Community Treatment Orders and Leveraged Treatment

The use of leveraged treatment pressures to promote adherence with community-based mental health treatment among people with serious mental illness (SMI) is a common albeit controversial practice. It frequently involves using the social welfare and legal system to pressure people with a SMI to adhere with treatment.

Supporters of this approach suggest such practices serve to improve engagement and treatment adherence among people with SMI who have challenges in voluntarily complying with prescribed treatment and ultimately promote personal autonomy by reducing illness relapse and preventing hospitalization.

Critics of this approach argue such practices could impinge on civil liberties, harm the therapeutic relationship, contribute to stigma, and undermine self-determination and the goal of reclaiming a meaningful life.

Treatment pressures include a number of practices that lay along a continuum of coercive measures ranging from subtle interpersonal interactions to compulsory treatment. A common form of compulsory treatment are community treatment orders (CTOs).

A CTO is an order issued by a physician and agreed to by an individual (and/or their Substitute Decision Maker) which requires the individual to receive care and treatment in the community, in lieu of detention in a psychiatric facility. CTOs are used with individuals.

Service users’ knowledge and views on outpatients’ compulsory community treatment orders: A cross-sectional matched comparison study

Arash Nakhost, Frank Sirotich, Alexander I F Simpson
Canadian Journal of Psychiatry, 2019; 64: 726-735.

This article examines the perceptions and knowledge of CTOs amongst outpatient service users in Toronto, Canada. Service users under a CTO were matched to a comparison control group of voluntary outpatients. Participants were interviewed using a series of questionnaires aimed at assessing their knowledge and perceptions of CTOs, as well as understanding their views about the utility and impact of CTOs in the treatment of individuals with mental health issues. Participants in the CTO group knew significantly more about CTO processes, restrictions, and procedural protections than the comparison group. Both groups thought that a CTO could improve certain individuals' mental health. The comparison group felt more strongly that a CTO could improve a service user's physical health by providing better access to care and closer monitoring while a significant proportion of the CTO group thought that being on a CTO was better than being in the hospital and that service users should be able to contest their CTO. In addition, CTO group participants were significantly more optimistic about the potential positive impact of CTOs on other service users' quality of life and mental health compared to themselves.
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Coercion in Outpatients under Community Treatment Orders: A Matched Comparison Study

Arash Nakhost, Frank Sirotich, Katherine M Francombe Pridham, Vicky Stergiopoulos, Alexander I F Simpson
Canadian Journal of Psychiatry, 2018; 63:757-765.

This article examines the perceptions of coercion among service users treated with a CTO. A cross-sectional study was undertaken where service users treated under a CTO were matched to a comparison group of voluntary psychiatric outpatients. Both groups were receiving intensive community mental health services. Participants were interviewed using a series of questionnaires aimed at evaluating their perceptions of coercion and other aspects of psychiatric treatment. The level of coercion reported by service users treated under a CTO was significantly higher than that in the comparison group. However, service users’ perception of coercion was associated with being on a probation order. Additionally service users who reported a sense of procedural justice in their treatment were less likely to report coercion, irrespective of whether or not they were on a CTO. Clinicians may be able to minimize experiences of coercion by incorporating procedural justice principles into their practice.
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