The proposed introduction of community treatment orders (CTOs) in the 1990s in England and Wales brought together opposition from a Mental Health Alliance including the Royal College of Psychiatrists, mental health charities, various groups of professionals, users of services and carers. However, CTOs were eventually introduced in 2007 as a part of the substantially amended Mental Health Act 1983. Their use has considerably exceeded predictions, with over 10 000 orders being made in England alone by March 2011. 1 Formal powers of compulsion in the community have existed for some time in Australasia and North America and have more recently been made available in a number of European countries (including Scotland, Sweden, Belgium, Portugal and Luxemburg). Reference Salize, Dreßing and Peitz2,Reference Lawton-Smith3 In England and Wales, CTOs do not allow for the forcible administration of medication in the community. A refusing patient can be compelled to return to hospital, at which point they can be forcibly treated if this is felt to be appropriate, and in practice under such circumstances they may decide to accept treatment in the community if they feel under pressure. It is possible for the treating team to make other conditions such as specifying the patient’s residency and abstinence from drugs or alcohol. Enforcement of these conditions may however be difficult to achieve in practice. The use of CTOs varies substantially between and within jurisdictions. 1 Dawson Reference Dawson4 has suggested that four main factors typically influence clinicians: (a) the legal structure of the CTO regime, (b) the community mental health services available, (c) the clinician’s views about the possible impact of coercion on their relations with patients, and (d) the expectations of third parties regarding the CTO scheme.
The evidence of benefits from CTOs is at best limited: two randomised controlled trials (RCTs) of CTOs in the USA showed no overall difference between those on a CTO and those not in terms of readmission and clinical and social outcomes. Reference Swartz, Swanson, Wagner, Burns, Hiday and Borum5,Reference Steadman, Gounis, Dennis, Hopper, Roche and Swartz6 A Cochrane review concluded that ‘there is no strong evidence to support the claims made for compulsory community treatment’. Reference Kisely, Campbell and Preston7 It has been suggested that a lack of research evidence or clinical consensus regarding CTOs may have contributed to their wider than forecasted uptake. Reference Appelbaum8-Reference Dawson, Romans, Gibbs and Ratter10 It appears that this relates to a number of factors as outlined by Dawson. Reference Dawson4 The legislation is enabling and there are broad criteria for its use. Given this, it is likely that factors such as family concerns, defensive practice and a natural clinical desire to alter previously unsuccessful treatment approaches all contribute. Politicians and legislators may also look to out-patient commitment to address a variety of issues in the community management of those with severe mental illnesses such as perceived dangerousness. Reference Appelbaum8,Reference Monahan, Bonnie, Appelbaum, Hyde, Steadman and Swartz9 An RCT of compulsory outpatient treatment in psychosis was conducted in the Oxford Department of Social Psychiatry under Professor Tom Burns and the study seeks to provide convincing scientific evidence of CTO efficacy with the results expected to be published this year. Reference Burns, Rugkåsa, Dawson, Doll, Molodynski and Priebe11 A national survey of members of the Royal College of Psychiatrists was conducted by Manning et al in 2009 to determine the views and experiences of psychiatrists in England and Wales regarding CTOs. Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12 Manning et al noted that a number of authors had examined professional attitudes to this newly developed, complex and politically sensitive legal process. A survey of consultant psychiatrists in England and Wales in 2000 revealed that 46% were in favour of their introduction, 35% against and 19% unsure. Reference Crawford, Hopkins and Henderson13 In New Zealand (where CTOs have been available since 1992), surveys of psychiatrists and other mental health professionals found that 79% of psychiatrists and 85% of non-psychiatrist mental health professionals preferred to work in a system with CTOs. Reference Romans, Dawson, Mullen and Gibbs14 A survey of 50 psychiatrists in Saskatchewan, Canada, reported that 62% of respondents were at least satisfied with the effect of CTOs on patient care. Reference O'Reilly, Keegan and Elias15 Two studies in the USA exploring clinicians’ views revealed similar opinions. Reference Scheid-Cook16,Reference Swartz, Swanson, Wagner, Hannon, Burns and Shumway17 In Manning et al’s 2009 survey of members of the Royal College of Psychiatrists, 566 usable questionnaires were returned out of the 1928 questionnaires that were posted out. They found that psychiatrists were generally positive about the introduction of CTOs and 60% expressed a preference to work in a system that included CTOs. Moreover, clinical reasons were rated as being the most important factors in the use of CTOs, both in terms of commencing and ending orders, rather than ethical or bureaucratic concerns. Promoting adherence to medication, protecting individuals from the consequences of relapse and ensuring contact with health professionals were considered to be the most important factors in commencing a CTO. The most important reasons for discharging a CTO were considered to be the development of insight, clinical improvement and adherence to treatment. Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12
In discussing their findings, Manning et al refer to the importance of seeking multidisciplinary input when making CTO decisions, and note that lack of professional consensus may be a challenging problem. Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12 This study develops the work of Manning et al by using a similar method to explore the views and experiences of a wider range of mental health professionals in a local area. The professionals surveyed included psychiatrists, nurses, social workers, team managers and other occupational groups (including psychologists, support workers, occupational therapists and physiotherapists) and the opinions of the different professional groups were compared and contrasted. We aimed to determine their views regarding the use of CTOs in adult mental health services.
All medical and non-medical staff in adult community mental health teams in 2Gether and Oxford Health NHS Foundation Trusts were invited to complete the survey. Researchers attended team meetings to explain the study and hand out questionnaires. Staff were sent a further questionnaire approximately 2 months later to increase the response rate. The approved mental health professional (AMHP) offices in the two trusts provided a comprehensive list of the AMHPs and all were invited to complete the survey. All responses were anonymous.
The study was approved by Gloucestershire 2Gether NHS Foundation Trust and Oxfordshire and Buckinghamshire Mental Health NHS Foundation Trust Research and Development Governance Committees. The National Research Ethics Service (NRES) advised that the study did not require ethical review by an NHS research ethics committee.
The questionnaire was developed to capture views and experiences across a range of issues in relation to the use of CTOs:
• indications for the use of CTOs
• factors influencing how CTOs work
• potential benefits and disadvantages
• potential impact on the therapeutic relationship
• the individual’s overall level of support for the introduction of CTOs
In order to allow comparison between this questionnaire and a tool used in previous work on attitudes towards CTOs, Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12 some questions were purposefully replicated. However, this study develops previous work by providing a detailed breakdown of results according to the mental health professional groups. In addition, this questionnaire contains other unique questions designed to further explore the views and experiences of the different professional groups.
Statistical analysis was carried out using SPSS version 18 for Windows. Kruskal-Wallis tests were used to assess differences between the views and experiences of mental health professionals working in different disciplines. P-values less than 0.05 were considered to be statistically significant.
The overall response rate was 48%, 288 of 606 surveys being returned, and 62% (177) of respondents were female. The majority of respondents were aged between 31 and 50 years (63%). The ethnic diversity of the sample approximately reflected that of the general population of the UK: 18 80% (n = 229) of respondents were White British. The majority of respondents (72%) worked full time and the mean length of service was 15 years.
A total of 21% (n = 59) of respondents were doctors (of whom 51% were consultant psychiatrists), 7% were team managers, 33% nurses, 18% social workers and 21% were classed as ‘other occupational group’. This latter group included psychologists, support workers, occupational therapists and physiotherapists. Respondents worked overwhelmingly in community services of different types: 47% in community mental health teams, 19% in crisis teams, 18% in assertive outreach, 12% in early intervention and 13% in other teams. The other teams included: emergency duty team/emergency out-of-hours AMHPs, community rehabilitation and criminal justice.
Respondents rated the importance of 12 factors when making the decision to use a CTO on a five-point Likert scale, ranging from one (very important) to five (not important at all). The results for the psychiatrists and other mental health professionals in our sample, together with a comparison of factor rankings with UK psychiatrists, Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12 New Zealand psychiatrists Reference Romans, Dawson, Mullen and Gibbs14 and other mental health professionals, Reference Romans, Dawson, Mullen and Gibbs14 are shown in Table 1. ‘Ensuring contact with mental health professionals’ was considered to be the most important factor by four of the five groups. All professional groups agreed on the five most important factors in decision-making.
Respondents rated the importance of nine possible mechanisms influencing how CTOs work. The results are shown in Table 2. The different groups ranked the three most important mechanisms similarly, although there was some difference in emphasis of the importance of adherence with prescribed medication.
Respondents rated nine possible factors that could potentially undermine the effectiveness of CTOs. Again, there was broad agreement, with the only significant difference being the importance ascribed to ‘inadequate access to psychological therapies’. Nurses and the ‘other’ occupational group tended to rate this as greatly undermining the effectiveness of CTOs, whereas it was rated as a relatively unimportant factor by the three other groups.
Respondents rated eight possible factors that could discourage the use of CTOs. Whereas respondents tended to avoid strong opinions, there were several significantly different results. Psychiatrists were more concerned than social workers by the additional administrative burdens. Nurses were more concerned than psychiatrists and social workers by the degree of coercion involved and the nurses were most concerned by the difficulty in accessing second-opinion doctors. Although not a significantly different result, there was a trend for the team managers to be least concerned by the loss of civil liberties.
Table 3 shows how respondents rated their level of agreement with the following statements on a five-point Likert scale: ‘I support the use of CTOs’ and ‘In the use of CTOs, their benefits outweigh any coercive impact on the patient’. The results showed that the vast majority supported the use of CTOs, with 83% (n = 48) of psychiatrists and 67% (n = 142) of non-psychiatrist mental health professionals in support of the use of CTOs. Overall, 74% of psychiatrists and 50% of other mental health professionals agreed that the benefits of the use of CTOs outweighed any coercive impact on the patient.
Of the psychiatrists, 52% believed that CTOs helped the development or maintenance of the therapeutic relationship with the patient and 17% believed that they hindered the relationship. Those from other professional groups had a less positive view, 45% believing they helped the relationship and 21% believing they hindered it.
Respondents rated their level of agreement with seven general statements regarding CTOs, as shown in Table 4. For the statement: ‘The introduction of CTOs has been a retrograde step for mental health services’, team managers and psychiatrists disagreed with this statement significantly more than the other professions. The same order of agreement was found for the statement: ‘CTOs infringe patients’ human rights’. All professional groups believed that CTOs provided greater treatment options. Overall, staff of all disciplines reported that the benefits of CTOs could ‘already be seen’.
There was overall agreement between the professional groups on a number of general statements regarding CTOs. Respondents disagreed with the proposition that the introduction of CTOs was a ‘retrograde step’. All groups believed they provided greater treatment options and could provide additional benefits over and above well-resourced voluntary community services.
The results of this survey of mental health professionals working in England shortly after the introduction of CTOs demonstrate broad agreement across professions on the main issues regarding CTOs. There was also some level of consensus across time and across countries as demonstrated by a comparison of our results with previous UK studies Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12,Reference Crawford, Hopkins and Henderson13,Reference Bindman19 and the New Zealand studies. Reference Romans, Dawson, Mullen and Gibbs14 Psychiatrists and other mental health professionals in England and in New Zealand believed that the same five factors were most important in their decision-making regarding CTOs. These factors were overwhelmingly clinical and included: ensuring contact with professionals, adherence with medication and rapid identification of relapse. The different groups reported similar views on the most important mechanisms influencing how CTOs work, which included ensuring adherence to medication for a lengthy period, ensuring a greater period of stability and signalling to the patient that they have a serious mental problem.
Although a response rate of 48% is high for this form of research and a strength of our study, respondents were all located in the South of England. It is possible that this may affect the generalisability of the results but it seems reasonable to assume that views are broadly representative of the national picture.
Despite substantial areas of agreement there were some significant differences between the professional groups. Nurses were most likely to feel that inadequate access to psychological therapies could undermine the effectiveness of CTOs and were most concerned by the negative effects of coercion. Psychiatrists (perhaps unsurprisingly, as they are responsible for so much of this) were most concerned regarding the burden of bureaucracy. Our results suggested that professional differences about different aspects of the deployment of CTOs can be expressed within a generally facilitating framework, in which most staff regard CTOs as a potentially valuable process for some cases. These differences could be important in shaping practice and providing balance in decision-making. They may also, if they can be shared in a supportive manner, serve to develop more consistent practice and reduce the considerable variations in practice that can be seen today.
Our respondents believed that CTOs could improve the development of a therapeutic relationship with the patient over time with continued treatment, support and greater insight on the part of the patient. The majority (74% of psychiatrists and 50% of other mental health professionals) also agreed to some extent that the benefits of CTOs outweighed any coercive impact on the patient. The vast majority supported the use of CTOs, with 83% of psychiatrists and 67% of other professionals in favour of their continued availability. It would appear that there has been a marked shift in the mental health professionals’ views and experiences of CTOs since the New Zealand mental health professionals’ survey Reference Romans, Dawson, Mullen and Gibbs14 and the UK psychiatrists’ survey. Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12 The New Zealand surveys of consultant psychiatrists and other mental health professionals found that 79% of psychiatrists and 85% of non-psychiatrist mental health professionals preferred to work in a system with CTOs. Reference Romans, Dawson, Mullen and Gibbs14 The survey of UK psychiatrists in 2009 found that 60% expressed a preference for working in a system with CTOs Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12 and our figure of 83% suggests a substantial increase in the level of support for the use of CTOs among psychiatrists in the few years since CTOs have been in use.
Current study - psychiatrists, n (%)
Current study - non-psychiatrist
mental health professionals, n (%)
2011 Reference Manning, Molodynski, Rugkåsa, Dawson and Burns12
2004 Reference Romans, Dawson, Mullen and Gibbs14 )
|New Zealand non-
(Romans, 2004 Reference Romans, Dawson, Mullen and Gibbs14 )Footnote c
|Ensure contact with mental health professionals||27 (47)||13 (22)||11 (19)||4 (7)||3 (5)||117 (56)||51 (24)||27 (13)||10 (5)||4 (2)||2.02 (1)||1.86 (3)||1.79 (1)||1.72 (1=)||(1)|
|Protect patients from the consequences of relapse in their illness||19 (34)||20 (36)||12 (21)||1 (2)||4 (7)||87 (42)||77 (37)||32 (16)||7 (3)||3 (2)||2.13 (2)||1.83 (2)||2.08 (5)||1.84 (3)||(4=)|
|Promote adherence to medication||18 (32)||26 (46)||4 (7)||5 (9)||4 (7)||72 (35)||84 (41)||38 (18)||11 (5)||2 (1)||2.14 (3)||1.78 (1)||2.03 (4)||1.97 (4)||(3)|
|Provide the authority to treat the patient||20 (35)||20 (35)||10 (17)||5 (9)||3 (5)||70 (34)||72 (35)||43 (21)||17 (8)||4 (2)||2.16 (4)||2.08 (4)||1.81 (2)||2.09 (5)||(2)|
|Ensure rapid identification of relapse||17 (29)||18 (31)||15 (26)||5 (9)||3 (5)||112 (54)||60 (29)||21 (10)||12 (6)||3 (1)||2.29 (5=)||2.24 (5)||1.90 (3)||1.72 (1=)||(4=)|
|Facilitate readmission to in-patient care||15 (26)||22 (38)||13 (22)||5 (9)||3 (5)||60 (29)||75 (36)||53 (25)||17 (8)||4 (2)||2.29 (5=)||2.56 (6)||2.43 (7)||2.19 (6)||(8)|
|Provide greater security for patients’ families or caregivers||3 (5)||18 (31)||19 (33)||12 (21)||6 (10)||54 (26)||76 (37)||53 (26)||15 (7)||10 (5)||3.00 (7)||2.70 (8)||2.41 (6)||2.28 (7)||(6)|
|Reduce the risk of violence to others||4 (7)||12 (21)||24 (41)||10 (17)||8 (14)||52 (25)||52 (25)||62 (30)||26 (13)||15 (7)||3.10 (8)||2.61 (7)||2.68 (8)||2.52 (8)||(9)|
|Reduce the risk of selfharm by the patient||5 (9)||13 (23)||18 (32)||13 (23)||8 (14)||51 (25)||49 (24)||67 (32)||27 (13)||13 (6)||3.11 (9)||2.81 (9)||2.74 (9)||2.53 (9)||(7)|
|Enhance the obligations of service providers to the patient||6 (10)||12 (21)||17 (29)||13 (22)||10 (17)||39 (19)||51 (25)||72 (35)||34 (16)||12 (6)||3.16 (10)||3.12 (10)||2.97 (10)||2.66 (10)||(10)|
|Help ensure police assistance with patients will be available||4 (7)||8 (14)||13 (22)||19 (33)||14 (24)||20 (10)||33 (16)||66 (32)||58 (28)||30 (15)||3.53 (11)||3.74 (11)||3.31 (11)||3.22 (12)||(11)|
|Reduce substance misuse by the patient||4 (7)||7 (12)||14 (25)||15 (26)||17 (30)||21 (10)||28 (14)||76 (37)||49 (24)||32 (16)||3.60 (12)||3.79 (12)||3.73 (12)||3.21 (11)||(12)|
a. Percentages may not add up to 100 owing to rounding.
b. Scores range from 1 (very important) to 5 (not important at all).
c. Only ranks available for New Zealand non-psychiatrist mental health professionals.
|Mean importanceFootnote a (rank)|
|Factor||Psychiatrist||Team manager||Nurse||Social worker||Other||Kruskal-Wallis, χ2||P|
|Ensures medication adherence for a lengthy period during which other changes can occur||2.21 (1)||1.95 (1)||1.89 (1)||2.43 (2)||2.04 (1=)||11.90||0.02|
|Ensures a greater period of stability||2.40 (2)||2.30 (3)||2.14 (2)||2.30 (1)||2.04 (1=)||3.31||0.51|
|Signals to the patient that they have a serious mental problem which needs active management||2.60 (3)||2.15 (2)||2.41 (3=)||2.79 (4)||2.50 (6)||8.91||0.06|
|Binds community mental health services into place||2.88 (4)||2.95 (7=)||2.74 (8)||2.85 (5)||2.58 (7)||2.48||0.65|
|Commits service providers to the patient||3.05 (5)||2.55 (5)||2.41 (3=)||2.77 (3)||2.10 (3)||23.68||<0.01|
|Encourages the patient to take responsibility||3.26 (6=)||3.05 (9)||2.69 (5)||2.89 (7)||2.41 (5)||17.32||<0.01|
|Gives others the confidence to care for the patient||3.26 (6=)||2.50 (4)||2.70 (6=)||3.21 (9)||2.64 (8)||16.08||<0.01|
|Mobilises social support for the patient||3.42 (8)||2.95 (7=)||2.70 (6=)||2.87 (6)||2.35 (4)||23.84||<0.01|
|The patient gives up key conflict areas to external agents||3.43 (9)||2.89 (6)||2.89 (9)||3.19 (8)||2.86 (9)||15.59||<0.01|
a. Scores range from 1 (very important) to 5 (not important at all).
|Level of agreement with statement|
|Psychiatrists, n (%)||Non-psychiatrist mental health professionals, n (%)|
|Agree a little||Neutral||Disagree
|Agree a little||Neutral||Disagree
|I support the use of CTOs||9 (16)||39 (67)||5 (9)||5 (9)||0 (0)||51 (24)||91 (43)||48 (23)||16 (8)||6 (3)|
|In the use of CTOs, their benefits outweigh any coercive impact on the patient||12 (21)||30 (53)||11 (19)||4 (7)||0 (0)||33 (15)||75 (35)||67 (31)||31 (15)||7 (3)|
a. Percentages may not add up to 100 owing to rounding.
|Mean for each professionFootnote a|
|Factor||Psychiatrist||Team manager||Nurse||Social worker||Other||Kruskal-Wallis, χ2||P|
|The introduction of CTOs has been a retrograde step for mental health services||-0.74||-0.95||-0.1||-0.51||-0.13||22.25||<0.01|
|CTOs infringe on patients’ human rights||-0.03||-0.6||0.24||0.17||0.17||11.20||0.02|
|The benefits of CTOs can already be seen||0.49||0.6||0.48||0.34||0.48||1.16||0.89|
|I think that in the long term, the use of CTOs will not show any overall benefit||-0.41||-0.55||-0.25||-0.19||-0.19||3.14||0.53|
|CTOs provide a greater choice of treatment options||0.5||0.6||0.26||0.06||0.37||5.41||0.25|
|Well-resourced voluntary community services could provide the same benefits as CTOs||-0.31||-0.5||-0.41||-0.6||0.04||8.35||0.08|
|CTOs are a more appropriate way of treating patients in the community than the long-term use of Section 17 leave||0.42||0.75||0.5||0.23||0.63||4.33||0.36|
a. Mean scores relate to scoring as follows: −2: strongly disagree; −1: disagree a little; 0: neutral; 1: agree a little; 2: strongly agree.
Although the introduction of CTOs in England was combined with a national training programme for psychiatrists and AMHPs, many from other professional backgrounds have had little or no training in this area. We believe that this is a concern as in many cases community psychiatric nurses and occupational therapists are the main professionals working with people subject to CTOs. Our survey demonstrates substantial experience and considerable understanding among such staff. The decision to initiate a CTO should be a multidisciplinary one and the differences in outlook suggested by our survey may protect against idiosyncratic or unhelpful practice. However, if this is to be the case, more education and training needs to be made available to staff of all professional groups who are involved in decisions regarding CTOs. This would enable other professionals to take a full role in decisions about deployment, ongoing management and discharge of CTOs - discharge being relatively unusual in practice so far. 1
We believe that it may be valuable to develop small groups in an area that can develop expertise and acquire more detailed knowledge regarding clinical practice involving compulsion. Such a group may include clinicians from different disciplines alongside service users and carers to provide a broad-based approach to such decisions. They could act as a resource for clinical teams who might only face these decisions relatively infrequently. Such a body may function in a similar way to an accommodation panel or a hospital ethics group by being available to consider cases with clinical teams on a fairly informal basis and provide advice and support. The question of resources inevitably arises but the benefits of a more coordinated and considered approach to the use of compulsion in community care could outweigh the resource burden.
The benefits of CTOs remain uncertain and there is a lack of high-quality research evidence for the outcomes and effectiveness of CTOs. Only two RCTs have been conducted, both in the USA. Reference Swartz, Swanson, Wagner, Burns, Hiday and Borum5,Reference Steadman, Gounis, Dennis, Hopper, Roche and Swartz6 Neither show an overall difference in outcome between those on a CTO and those not in terms of readmission and clinical and broadly defined social functioning. Also, CTOs have the potential to infringe on human rights such as Article 3 (prohibition of torture, which includes inhuman or degrading treatment), Article 5 (right to liberty and security) and Article 8 (right to respect for private and family life) of the Human Rights Act 1998. 20 Given this, there remain concerns regarding the practice of restricting patients’ freedoms under a CTO when there is little objective evidence of improved outcome as a result of such restrictions. There is a lack of professional consensus or guidance in this area of practice. Ultimately, the current lack of evidence needs to be addressed and further research is urgently required, including studies that consider the experiences and views of service users and carers and to analyse the processes involved in deciding on and utilising compulsion.
We thank Genevieve Riley, Krishen Ranganath, Mark Walker, Caroline Marrow and Nicola Hovey for their help with the design and implementation of the study and Cate Manning for allowing the use of part of her research instrument. We also thank Mike Blackburn, Caroline Jennings, Anne Jones, Judith Rimell and Dave Buckle of the Gloucester assertive outreach team for their positive involvement, and all other staff who participated.