative cross-sectional study of leverage, a qualitative study of patient and professional perceptions, and an ethical analysis.

Participants

Participants in the OCTET Study were 336 patients with psychosis diagnoses, currently admitted involuntarily and considered for ongoing community treatment under supervision. Participants in the ULTIMA Study were 417 patients from Assertive Outreach Teams, Community Mental Health Teams and substance misuse services.

Outcomes

The OCTET Trial primary outcome was psychiatric readmission. Other outcomes included measures of hospitalisation, a range of clinical and social measures, and a newly developed measure of capabilities – the Oxford Capabilities Questionnaire – Mental Health. For the follow-up study, the primary outcome was the level of disengagement during the 36 months.

Results

Community treatment order use did not reduce the rate of readmission [(59 (36%) of 166 patients in the CTO group vs. 60 (36%) of 167 patients in the non-CTO group; adjusted relative risk 1.0 (95% CI 0.75 to 1.33)] or any other outcome. There were no differences for any subgroups. There was no evidence that it might be cost-effective. Qualitative work suggested that CTOs’ (perceived) focus on medication adherence may influence how they are experienced. No general ethical justification was found for the use of a CTO regime. At 36-month follow-up, only 19 patients (6% of 329 patients) were no longer in regular contact with services. Longer duration of compulsion was associated with longer time to disengagement (p = 0.023) and fewer periods of discontinuity (p < 0.001). There was no difference in readmission outcomes over 36 months. Patients with longer CTO duration spent fewer nights in hospital. One-third (35%) of the ULTIMA sample reported lifetime experiences of leverage, lower than in the USA (51%), but patterns of leverage experience were similar. Reporting leverage made little difference to patients’ perceived coercion. Patients’ experiences of pressure were wide-ranging and pervasive, and perceived to come from family, friends and themselves, as well as professionals. Professionals were committed to patient-centred approaches, but felt obliged to assert authority when patients relapsed. We propose a five-step framework for determining the ethical status of offers by mental health professionals and give detailed guidance for professionals about how to exercise leverage.

Conclusions

Community Treatment Orders do not deliver clinical or social functioning benefits for patients. In the absence of further trials, moves should be made to restrict or stop their use. Informal coercion is widespread and takes different forms.

Trial registration

Current Controlled Trials ISRCTN73110773.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Care planning for consumers on community treatment orders: an integrative literature review

BACKGROUND

Case management is the established model for care provision in mental health and is delivered within current care philosophies of person-centred and recovery-oriented care. The fact that people with a mental illness may be forced to receive care and treatment in the community poses challenges for clinicians aiming to engage in approaches that promote shared decision-making and self-determination. This review sought to gain an in-depth understanding of stakeholders' perspectives and experiences of care planning for consumers' on CTOs.

METHODS

An integrative review method allowed for inclusion of a broad range of studies from diverse empirical sources. Systematic searches were conducted across six databases. Following appraisal, findings from included papers were coded into groups and presented against a framework of case management.

RESULTS

Forty-eight papers were included in the review. Empirical studies came from seven countries, with the majority reporting on qualitative methods. Many similarities were reported across studies. Positive gains from CTOs were usually associated with the nature of support received, highlighting the importance of the therapeutic relationship in care planning. Key gaps in care planning included a lack of connection between CTO, treatment and consumer goals and lack of implementation of focussed interventions.

CONCLUSIONS

Current case management processes could be better utilised for consumers on CTOs, with exploration of how this could be achieved warranted. Workers need to be sensitive to the 'control and care' dynamic in the care planning relationship, with person-centred approaches requiring core and advanced practitioner and communication skills, including empathy and trust.

Perceptions Among Psychiatric Staff of Creating a Therapeutic Alliance With Patients on Community Treatment Orders

A therapeutic alliance with a continuing collaboration between a patient and psychiatric staff is a resource for helping patients cope with the demands of coercive legislation. Knowledge exists describing coercion in inpatient care while the knowledge regarding the perceptions of creating a therapeutic alliance with patients on Community Treatment Orders (CTO) among psychiatric staff is scarce. To describe perceptions among psychiatric staff of creating a therapeutic alliance with patients on CTOs, an exploratory design using a phenomenographic method was employed. Thirteen semi-structured audio-taped interviews were conducted with psychiatric staff responsible for patients on CTOs. The staff worked in five different outpatient clinics and the interviews were conducted at their workplaces. The analysis resulted in in four metaphors: the persevering psychiatric staff, the learning psychiatric staff, the participating psychiatric staff, and the motivating psychiatric staff. Patients on CTOs were more time-consuming for psychiatric staff in care and treatment. Long-term planning is required in which the creation of a therapeutic alliance entails the patient gradually gaining greater self-awareness and wanting to visit the outpatient clinic. The professional-patient relationship is essential and if a therapeutic alliance is not created, the patient's continued care and treatment in the community is vulnerable.

Commitment without confinement. Outpatient compulsory care for substance abuse, and severe mental disorder in Sweden

In Sweden, a person with severe substance abuse or a severe mental disorder may be committed to compulsory care according to two different legislations. Both acts include an option of providing involuntary care outside the premises of an institution - care in other forms (COF) and compulsory community care (CCC), respectively. As co-occurring disorders are commonplace many individuals will be subject to both types of compulsory care. The structures of both legislations and their provisions for compulsory care in the community are therefore scrutinized and compared. Based on a distinction between "least restrictive" or "preventative" schemes the article compares COF and CCC in order to determine whether they serve different purposes. The analysis shows that COF and CCC both share the same avowed aims of reducing time spent in confinement and facilitating transition to voluntary care and the community. But they also serve different purposes, something which is reflected in disparate scopes, eligibility criteria, rules, and practices. Overall, COF was found to be a more "least restrictive" and CCC a more "preventative" scheme. The distinction is associated with COF being an established part of legislation on compulsory care for substance abuse with a universal scope and CCC being a recent addition to compulsory psychiatric care legislation with a selective character.

Effectiveness of Community Treatment Orders: The International Evidence

OBJECTIVE

Community treatment orders (CTOs) exist in more than 75 jurisdictions worldwide. This review outlines findings from the international literature on CTO effectiveness.

METHOD

The article draws on 2 comprehensive systematic reviews of the literature published before 2013, then uses the same search terms to identify studies published between 2013 and 2015. The focus is on what the literature as a whole tells us about CTO effectiveness, with particular emphasis on the strength and weaknesses of different methodologies.

RESULTS

The results from more than 50 nonrandomized studies show mixed results. Some show benefits from CTOs while others show none on the most frequently reported outcomes of readmission, time in hospital, and community service use. Results from the 3 existing randomized controlled trials (RCTs) show no effect of CTOs on a wider range of outcome measures except that patients on CTOs are less likely than controls to be a victim of crime. Patients on CTOs are, however, likely to have their liberty restricted for significantly longer periods of time. Meta-analyses pooling patient data from RCTs and high quality nonrandomized studies also find no evidence of patient benefit, and systematic reviews come to the same conclusion.

CONCLUSION

There is no evidence of patient benefit from current CTO outcome studies. This casts doubt over the usefulness and ethics of CTOs. To remove uncertainty, future research must be designed as RCTs.

CTOs: what is the state of the evidence?

PURPOSE

Community Treatment Orders (CTOs) require outpatients to adhere to treatment and permit rapid hospitalisation when necessary. They have become a clinical and policy solution to repeated hospital readmissions despite some strong opposition and the contested nature of published evidence. In this article, we appraise the current literature on CTOs from the viewpoint of Evidence-Based Medicine and discuss the way forward for using and researching CTOs.

RESULTS

Non-randomised outcome studies show conflicting results, but their lack of standardisation of methods and measures makes it difficult to draw conclusions. In contrast, all three randomised controlled trials (RCTs) conducted concur in their findings that CTOs do not impact on hospital outcomes. No systematic review or meta-analysis has identified any clear clinical advantage to CTOs.

CONCLUSION

The evidence-base does not support the use of CTOs in their current form. Involuntary clinical interventions must conform to the highest standard of evidence-based care. To enable clinicians to take an evidence-based approach and to settle remaining uncertainties about the current evidence, high-quality RCTs should be designed and undertaken, using standardised outcome measures.

Community treatment orders in New Zealand: regional variability and international comparisons

OBJECTIVES

Community treatment orders (CTOs) have been used in New Zealand since 1992 and are now used in most Commonwealth countries. There is little research on the rate of use of CTOs in New Zealand. This study compares the prevalence of CTO use across New Zealand's 20 health districts and makes comparisons with international prevalence rates.

METHODS

New Zealand Ministry of Health reports provided data on rates of CTO use in New Zealand between 2005 and 2011. International rates were obtained from published reports and academic literature on CTO use.

RESULTS

Rates of CTO use in New Zealand show marked and persistent regional variation over the period of data collection. National average rates increased from 58 per 100,000 in 2005 to 84 per 100,000 in 2011. Rates of use of CTOs are increasing internationally. New Zealand's CTO use is high by international comparisons.

CONCLUSIONS

New Zealand's high and increasing rate of CTO use by international standards raises questions about the delivery and functioning of mental health services, and about mental health service users' experience of mental health care. The high rate of CTO use needs to be addressed as a human rights issue as well as a clinical issue.

The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers

OBJECTIVE

To describe the lived experiences of people subject to community treatment orders (CTOs) and their carers.

METHOD

We recruited 11 participants (five mental health consumers and six carers) through consumer and carer networks in NSW, Australia, to take part in interviews about their experiences. We analysed the interview data set using established qualitative methodologies.

RESULTS

The lived experiences were characterised by 'access' concerns, 'isolation', 'loss and trauma', 'resistance and resignation' and 'vulnerability and distress'. The extent and impact of these experiences related to the severity of mental illness, the support available for people with mental illnesses and their carers, the social compromises associated with living with mental illness, and the challenges of managing the relationships necessitated by these processes.

CONCLUSIONS

The lived experience of CTOs is complex: it is one of distress and profound ambivalence. The distress is an intrinsic aspect of the experience of severe mental illness, but it also emerges from communication gaps, difficulty obtaining optimal care and accessing mental health services. The ambivalence arises from an acknowledgement that while CTOs are coercive and constrain autonomy, they may also be beneficial. These findings can inform improvements to the implementation of CTOs and the consequent experiences.

Effectiveness of the Community Treatment Order in streamlining psychiatric services

BACKGROUND

The implementation of the Community Treatment Order (CTO) has created controversy surrounding its beneficence.

AIMS

The study aims at examining the effectiveness of the CTO in reducing the rate and duration of revolving door admissions for patients who were made subject to this Order.

METHOD

All patients who were made subject to CTO between November 2008 and August 2009 in South Essex were involved in the study where patients acted as their own control through comparing their pre-CTO, during CTO and post-CTO's admission rate and duration.

RESULTS

There was a significant reduction in the rate and duration of admissions in the period during and post-CTO state.

CONCLUSIONS

The CTO proved to be effective in reducing revolving door admissions and it has a beneficial carryover effect in the post-CTO state.

Revocation of Community Treatment Orders in a mental health service network

OBJECTIVE

Community Treatment Orders (CTOs) require patients to co-operate with involuntary treatment in the community or risk having their CTO revoked and being readmitted to hospital. CTOs are used frequently in Australia. Their revocation has been under-investigated but is important because of the significant impact this process has on patients, families/carers and service-providers. This paper reports on an investigation of CTO revocations in a Victorian area mental health service in the period 2008-2010.

METHOD

This was a mixed-methods study involving extraction of data from the Victorian statewide clinical database, a file audit and semi-structured group interviews with key stakeholders. Two different time periods were compared.

RESULTS

CTOs are commonly revoked within three months of discharge from the inpatient unit and multiple service-providers and family/carers have varying involvement that appears to depend on the timing of the referral to the Crisis Assessment and Treatment Team.

CONCLUSIONS

The study identified opportunities for improving policy and practice, particularly in relation to reducing the amount of coercion experienced by people on CTOs and improving flexibility of service delivery.

Community treatment orders: beyond hospital utilization rates examining the association of community treatment orders with community engagement and supportive housing

The purpose of this paper is to examine the association of community treatment orders (CTO) with community engagement and housing arrangements for one population of psychiatric patients in Ontario, Canada. Socio demographic characteristics and health service utilization information were collected for each patient placed on a CTO during a 3 year period. Information was collected for each of the 84 patients when a CTO was first issued and then updated to reflect both the patient's ongoing involvement with the legislation and related clinical outcomes. A significant increase in the number of community services and a shift to supportive housing arrangements was found for patients following issuance of a CTO.

Community treatment orders and competence to consent

OBJECTIVE

The aim of this paper is to explore the relationship between civil commitment under a Community Treatment Order (CTO) and competence to consent to treatment.

METHOD

A purposive convenience sample of 10 service users under CTOs were interviewed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Ratings were compared with the ratings of 10 matched voluntary service users.

RESULTS

Seventy percent of the CTO sample were found to be incompetent according to the MacCAT-T, compared to 20% of the comparison group (p = 0.004). The proportion of the CTO sample found to be incompetent reduces to 50% if the subscale of appreciation is excluded (p = 0.004). Most people in each group would elect to continue their current treatment if given the choice.

CONCLUSION

Findings of this study suggest that mental health law reform introducing considerations of competence could lead to a substantially different group of people being subject to CTOs. If the CTO is carefully targeted and not used excessively, it is likely to be accorded qualified acceptance for most service users for whom it is used.

Compulsory community mental health treatment: literature review

Following their introduction in the United States in the 1970s various forms of compulsory treatment in the community have been introduced internationally. Compulsory treatment in the community involves a statutory framework that mandates enforceable treatment in a community setting. Such frameworks can be categorized as preventative, least restrictive, or as having both preventative and least restrictive features. Research falls into two categories; descriptive, naturalistic studies and controlled and uncontrolled comparative studies. The research has produced equivocal results, and presents numerous methodological challenges. Where programmes have demonstrated improved outcomes debate continues as to whether these outcomes are associated with legal compulsion or enhanced service provision. Service user, family and clinician perspectives demonstrate a divergence of views within and across groups, with clinicians more strongly in support than service users. The issue of compulsory community treatment is an important one for nurses, who are often at the forefront of clinical service provision, in some cases in statutory roles. Critical reflection on the issue of compulsory community treatment requires understanding of the limitations of empirical investigations and of the various ethical and social policy issues involved. There is a need for further research into compulsory community treatment and possible alternatives.

Community treatment orders in Toronto: the emerging data

OBJECTIVE

Over a 4-year period in Toronto, this study aimed to compare individuals on a community treatment order (CTO) with individuals not on a CTO in terms of sociodemographic and clinical variables, hospital use, and continued engagement with health services on exit from the case management program. Hospital stay reductions from preadmission into the program to various postadmission periods were compared across the 2 groups.

METHODS

Descriptive statistics and tests of statistical significance (chi-square and t test) were run on regularly collected administrative data for both groups.

RESULTS

Categorical data analysis indicated the 2 groups were statistically similar on a range of sociodemographic and clinical variables. Although both groups displayed reductions in hospital use, the CTO group displayed a significantly higher reduction in cumulative days in hospital per hospital admission within both the first and second 6-month period postadmission. This same group also had significantly greater reduction in hospital admissions during the second 6-month period postadmission. The CTO group also had a significantly higher portion of individuals exiting the program within these first two 6-month periods; as well, they were less likely to exit with support such as case management or assertive community treatment and more likely to continue with ongoing medical supervision than the comparison group.

CONCLUSION

Although we were unable to rule out regression to the mean for hospitalization reductions, the Toronto experience has shown that CTOs are helpful in assisting individuals who historically refused services to remain engaged with treatment and support services. The study also calls for broadening operational measures of outcomes for CTO studies.

Dilemmas for clinicians in use of Community Treatment Orders

Clinicians who treat patients using Community Treatment Orders (CTOs) face many potential dilemmas in their relations with involuntary outpatients and the exercise of their powers. We compare the dilemmas identified in the literature with those reported by responsible clinicians in New Zealand (NZ). These clinicians experienced a number of well-known dilemmas, such as determining the right moment for a person's discharge from a CTO, but they seemed less troubled by some other difficulties than might be expected, usually because they considered involuntary outpatient treatment the best option for the patient or the best way to manage the risks involved. Further dilemmas were identified by the NZ clinicians that have not been widely discussed, concerning the proper scope of clinical authority over patients under CTOs and the decision to revoke involuntary outpatient status. In conclusion, some suggestions are made as to how clinicians might best manage the dilemmas involved.

A cluster analysis of people on Community Treatment Orders in Victoria, Australia

This paper explores the clinical, social and demographic characteristics of 164 people on Community Treatment Orders (CTOs) in one area mental health service in Victoria, Australia. The results of an exploratory cluster analysis are presented to address the question of whether people on Community Treatment Orders can be categorised into statistically reliable, qualitatively distinct groupings. The data are presented in the context of key stakeholder perspectives on the current use and purpose of CTOs. Three stable clusters emerged and each potentially reflects how social dimensions, as well as clinical issues, influence decision making regarding the implementation of CTOs. These findings are important in the context of policy and practice in Victoria, where the use of CTOs is common practice, and orders are generally made for a 12 month period. The potential for improved targeting of CTOs and more specific treatment planning is identified.

Is mandatory outpatient treatment effective?

This paper reviews the major studies of mandatory outpatient treatment (MOT) and examines why there has been inconsistency in some of the findings. Attempts to answer the question "is mandatory treatment effective?" must first clarify the type of mandatory treatment being examined, the type of patient being treated, and the outcome by which effectiveness is measured. There is consistent evidence that various forms of MOT increase follow-up with psychiatric services and that court-ordered outpatient committal decreases victimization of patients in the community. It also appears likely that MOT reduces the use of hospitalization; but, due to methodological problems associated with the research, this conclusion remains controversial.

Outpatient commitment and coercion in New Zealand: a matched comparison study

BACKGROUND

It has been hypothesized that a degree of coercion is a necessary component in using outpatient commitment to attain therapeutic outcome for those people subject to mental health law. However, what degree of coercion is required and how it is sustained is poorly understood. There is speculation that patients' recognition of beneficial as well as unwanted aspects of outpatient commitment (ambivalence) maybe an indicator that the necessary level of coercion has been achieved to facilitate a therapeutic outcome.

AIM

The aim of this study was to determine the level of coercion perceived by those under outpatient commitment in New Zealand. Emphasis was given to consideration of the presence of ambivalence and the role of interactive processes, including procedural justice, in influencing patients' perceptions of coercion.

METHOD

A cross-sectional comparative study was undertaken to compare the perceptions of coercion of patients on outpatient commitment (n = 69) to a matched sample of voluntary outpatients (n = 69), using the Perceived Coercion Scale. The influence of a range of variables, including patients' knowledge of and beliefs concerning outpatient commitment, were considered.

RESULTS

Although the level of coercion for involuntary outpatients was relatively low, it was significantly higher than that experienced by voluntary outpatients. Yet involuntary outpatients were more likely to espouse benefits of outpatient commitment. Although there was an inverse correlation between perceptions of procedural justice and perceived coercion, procedural justice did not feature in the linear regression analysis.

DISCUSSION

In the New Zealand context, involuntary outpatients hold contrasting views to outpatient commitment. We suggest that this ambivalence is an indicator that the degree of coercion is suffice to achieve therapeutic outcome. Furthermore, this study suggests the impact of procedural justice on patients' perceptions of coercion may be more crucial during admission to hospital than in the context of on-going community care.

Community treatment orders: profile of a Canadian experience

OBJECTIVE

This study reports the first published Canadian profile of a sample of psychiatric patients from the Royal Ottawa Hospital in Ottawa, Ontario, who were issued community treatment orders (CTOs).

METHOD

We undertook a population study of sociodemographic and health care use patterns from January 2001 to September 2003, using a standardized information collection tool.

RESULTS

The issuance of CTOs was associated with a statistically significant reduction in the number and length of hospital admissions and increased use of supportive community-based services and supportive housing.

CONCLUSION

CTOs are effective tools for allowing patients to live in the least restrictive setting possible while they receive diverse services. They also effectively reduce rates and lengths of readmission to hospital.

How mental health clinicians view community treatment orders: a national New Zealand survey

OBJECTIVE

To determine New Zealand mental health clinicians' views about community treatment orders, indications for their use, their benefits, problems and impact on patients and therapeutic relationships.

METHOD

A national survey of New Zealand psychiatrists and a regional survey of non-psychiatric community mental health professionals for comparison.

RESULTS

The great majority of NZ psychiatrists prefer to work with community treatment orders as an option. They consider they are used properly in most cases, can enhance patients' priority for care, provide a structure for treatment, support continuing contact and produce a period of stability for patients during which other therapeutic changes can occur. They consider these orders can harm therapeutic relationships, especially in the short term, but when used appropriately their overall benefits outweigh their coercive impact. The other mental health professionals surveyed have similar views. A minority of clinicians do not support their use.

CONCLUSIONS

The precise impact of community treatment orders on patients' quality of life remains an open question. Until that matter is more clearly resolved, New Zealand law should continue to authorise compulsory outpatient care, provided it is carefully targeted and adequate community services are available.

Maori experience of community treatment orders in Otago, New Zealand

OBJECTIVE

To consider the impact of community treatment orders (CommTOs) on Maori patients and their whanau (extended family) and the associated views of mental health professionals.

METHOD

As a distinct aspect of a larger study of CommTOs, eight Maori patients under compulsory community care were interviewed and, where possible, members of their whanau. Associated interviews were held with their psychiatrists, key workers and other carers: 39 interviews in total.

RESULTS

Both benefits and drawbacks of CommTOs for Maori were identified by patients and whanau. CommTOs were considered helpful in increasing patient safety and whanau security and in promoting access to services. They were favoured over hospital care, forensic care and homelessness. The drawbacks included the sense of external control imposed on both Maori patients and staff, particularly concerning medication and restrictions on choices.

CONCLUSIONS

This was a small study of a limited number of Maori patients under CommTOs. Their views may not be fully representative. There was a general consensus among those interviewed that the timely use of CommTOs can enhance the mental wellbeing and social relationships of Maori patients. Continuing efforts are needed by health professionals to communicate effectively with whanau and to understand the conflicts experienced by Maori in reconciling their traditional beliefs with the medical model of mental illness.

Why are community treatment orders controversial?

The use of community treatment orders and other forms of mandatory outpatient treatment has been controversial. The debate on the appropriateness of compulsory treatment in the community addresses a volatile mix of clinical, social policy, legal, and philosophical issues. This paper describes the major sources of contention, outlines the position of the protagonists, and where possible, attempts to answer some of the questions raised and identify common ground.