Community treatment orders: the ethical balancing act in community mental health

Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review

In mental health and psychiatric care, the use of involuntary psychiatric treatment for people with mental disorders is still a central and contentious issue. The main objective of this scoping review was to map and systematize the literature on ethical issues in clinical decision-making about involuntary psychiatric treatment. Five databases (Embase, PsycINFO, CINAHL, Medline, and Scopus) were searched for articles on this topic. Out of a total of 342 articles found, 35 studies from 14 countries were included based on the selection criteria. The articles were analyzed using the inductive content analysis approach. The following main categories were identified: (1) ethical foundations that guide clinical decision-making; (2) criteria for involuntary psychiatric treatment; (3) gaps, barriers, and risks associated with involuntary psychiatric treatment; (4) strategies used to reduce, replace, and improve the negative impact of involuntary treatment; and (5) evidence-based recommendations. Most of the selected articles discuss the logic underlying involuntary treatment of the mentally ill, exploring ethical principles such as autonomy, beneficence, non-maleficence, or justice, as well as how these should be properly balanced. During the process of involuntary psychiatric admission, there was a notable absence of effective communication and a significant power imbalance that disenfranchised those seeking services. This disparity was further intensified by professionals who often use coercive measures without a clear decision-making rationale and by family members who strongly depend on hospital admission. Due to the pluralistic and polarized nature of opinions regarding legal capacity and the complexity and nuance of involuntary admission, further studies should be context-specific and based on co-production and participatory research.

Community Treatment Orders use Among Persons With a First Episode of Psychosis in Quebec

OBJECTIVES

Specialized early intervention for psychosis can reduce the duration of untreated psychosis and improve clinical and functional outcomes. However, poor adherence to treatment is frequent. The literature on community treatment orders (CTOs) use in first-episode psychosis (FEP) as a means to improve treatment adherence is limited. In the context of early intervention for psychosis services (EIS), this study aims to describe (1) the frequency of CTOs utilisation, (2) the trend of CTOs use over time, (3) the timing and reasons for requesting CTOs and (4) the baseline characteristics of FEP patients on CTOs compared to those who were not.

METHOD

A 5-year prospective longitudinal study describing the use of CTOs among persons with FEP admitted to two urban EIS in Montreal, Quebec, from 2005 to 2013. At admission, and then annually for 5 years, CTOs data were collected through chart review. Baseline characteristics, assessed by patient interviews, standardized questionnaires and chart review, included socio-demographic data, illness severity, functioning and alcohol and substance use. Descriptive analyses were performed, and FEP patients on CTOs during follow-up and those who were not were compared using analyses of variance, chi-square test and multivariate logistic regression.

RESULTS

Among 567 FEP patients, 19.2% were placed on CTOs. The main reasons for requesting CTOs were to prevent further deterioration in mental state, social functioning, harmful behaviours to self and others and homelessness. FEP patients on CTOs had poorer premorbid and baseline functioning, more severe symptoms and social dysfunction at admission, including legal problems and homelessness.

CONCLUSIONS

CTOs can be a tool to improve adherence to treatment, which is crucial for relapse prevention in FEP. However, since it is a coercive method that limits a person's fundamental rights, further research is warranted to assess its impact on patients' lives, clinical and functional outcomes, as well as patients' and carers' perception.

Where the public health principles meet the individual: a framework for the ethics of compulsory outpatient treatment in psychiatry

Background

Compulsory treatments represent a legal means of imposing treatment on an individual, usually with a mental illness, who refuses therapeutic intervention and poses a risk of self-harm or harm to others. Compulsory outpatient treatment (COT) in psychiatry, also known as community treatment order, is a modality of involuntary treatment that broadens the therapeutic imposition beyond hospitalization and into the community. Despite its existence in over 75 jurisdictions worldwide, COT is currently one of the most controversial topics in psychiatry, and it presents significant ethical challenges. Nonetheless, the ethical debate regarding compulsory treatment almost always stops at a preclinical level, with the different ethical positions arguing for or against its use, and there is little guidance to support for the individual clinicians to act ethically when making the decision to implement COT.

Main body

The current body of evidence is not clear about the efficacy of COT. Therefore, despite its application in several countries, evidence favouring the use of COT is controversial and mixed at best. In these unclear circumstances, ethical guidance becomes paramount. This paper provides an ethical analysis of use of COT, considering the principlist framework established by Ross Upshur in 2002 to justify public health interventions during the 2002–2004 severe acute respiratory syndrome outbreak. This paper thoroughly examines the pertinence of using the principles of harm, proportionality, reciprocity, and transparency when considering the initiation of COT.

Conclusion

Ross Upshur’s principlist model provides a useful reflection tool for justifying the application of COT. This framework may help to inform sounder ethical decisions in clinical psychiatric practice.

Control in the community: A qualitative analysis of the experience of persons on conditional discharge in Hong Kong

Mandatory outpatient treatment schemes such as community treatment orders remain controversial despite being commonly used around the world. Given concerns about patient autonomy and civil liberties, such schemes need to be closely scrutinised. Though Hong Kong's mandatory outpatient treatment scheme, the conditional discharge (CD) regime, has a number of significant legal concerns, empirical research on how it operates on the ground remains limited, and data on the subjective experience of relevant stakeholders is limited to healthcare professionals. This two-part cross-sectional study, the first on the service user perspective in Hong Kong, rectifies this gap. Data was collected through a self-reported survey and semi-structured interviews. Results demonstrated that, while similar themes to those in the literature were raised, such as powerlessness, a lack of understanding about the regime and in particular their rights thereunder, concerns about restrictive aspects of the regime and poor attitudes of healthcare professionals, and in some cases positive sentiments about beneficial aspects, the Hong Kong experience differs in the significant extent to which many of these concerns are demonstrated. The insights which this data provides in relation to how the implementation of the CD regime can be improved prior to legal reform is discussed, and suggestions for the way forward are proposed.

Exploring experiences with compulsory psychiatric community treatment: A qualitative multi-perspective pilot study in an urban Canadian context

As medical, ethical and clinical effectiveness debates about the use of compulsory psychiatric treatment continues, it is important to further explore the actual experiences and perspectives of all relevant stakeholders in community treatment orders (CTOs). This qualitative pilot study engaged a total of twenty-seven clients, their family members, and care providers in Toronto, Canada. Semi-structured, one-on-one interviews were conducted between February and July 2013 and analyzed using thematic analysis. Top key themes from all the participants identified include, among others: 1) clients' experiences of coercion while treated under CTO, but a preference for CTOs compared to involuntary hospitalization, nevertheless; 2) limited real opportunities for collaboration in treatment decisions expressed by clients and family members; 3) acceptance of the potential for clinical recovery on CTOs while debating the role of CTO in a broader recovery journey by all stakeholders; 4) general preservation of therapeutic relationships between clients and care providers, while acknowledging the tension of taking on an "enforcer" role by providers; and 5) existence of different avenues for asserting agency by clients. The findings of this research illuminate the nuanced, complex, and adaptive perspectives held by different stakeholders, point to the importance of preserving and enhancing procedural justice in their use, and alert the field to incorporate recovery-based approaches in this controversial practice that is a widely and commonly used clinical tool across many jurisdictions.

Community treatment orders: an analysis of the first five years of use in England

BACKGROUND

Community treatment orders (CTOs) were introduced in England in 2008. Aims To measure the rate of CTO use in England during the first 5 years following introduction.

METHOD

The number of involuntary detentions and CTOs in National Health Service (NHS) hospital trusts was collected between 2009 and 2014. Rates of CTO use and the ratio of CTOs to detentions on admission were calculated, and how these varied between trusts.

RESULTS

The number of new CTOs each year ranged between 3834 and 4647. The number subject to a CTO per 100 000 population increased from 6.4 in 2009/10 to 10.0 in 2013/14. There was variation between NHS trusts in the use of CTOs when compared with the number of involuntary detentions CONCLUSIONS: The number of patients on CTOs increased year on year. Those on forensic sections were more likely to be discharged on a CTO than those on civil sections. There was considerable variation in the pattern of use between hospitals. Declaration of interest None.

Community treatment orders: Are they useful?

In the wake of the deinstitutionalisation of mental health services, community treatment orders (CTOs) have been introduced in around 75 jurisdictions worldwide. They make it a legal requirement for patients to adhere to treatment plans outside of hospital. To date, about 60 CTO outcome studies have been conducted. All studies with a methodology strong enough to infer causality conclude that CTOs do not have the intended effect of preventing relapse and reducing hospital admissions. Despite this, CTOs are still debated, possibly reflecting different attitudes to the role of evidence-based practice in community psychiatry. There are clinical, ethical, legal, economic and professional reasons why the current use of CTOs should be reconsidered.

Learning Objectives

• Gain an overview of the development and use of CTOs in the UK and internationally

• Get up-to-date information about the evidence base for CTO effectiveness and the relative contributions of different levels of evidence

• Appreciate the nature of the current controversy around the use of CTOs and become familiar with the factors in the ongoing debate about their future

Caring as Coercion: Exploring the Nurse's Role in Mandated Treatment

When nurses work in environments that have overlapping medical, legal, institutional, social, and therapeutic priorities, nursing care can become an effective tool in advancing the competing goals of these multiple systems. During the provision of patient care, nurses manage the tensions inherent in the competing priorities of these different systems, and skillful nursing can have the effect of rendering these tensions invisible. This puts nurses in an ethically complex position, where on one hand, their humanizing empathy has the potential to improve the delivery and effect of mandated care yet, on the other hand, their skillfulness can render invisible the weaknesses in medicolegal structures. In this article, we present a composite case study as a vehicle to illustrate the way this dilemma manifests in day-to-day nursing interactions and explore the potential of microethics to inform the everyday decisions of nurses delivering care-as-coercion.

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.

Community treatment orders: exploring the paradox of personalisation under compulsion

The introduction of supervised community treatment, delivered through community treatment orders (CTOs) in England and Wales, contrasts with the policy of personalisation, which aims to provide service users autonomy and choice over services. This article draws upon findings from a primarily qualitative study which included 72 semi-structured interviews (conducted between January and December 2012) with practitioners, service users and nearest relatives situated within a particular NHS Trust. The article also refers to a follow-on study in which 30 Approved Mental Health Practitioners were interviewed. The studies aimed to develop a better understanding of how compulsory powers are being used in the community, within a policy context that emphasises personalisation and person-centred care in service delivery. Findings from the interview data (which were analysed thematically) suggest that service users were often inadequately informed about the CTO and their legal rights. Furthermore, they tended to be offered little, or no, opportunity to make choices and have involvement in the making of the CTO and setting of conditions. Retrospectively, however, restrictions were often felt beneficial to recovery, and service users reported greater involvement in decisions at review stage. Areas of good practice are identified through which person-centred care can be better incorporated into the making of CTOs.

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.

'Working behind the scenes'. An ethical view of mental health nursing and first-episode psychosis

The aim of this study was to explore and reflect upon mental health nursing and first-episode psychosis. Seven multidisciplinary focus group interviews were conducted, and data analysis was influenced by a grounded theory approach. The core category was found to be a process named 'working behind the scenes'. It is presented along with three subcategories: 'keeping the patient in mind', 'invisible care' and 'invisible network contact'. Findings are illuminated with the ethical principles of respect for autonomy and paternalism. Nursing care is dynamic, and clinical work moves along continuums between autonomy and paternalism and between ethical reflective and non-reflective practice. 'Working behind the scenes' is considered to be in a paternalistic area, containing an ethical reflection. Treating and caring for individuals experiencing first-episode psychosis demands an ethical awareness and great vigilance by nurses. The study is a contribution to reflection upon everyday nursing practice, and the conclusion concerns the importance of making invisible work visible.

Compulsory treatment in psychiatry

PURPOSE OF REVIEW

Compulsory treatment is a common, yet controversial, practice in psychiatry. This paper reviews recent studies on the use of compulsory measures in hospital, the community and special populations.

RECENT FINDINGS

Researchers continue to examine the rates and patterns of involuntary hospitalization. However, they have extended their investigations to care in the community, acknowledging it as the primary locus of treatment for most patients. Research shows that the implementation of community mental health legislation presents complex clinical and practical issues that require further investigation. Recognition that compulsory treatment is an objective event which is subjectively experienced by patients, families and clinicians has led to research investigating stakeholder views. The therapeutic relationship has been found to be an important modifier of the experience of compulsory treatment. Recent studies have also focused on specific coercive practices, such as forced medication and seclusion, and the use of these in patient subgroups, including those with eating disorders and adolescents. The debate about whether compulsory treatment is ethical continues in the literature.

SUMMARY

Compulsory treatment in psychiatry remains an ethically and clinically contentious issue. As ethical concerns are generally countered by the argument that compulsory measures can lead to beneficial clinical outcomes, further empirical investigation in this area is required.