Perception of Coercion Among Patients With a Psychiatric Community Treatment Order: A Literature Review
Abstract
Objective:
Various forms of compulsory psychiatric community treatment orders (CTOs) are commonly utilized internationally. CTOs remain contentious because of the ethical implications of coercing patients to receive treatment. Understanding patients’ experience of CTOs can assist in the development of more patient-centered and recovery-focused community care. This review examined the relationship between CTOs and patients’ perceptions of coercion in the literature.
Methods:
A search of key terms relating to CTOs and patients’ perceptions of coercion was conducted of relevant databases from their inception to March 31, 2014. Publications were included if they were peer reviewed, reported on original research, surveyed or interviewed patients who were or had been subject to a CTO, and were written in English. Factors influencing patients’ perceptions of coercion, including the regional context of the studies, were identified.
Results:
Twenty-three primary research articles, reporting on 14 studies from seven countries, were included. Evidence indicated that CTOs may contribute to a patient’s sense of coercion, with marked variations among studies in the levels of coercion. Contextual factors, including perceptions of alternatives to CTOs, the presence of additional forms of leverage in patients’ lives, and the process of CTO initiation and enforcement, may mitigate or enhance perceptions of coercion.
Conclusions:
Coercive elements of CTOs may be reduced through increased patient access to information, better working relationships with service providers, and accessible, fair processes. The coercive aspects of CTOs should be seen as part of a broader understanding of the daily pressures and leverage applied in outpatient psychiatric treatment.
The use of coercion in psychiatric care has been conceptualized as a continuum of practices to obtain treatment compliance, from outright force to “subtle manifestations of social control” (1). These practices are generally used for patients who otherwise do not adhere to prescribed mental health treatment and who may pose a danger to themselves or the public, resulting in frequent psychiatric hospitalizations.
Coercive interventions are often based on the rationale that some psychiatric patients may lack insight into the elevated risk that they pose to themselves or others. Research indicates that between one-third and one-half of people diagnosed as having schizophrenia do not recognize their experiences as symptoms of illness and, therefore, may not follow a treatment plan voluntarily (2,3). Since the 1960s, when deinstitutionalization began in many parts of the world, many mental health care interventions have been moved to outpatient settings. This increase in the scope of outpatient care has led to the introduction of more coercive community practices, including the use of mandated community-based treatment orders across North America, Europe, and Australasia. These orders are referred to by different names, including assisted outpatient treatment order, outpatient commitment, and community treatment order (CTO); for simplicity and consistency, the term CTO will be used in this review. Although terminology, legal specificities, and their reach vary by locale, these orders all aim to treat patients in the community and reduce recurring hospitalization.
The efficacy and ethics of the use of coercion in outpatient mental health treatment, and CTOs in particular, have been the subject of active debate, and there is no consensus that coercive practices are sometimes necessary for patient recovery. Even among those who argue in favor of mandatory community treatment, however, there remains a firm belief in the importance of patient-centered care and in the involvement of patients in treatment decisions whenever possible (4,5). The concept of procedural justice is often invoked as a counterweight to coercion; it is defined as a process of decision making and enactment characterized by fairness (6). The more a person perceives a decision process to be just, the less coerced he or she may feel (6–8). Some literature indicates that patients’ reports of coercion are inversely correlated with the experience of having a voice in treatment planning (9), being given information, and feeling treated with respect during interventions (6,7). In addition, a recent systematic review of coercion in psychiatric settings highlighted that a lack of input in treatment decisions increases a patient’s perception of coercion and generates negative impressions of treatment (9). The authors concluded that a greater body of evidence is necessary to infer that coercive practices can improve patient outcomes.
Research on the patient experience of coercion in outpatient settings is less extensive than research on the patient experience of involuntary hospitalization. The available literature shows that CTOs are only one of many forms of leverage applied to patients in the community to encourage treatment compliance. A 2005 U.S. study in five cities across different states surveyed 1,011 psychiatric outpatients about their lifetime experiences with various forms of leverage aimed at improving adherence to psychiatric treatment in the community. These included restrictions on patients’ control of their own finances and housing as well as the use of criminal justice sanctions (court sentencing, parole requirements) and CTOs (10,11). The percentage of participants who experienced at least one of these forms of leverage over their lifetime ranged from 44% to 59% across sites, with only 12% to 20% having been subject to a CTO (10). Depending on the site, Redlich and Monahan (11) reported, between 41% and 55% of the study participants felt pressured to adhere to treatment over the past six months. Another study conducted in England before CTOs were introduced found that 35% of psychiatric outpatients reported having experienced a form of leverage (12). Conversations regarding community coercion must acknowledge that CTOs are only one source of patients’ coercive experiences.
CTOs are often presented as a less restrictive alternative to involuntary hospitalization, but, particularly given their coercive nature, they have come under criticism based on an absence of consistent efficacy data. Three randomized controlled trials (RCTs), two in the United States and one in England, have studied clinical outcomes of patients with CTOs (13–15). All three studies have faced significant criticism because of methodological shortcomings (16–20), and they were unable to provide conclusive evidence regarding CTO effectiveness. However, pre-post comparison and cohort studies, including two large-scale longitudinal studies in New York State (N=3,576) (21) and Western Australia (N=2,592) (22) showed some positive effects of CTOs in reducing frequency or length of psychiatric hospitalizations and improved treatment adherence.
The effect of CTOs on patients’ quality-of-life measurements over time appears to be inconclusive (1,14,22–24), but there is evidence associating CTOs with an increase in contact with service providers (25,26), lower patient victimization and violence perpetration (13), and greater adherence to medication (21,25). The significant variety of CTO legislation and enactment practices across regions must be kept in mind when attempting to translate recommendations for “best practices” to different locales (17,27).
Although the debate on the efficacy of CTOs should be encouraged, it is also important to develop a greater understanding of patient experience of these orders and the outpatient context in which CTOs are used. The objective of this review, therefore, was to examine the current literature for information about the relationship between CTOs and patients’ perceptions of coercion and to identify factors that might improve the experience of being placed under such an order.
Methods
Design
We conducted a review of both quantitative and qualitative original peer-reviewed research on the attitudes and experiences of patients who were subject to treatment orders in the community. The results of eligible studies were examined for common themes, and the implications of the findings for practice and further research are discussed.
Search Methods and Eligibility Criteria
A medical research librarian assisted in the development of an electronic search strategy. We determined a comprehensive list of terms regarding compulsory community treatment on the basis of the Cochrane Review and the Canadian Psychiatric Association position paper on outpatient committal and through examining gray and peer-reviewed literature on the topic from Europe, Australia, New Zealand, and North America (16,28). A search of relevant databases from their inception to March 31, 2014, was conducted. [Further details on our search methods are available as an online supplement to this article.]
Publications were included if they were peer reviewed, reported on original quantitative or qualitative research, surveyed or interviewed patients who were or had been subject to a CTO, and were written in English. Dissertations and conference abstracts were excluded, as were studies focused on forensic patient populations. Two reviewers screened article titles and abstracts to ensure basic study eligibility. Any discrepancies were resolved through discussion. A review of the reference lists of all relevant articles did not result in additional material.
Data Synthesis
The results of each article were analyzed for factors associated with patients’ perception of coercion. These factors were pooled and organized thematically; quantitative and qualitative articles were grouped and reviewed separately to determine if any themes arose that were specific to methodology. Multiple papers reporting on the same study were examined in concert. Once reviewers arrived at consensus on themes related to patients’ perceptions of coercion and CTOs, each quantitative and qualitative study was examined individually for additional detailed data related to each theme, and the results were synthesized and grouped by theme.
Results
The initial search was wide, using many different terminologies to describe CTOs. It yielded 439 unique articles, of which 31 appeared to meet selection criteria. Eight articles were excluded because they reported on prospective attitudes about hypothetical compulsory community treatment, rather than firsthand experience (29–33), or discussed the use of leverage in mental health care but did not focus on CTOs (34–36). If a study of multiple forms of leverage presented CTO experiences separately, it was included and the CTO data were extracted (37). If more detailed analysis of a given data set became available, we included the most recent results (24,38).
The final review included 23 articles—12 quantitative and 11 qualitative articles—reporting on results of 14 studies from ten jurisdictions in seven countries. Table 1 summarizes CTO legislation and implementation by state or country based on the information provided in these studies. Details of study design and major findings are abstracted in Table 2.
| Region | Studiesb | Term | Patient eligibility | Methods | Reach | Enforcement and review |
|---|---|---|---|---|---|---|
| New Zealand | Newton-Howes, 2013 (39); McKenna et al., 2006 (40); Gibbs et al., 2005 (44); Gibbs, 2010 (45); Gibbs et al., 2004 (49); Gibbs et al., 2006 (56) | CTO | Has a mental illness and poses a serious danger to the health or safety of that person or others, seriously diminished capacity for self-care, involuntary treatment necessary for recovery, adequate outpatient care available, and adequate patient social circumstances | Court ordered after a hearing or by a psychiatrist (or physician) substituting for an involuntary inpatient order; if eligible, CTO preferred over hospital care | Mandatory judicial reviews at 6 and 12 months; after 12 months may be placed on CTO indefinitely; attend and accept treatment and meet with workers; possible restrictions: specified residence, abstinence from substances, travel beyond set boundaries | Recalled to hospital or clinic if conditions breached; police may be involved. Not possible to forcibly medicate in community setting |
| Victoria, Australia | Brophy and Ring, 2004 (51) | CTO | Presence of serious mental illness, treatment can be obtained through a CTO, untreated mental illness would result in deterioration or dangerousness, the person has refused treatment or is unable to consent to the necessary treatment, and no adequate treatment for the mental illness possible in less restrictive form | Within 8 weeks of initial order by psychiatrist, CTO reviewed by the Mental Health Review Board (MHRB), an external review tribunal of community, legal, and psychiatrist members | Judicially reviewed at least once every 12 months; may be renewed indefinitely; legislation does not outline treatment; psychiatrist, not board, determines treatment specificities | Reviewed by MHRB at least once a year; appeals may be made to MHRB at any time by patient; order may be revoked by psychiatrist and patient returned to inpatient unit |
| New York | Link et al., 2008 (1); Steadman et al., 2001 (14); Rain et al., 2003 (47); Phelan et al., 2010 (50) | AOT | Current inpatient, 18 or older, at least 2 involuntary hospitalizations in the past 18 months due to noncompliance with treatment, unlikely or unable to access treatment voluntarily once discharged, involuntary treatment necessary for recovery, history indicates likely to benefit from treatment | Ordered by the court; individuals with mental illness and a history of multiple hospitalizations or violence toward self or others; petition initiated by treatment provider | Valid for up to 180 days with option to be renewed; attend and accept treatment and meet with outpatient treatment team | Treatment adherence can be enforced by the sheriff’s department “but in practice nonadherence alone does not justify a sheriff’s pickup” (1) |
| North Carolina | Swartz et al., 1999 (24); Swartz et al., 2002 (38); Elbogen et al., 2003 (46); Scheidcook, 1993 (54); Swartz et al., 2003 (57) | OPC | Presence of serious mental illness, the capacity to survive in the community with available supports, untreated mental illness would predictably result in deterioration or dangerousness, unlikely to access treatment voluntarily once discharged, history indicates likely to benefit from treatment | Court ordered after a hearing | Valid for up to 90 days with option to be renewed | A noncompliant patient can be brought back to a hospital by the police for “hopeful persuasion” (38) to accept treatment or evaluation for involuntary inpatient commitment; forced medication in community not permitted |
| Pennsylvania | Gjesfjeld and Kennedy, 2011 (52) | OPC | No Pennsylvania-specific information provided | Court ordered after a hearing | No length or renewal information provided; requires compliance with designated outpatient treatment plan | No information provided |
| Ohio | Galon and Wineman, 2011 (41); Galon et al., 2012 (48) | OPC | No Ohio-specific information provided | Court ordered after a hearing | No information provided | No information provided |
| Saskatchewan, Canada | O’Reilly et al., 2006 (43) | CTO | At least 3 involuntary admissions or over 60 days of hospitalization in 24 months, meets inpatient committal criteria | Two psychiatrists must agree about need for initial CTO | Valid for 90 days; renewed if there is agreement from 2 psychiatrists | Admitted to inpatient unit if fails to meet conditions |
| England and Wales | Canvin et al., 2002 (42) | SDO | Inpatient approaching discharge | Client consents to be placed on order or guardianship | Valid for 6 months, renewable; compulsory attendance of appointments; mandated place of residence; providing access to the clinical team | Recalled to hospital if fails to meet conditions; no compulsory medication adherence |
| Scotland | Ridley and Hunter, 2013 (37) | CTO | Eligibility criteria not described | Involves appearance at mental health tribunal and development of care plan with providers, patient, and substitute decision maker | Compliance with outpatient treatment program, particularly medication | No information provided |
| Israel | Greenberg et al., 2005 (53) | IOC | Presence of mental illness, presence of danger to self or others, and refusal to accept voluntary care | Issued by a district psychiatrist on the recommendation of the patient’s psychiatrist | Valid for 6 months; must continue to attend appointments and receive treatment in the community | Recalled to hospital if fails to attend appointments |
a
Abbreviations: AOT, assisted outpatient treatment; CTO, community treatment order or community-based compulsory treatment order; IOC, involuntary outpatient commitment; OPC, outpatient commitment; and SDO, supervised discharge order and guardianship
b
Multiple articles from the same study are grouped together.
| Studya | Location | Description | Relationship of PC and CTOs | Additional factors and findings |
|---|---|---|---|---|
| Quantitative | ||||
| Steadman et al., 2001 (14); Rain et al., 2003 (47) | New York | Randomized controlled trial (RCT): 142 patients recruited from Bellevue Hospital at discharge; pilot study of CTO. Pilot group, N=78; control group (enhanced services only), N=64. Chart review and structured interviews at baseline and 1, 5, and 11 months posthospital discharge (57%–68% follow-up rates) | No significant correlation between greater PC and CTOs; majority of participants at baseline scored >3 on an adapted MacArthur PC Scale (range 1–5) (72% CTO, 63% control group) | No significant differences in main outcome measurements; some correlation between greater PC and adherence to injected medication at first follow-up (r=.524) but not significant at second or third follow-ups; no pick-up orders issued by police for enforcement of the CTO during pilot study |
| Link et al., 2008 (1); Phelan et al., 2010 (50) | New York | Longitudinal comparative study: 184 outpatients recruited from clinics in New York City. CTO group, N=76; voluntary outpatient group, N=108. Interviews at baseline and 3, 6, 9, and 12 months (62%–84% follow-up rates) | No significant correlation between greater PC and CTOs; mean scores on adapted MacArthur PC Scale (possible range 0–3) of 1.45 for CTO participants and 1.33 for control group. CTO patients marginally less likely to have greater PC (p<.10) during follow-up period | Some correlation between a greater number of past involuntary hospitalizations and increased PC (r=.331, p<.001) |
| Swartz et al., 1999 (24); Swartz et al., 2002 (38); Swartz et al., 2003 (57) | North Carolina | RCT: 258 patients at hospital discharge. CTO group, N=100; voluntary outpatient group, N=113; nonrandomized CTO patients with violent history, N=45. Chart review and structured interviews at baseline and 4, 8, 12, and 16 months; interviews with family member or collateral informant and case manager | Significant difference in PC between CTO patients (median=5.51) and control groups (median=3.80) (p=.002) on the adapted 15-item MacArthur Admissions Experience Survey measuring coercion, negative pressures, and process exclusion (possible range 1–15; logistical regression completed after dichotomizing participants as higher or lower than median, as scores were skewed to the low end of the scale) | Higher PC significantly associated with African-American patients (p≤.05), more severe psychiatric symptoms (p≤.05), mood disorder (p≤.05), problems related to substance use (p≤.01), increased days on CTOs (p≤.05), increased case managers’ reminders and warnings of consequences of nonadherence to treatment (p≤.05), patients whose orders were enforced due to nonadherence (p≤.05). Lower PC significantly associated with greater levels of insight (p≤.05), being married or cohabiting (p≤.01). Patients who experienced greater PC unlikely to endorse benefits of CTOs unless they experienced positive treatment outcomes (p<.05) |
| Elbogen et al., 2003 (46) | North Carolina | RCT (secondary analysis of North Carolina RCT) (24,36,38) using 12-month follow-up data. Patients reorganized in 4 nonrandomized subgroups: neither CTO nor financial guardianship (N=65, (25%), financial guardianship only (N=46, 18%), CTO only (N=62, 24%), both CTO and financial guardianship (N=62, 24%) | Significantly higher rates of PC for patients with both financial guardianship and CTO compared with neither (p=.004). No significant difference in PC between patients with a CTO or financial guardianship alone compared with neither | Significant effect of number of types of leverage on increased PC for medication-nonadherent patients (p=.023), but not for adherent patients |
| Galon and Wineman, 2011 (41); Galon et al., 2012 (48) | Ohio | Quasi-experimental comparative study: 154 outpatients recruited from 2 clinics. Four comparison groups: assertive community treatment (ACT) and CTO (N=31), ACT and no CTO (N=45), usual care and CTO (N=34), and usual care only (N=45); did not reach the sample sizes necessary for strong analysis | CTO groups nearly 3 times more likely to have higher PC scores compared with those without a CTO (p<.001); overall PC scores lower than for other CTO studies (1.73±1.88, CTO; .67 [SD not reported], non-CTO) based on an adapted MacArthur PC Scale, range 0–5) | Strong inverse correlation between procedural justice and PC (r=–.51, p<.001), accounted for 25.8% of variance in PC scores; less strong with African-American patients (accounted for 8.9% of variance, with CTO status accounting for 2%). College graduates (2.57±1.98) had higher PC, compared with non–high school graduates (.70±1.20, p=.004), and lower perceived procedural justice (2.29±2.36, p=.012), compared with non–high school graduates (4.37±1.91, p=1.91) and high school graduates (4.16±2.01, p=.20). No additive effect of CTO and ACT on PC |
| McKenna et al., 2006 (40) | Auckland, New Zealand | Comparative study: 138 outpatients, 2 comparison groups (CTO, N=69; voluntary outpatients, N=69). One-time interview; overall response rate of those able to be contacted or able to be involved in informed consent of 86% | Significant difference in PC between CTO and control groups (p<.001); overall levels of perceived coercion low in both cohorts | Both cohorts showed an overall high level of procedural justice. In bivariate analysis, greater insight into illness significantly associated with lower PC (p=.003); previous hospital admission (p=.004) or involuntary hospitalization (p≤.001) associated with higher PC; weak inverse correlation between PC and procedural justice (rs=–.286, p≤.001); correlation between lower PC and having a partner (p=.001) |
| Newton-Howes, 2013 (39) | Otago, New Zealand | Self-administered survey: 79 outpatients; one-time survey of patients with a current or recent CTO | CTO status accounted for 41% of variance in client’s interpersonal problems, encompassing difficulties with mental health services and the legal system | Some patients identified benefits in treatment due to a perceived increase in availability of support services |
| Qualitative | ||||
| Scheidcook, 1993 (54) | North Carolina | Interviews and participant observation over 2 years with outpatients with a CTO (N=68) and clinicians (N=123) in rural community mental health care centers | Patients felt forced to take medication, found CTOs less coercive than hospitalization | Patients’ lack of knowledge of legislation |
| Gjesfjeld and Kennedy, 2011 (52) | Pennsylvania | 1-time individual interviews with outpatients with current or recent (within 2 years) CTO (N=9) and client-nominated service providers (N=8) | Patients expressed lack of control in decision making | Patients’ lack of knowledge of legislation; patients identified benefits in treatment due to increase in availability of support services; positive relationship with mental health providers associated with reduced coercion and increased benefits of CTO |
| O’Reilly et al., 2006 (43) | Saskatchewan, Canada | 8 stakeholder focus groups with CTO-experienced family members (N=14) and mental health care providers (N=50); individual interviews with outpatients with a CTO (N=14) | Patients expressed perception of coercion in treatment; found CTOs less coercive than hospitalization | More acceptance of CTO after time because of increase in safety and security provided by structure. Patients had awareness of their rights on CTOs but exercising those rights felt futile |
| Gibbs et al., 2005 (44); Gibbs, 2010 (45); Gibbs et al., 2004 (49); Gibbs et al., 2006 (56) | Otago, New Zealand | 1-time individual interviews with outpatients with a current or recent (within 2 years) CTO (N=42), patient-nominated family members (N=27), and mental health providers (N=90); additional subanalyses of female clients (N=10) and Maori clients (N=8) and their families | Minority of patients perceived coercion related to medication adherence; travel and residence restrictions; control over treatment decisions by providers, particularly psychiatrists | Patients identified benefits in treatment due to increase in availability of support services; positive relationship with mental health providers reduced coercion and increased benefits of CTO; important to account for unique needs and concerns of women and Maori patients with a CTO |
| Brophy and Ring, 2004 (51) | Victoria, Australia | 1-time focus groups with outpatients with a CTO (N=30) and patient-nominated service providers (N=18). Some Likert scales used with providers | Patients felt under threat of sanctions; disliked forced treatment, particularly intramuscular medication injections | Patients identified benefits in treatment due to increase in availability of support services; patients felt disempowered because of process and order |
| Ridley and Hunter, 2013 (37) | Scotland | Baseline and 12-month individual interviews with outpatients with a CTO (N=49) from across the country | Patients found compulsion overall negative, but saw some benefits | Patients’ lack of knowledge of legislation; some patients identified benefits in treatment due to a perceived increase in availability of support services |
| Canvin et al., 2002 (42) | South East England | 1-time interviews with outpatients with a CTO (N=20) | Patients disliked lifestyle restrictions; some expressed resistance to the order; CTO found less coercive than hospitalization | Patients’ lack of knowledge of legislation and patient rights; patients who successfully appealed their CTO were not included in this study due to recruitment methodology |
| Greenberg et al., 2005 (53) | North Jerusalem | 1-time interviews with outpatients with a CTO (N=13) and psychiatrists (N=17); patient chart review (N=26) | Patients saw practice as coercive | Lack of knowledge of patient rights and ability to appeal; orders did not seem to have a great impact on relationship between patients and psychiatrists |
a
Multiple articles from the same study are grouped together.
Ten of the 12 quantitative articles refer to U.S. studies, and the other two were from New Zealand. RCTs from New York (14) and North Carolina (38) produced the majority of quantitative findings. All but one (39) of the quantitative studies employed adapted outpatient versions of the MacArthur Admission Experience Survey to measure perceived coercion and procedural justice. Adaptations of the MacArthur Likert scales allowed patients to rate their involvement in treatment and decision making as well as positive and negative pressures they experienced in the course of treatment (Table 2). The 11 qualitative studies were from New Zealand, the United States, Canada, the United Kingdom, Israel, and Australia, all regions with unique CTO legislation (Table 1). All studies discussed the CTO process, patients’ perceptions of the role of the CTO in their lives, and relationships with those involved in implementing the order.
As a group, the studies assessed the direct relationship between patients’ perception of coercion and CTOs as well as a number of potentially mitigating or enhancing factors, including procedural justice, involvement in mental health services and other forms of leverage, and patients’ clinical and demographic characteristics.
Patient Characteristics
Many studies examined the effect of patient characteristics on perceived coercion irrespective of patient CTO status, contextualizing the effect of the orders.
Clinical history and characteristics.
Greater severity of psychiatric symptoms, a mood disorder (largely bipolar disorder as opposed to a primary psychotic illness), and problems related to substance use were associated with higher perceived coercion in the North Carolina RCT, with substance use–related problems more than doubling the odds of scoring above the median on the study’s coercion scale (38). Neither current substance abuse issues nor psychiatric diagnoses were significantly associated with perceived coercion in the New Zealand study (40).
Both the North Carolina and New Zealand studies found that greater insight into illness was significantly associated with lower levels of perceived coercion (38,40). However, possible correlations between insight and perceived coercion either were not investigated or were not reported in other studies (1,14,41). Past history of involuntary hospitalization was also related to higher perceived coercion ratings in two studies. A cohort comparison study conducted in New York City found a moderately large and significant correlation between multiple involuntary hospitalizations and perceived coercion (1). In a New Zealand study, persons with a past involuntary hospitalization or incarceration or any contact with forensic psychiatry had significantly higher levels of perceived coercion (40). Qualitative findings also reflected the influence of past inpatient hospitalization experiences: patients considered CTOs to be coercive but compared the orders favorably with involuntary psychiatric hospitalization if they had to choose between these two options (42–45).
Studies that explored the relationship between treatment adherence and levels of perceived coercion came to contradictory conclusions. Patients who did not adhere to treatment reported higher levels of coercion on CTOs than those who did adhere in the North Carolina RCT (46). Two other studies found no correlation between perceived coercion and adherence to medication (41,47). Although a positive correlation was found in the New York RCT between perceived coercion and adherence to intramuscular-injected medication at first follow-up, the correlation became insignificant at six and 12 months (47). It is important to keep in mind that because of a lack of engagement between the New York City pilot study and the city’s police department, no pick-up orders were issued or completed during the New York RCT (14,47). This lack of enforcement may explain, in part, why the CTOs were not experienced as coercive during the latter part of the study.
Demographic factors.
Certain demographic factors were found to influence perceptions of coercion. Two studies found lower perceived coercion among patients with a spouse or partner (38,40). In one study, college graduates had higher scores on perceived coercion and lower rates of procedural justice compared with persons who had not graduated from high school (41). At initial interviews at hospitalization, the New York RCT also found that those with high perceived coercion scores were more likely to have more years of education, and to be white and female, but this finding was not significant at later points in the study (47).
African-American participants in the North Carolina RCT had higher perceived coercion scores independent of their CTO status (38). Although this finding was not replicated in the Ohio study (41), further analysis using a hierarchical multiple regression method found an inverse correlation between procedural justice and coercion scores among African-American participants; 8.9% of the variance in coercion scores for this group was explained by procedural justice, and 2% was accounted for by CTO status (48). In contrast, 38.4% of the variance in coercion scores for white participants was attributable to procedural justice, and 8.3% was explained by CTO status, suggesting that procedural justice and CTOs were much more salient issues for white patients (48). A large New Zealand qualitative study found few differences in the experiences of white and Maori patients regarding CTOs, but, like Galon and colleagues in Ohio (48), the authors urged further investigation and development of culturally supportive outpatient services (49). They also suggested that Maori patients, particularly, value involvement in treatment and decision making (49). New Zealand mental health law requires involvement of family, which may contribute to an increased sense of participation in the decision-making process.
Perceived Coercion and CTOs
Levels of perceived coercion among patients with a CTO versus a control group varied significantly by jurisdiction. Neither an RCT nor a cohort study from New York found statistically significant differences in perception of coercion between participants with or without a CTO (1,14,47,50). However, in the RCT, 72% of participants with a CTO and 63% of participants in the control group reported high levels of coercion (14). The cohort study found that patients with a CTO reported marginally less coercion compared with the control group in the 12-month follow-up period (50).
Three other quantitative studies found evidence of a significantly greater sense of perceived coercion among patients with a CTO compared with voluntary patients (38,40,41). In an Ohio comparison study, perceived coercion scores were more than three times higher among participants with a CTO compared with participants receiving usual care or only assertive community treatment (41); however, overall scores on the MacArthur Perceived Coercion Scale were substantially lower compared with scores from other jurisdictions. In New Zealand, McKenna and colleagues (40) also identified significantly higher levels of perceived coercion in the group with a CTO compared with the control group, but, overall, levels of perceived coercion were low. Notably, the authors reported that the majority of study participants with a CTO did not feel forced into treatment (58%) or feel threatened by the use of a CTO (68%) (40), even though the CTO legislation in New Zealand appears to be more far reaching compared with laws in other regions where the studies reviewed in this article were conducted (Table 1). The North Carolina RCT followed participants with a CTO and participants in a control group after discharge from involuntary hospitalization and concluded that CTO patients perceived significantly higher levels of coercion compared with the control group (38). In qualitative studies, many participants regarded a CTO as a restrictive imposition on their freedom, although they considered it less restrictive than other options, such as involuntary hospitalization, which was viewed as the likely alternative (42–44).
There is evidence to suggest that CTOs contribute to patients’ perceptions of coercion, although levels of perceived coercion varied quite markedly in studies using the same MacArthur tool. Assessed in concert with the qualitative studies, the results of quantitative studies suggest the importance of contextual factors affecting perceived coercion, including other interventions that might be utilized in the absence of a CTO in a given jurisdiction.
Procedural Justice and CTO Enactment
Procedural justice was explored in a number of studies in this review. One study in Ohio and one in New Zealand found significant inverse correlations between procedural justice and perceived coercion among participants with a CTO (40,41). In Ohio, the CTO group reported significantly lower procedural justice scores and significantly higher coercion scores than the usual care group (41); further analysis indicated procedural justice accounted for 25.8% of the variance in coercion scores across both cohorts (48). In the New Zealand study, both the CTO and control groups showed a very high sense of procedural justice (40). Bivariate analysis found a significant but weak negative correlation between procedural justice and coercion, indicating that as the sense of procedural justice increased the sense of coercion decreased. However, the linear regression analysis rendered this relationship insignificant (40). Together, these studies suggest that there may be an inverse relationship between procedural justice and perceived coercion, although further examination is necessary.
The large majority of qualitative studies, and some quantitative studies, have found patient confusion or disenchantment with the CTO legal process (37–40,42,51–54). This was consistent across legislation types, whether a CTO was court ordered or physician ordered and whether clients had any choice but to accept the order. In a study in Saskatchewan, Canada, patients expressed awareness and understanding of their rights regarding treatment decisions and the appeal process to contest their CTO but felt that an appeal was futile (43). Similar impressions were also articulated by patients in a 2011 study in Pennsylvania (52), who described the process of being placed under a CTO as arbitrary. Perception of procedural justice may also be influenced by legislative differences in initiation (how a CTO is issued and patient eligibility), continuation, and enforcement processes governing CTOs in different jurisdictions (Table 1). New Zealand legislation allows for CTOs to be approved “proactively” for patients with a history of intermittent mental illness (40), whereas many other jurisdictions focus on patient capacity to consent to treatment at the time a CTO is issued (55).
Findings also indicate that communication with service providers may affect experiences of procedural justice. One study highlighted a concern that mental health providers may not represent CTOs accurately to patients, using the legislation as a bluff to ensure medication adherence (40). A large-scale qualitative study in New Zealand found that patients felt less coerced when there was space to discuss the negative aspects of the order with their providers (44,56). The RCT in North Carolina found that treatment reminders and warnings of consequences of nonadherence by case managers significantly raised perceived coercion scores among patients with a CTO (38). As a whole, these findings emphasize the relationship between procedural justice and coercion, suggesting the importance of building ongoing relationships and sharing information with patients. Transparent, well-implemented legal procedures can contribute to a sense of procedural justice but may not be able to achieve this result on their own.
Service Involvement
Perceptions of coercion among patients with a CTO may be affected by aspects of CTO legislation and enforcement as well as the health services context in each region (Table 1). One such aspect is how long a CTO remains in effect. A Canadian qualitative study suggested that patients who had a CTO for longer than a year were more likely than patients with shorter CTOs to experience benefits from CTOs, including increased structure and support (43). The North Carolina RCT did not reflect these results: a minority of participants reported having derived personal benefit from a CTO, with fewer patients ascribing benefits to the CTO after one year (27.6%) than at baseline (47.9%) (57). Positive treatment outcomes (defined as higher than average community functioning scores, remaining out of the hospital, and avoiding violence) had a large influence on CTO endorsement among patients who experienced high degrees of coercion while on the order. Fifty-three percent of patients who experienced high degrees of coercion and positive outcomes saw CTOs as beneficial versus 16.7% of patients who experienced high degrees of coercion and poor outcomes. The same North Carolina RCT found that rates of perceived coercion increased by 10% every month that a patient remained subject to a CTO but that longer CTOs (>180 days) were related to reduced hospital admissions and total hospital days for some patients (38). In New Zealand no significant association was found between length of the CTO and perceived coercion (40).
Enforcement of treatment orders may also play a role in perceived coercion rates. Whereas the RCT in North Carolina found that patients who had been picked up by law enforcement and transported to treatment had significantly higher coercion scores, the New York RCT acknowledged no pick-up orders were issued or completed during the study (14,47). This may explain, in part, why CTOs were not experienced as coercive over time in the New York study. Little additional information is known about enforcement in other jurisdictions (Table 1).
Some CTOs may confer associated services that influence perspectives on coercion. Patients in some qualitative studies viewed the provision of additional community support, such as access to a community mental health team, as a positive aspect of treatment orders, suggesting that in some regions the CTO was seen as a tool for providing clinical services as well as committing the patient to care (37,42,44,45). In other jurisdictions, community mental health support may be available to patients with or without a CTO; this clinical service context is rarely discussed in the literature.
The Ohio comparative study investigated whether combining a CTO with additional nonmandated intensive community support in the form of ACT teams affected overall perceptions of coercion (41). They found that ACT services had no relationship to perceived coercion but also noted that the study population had a generally favorable view of the ACT teams’ services (41).
Concurrent use of additional types of leverage may also play an important role in patients’ perception of coercion while receiving mental health services in the community. A secondary analysis of the North Carolina RCT data investigated the effect of financial guardianship, a form of legal leverage whereby a patient’s finances are managed by a family member or government representative. Applied in concert with a CTO, financial guardianship was correlated with significantly higher perceived coercion scores, although neither CTOs nor financial guardianship was independently correlated with higher rates of perceived coercion (46).
Discussion
Implications for Practice and Research
There were some consistent findings in the literature regarding patient experiences of CTOs. The combined quantitative and qualitative evidence indicated that patients subject to CTOs felt more coerced than voluntary patients, although the level of coercion varied considerably among the studies. There was also an indication in both qualitative and quantitative studies of an inverse relationship between procedural justice and perceived coercion.
The literature drew attention to the possibility that knowledge of legislation, the relationship between mental health providers and patients, and patient participation in treatment decisions wherever possible serve an important role in decreasing perceived coercion. Lack of knowledge and understanding of the legal processes among patients was a common theme and is an area that can be improved. The development of caseworker skills to support adherence in positive ways, rather than by invoking the threat of CTO consequences, would be another area for enhancement (38).
Current evidence regarding demographic and clinical factors did not provide definitive answers as to which patients may be at greater risk of perceived coercion. The variation between studies suggested that this is an area requiring further research. Ensuring procedural justice may be particularly important for patient groups reporting higher rates of perceived coercion, including those with a history of multiple involuntary hospitalizations or limited insight into their illness.
Although findings regarding type of leverage, services, and legislation enactment are inconclusive and challenging to compare across jurisdictions, they emphasize the context-specific nature of CTOs. More work is needed to examine other factors that contribute to the perception of coercion in patients’ lives. The increased coercion experienced by patients placed on financial guardianship concurrent with a CTO may suggest that using more than one form of outpatient leverage has a cumulative coercive effect (46). In addition, the high level of coercion perceived by outpatients in some studies, regardless of CTO status, is perhaps an indicator of the breadth and influence of formal and informal types of leverage applied to outpatients, demonstrated in previous work on leverage (10,12). These contextual factors merit further attention in research and practice.
Despite the variability in CTO legislation and services across the world, in every region it is always possible for mental health practitioners to address the way CTOs are administered and strive to study and improve performance. This review highlights the importance of continued consideration of how psychiatric interventions can ensure that patient recovery and patient-centered care remain at the forefront of treatment plans. Although CTOs are often seen as an alternative to hospitalization, it is important to explore alternatives to CTOs themselves. Additional approaches to community treatment, including advance directives and Ulysses contracts, should also be given careful thought and studied in more detail. All options should be examined when providers are considering the use of leverage or coercion in psychiatric care.
Limitations
The studies reviewed in this article acknowledged limitations in recruitment of participants that make the data challenging to analyze and, for quantitative comparison studies, may have led the comparison and CTO participant groups to have greater similarities than would be likely in practice. For example, as highlighted in the Cochrane review of CTOs, neither RCT in the United States included patients with histories of violence, although patient eligibility criteria for a CTO in those states include being considered a danger to others (16). Low rates of recruitment and longitudinal follow-up also restricted the interpretability of many studies (14,38,41). Qualitative studies recognized that patients who feel more favorably toward CTOs may self-select for interview participation, whereas patients who have less positive experiences with CTOs and their treating mental health team may not engage with a study associated with those providers (44).
CTOs are a treatment tool shaped by local legal and health services contexts. Legislation, implementation, and enforcement factors, such as police engagement, differ across regions. The community mental health services that are available as part of, or as alternatives to, CTOs also vary widely. However, the level of detail provided by publications on these topics was inconsistent (Table 1). It may be difficult for authors to know or describe all the factors influencing implementation of CTOs, although these details could have great implications for their findings.
Conclusions
Given their involuntary nature, CTOs are a clear target for ethical debates on coercion in psychiatric practice. However, the current literature pointed to significant variation in patients’ perception of the coercive nature of CTOs in different regions, mental health systems, and patient groups. Although limited by regional context, study design, and sample characteristics, this literature review indicated that the coercive aspects of CTOs may be reduced through identification of coercive elements of local CTO legislation and process as well as by ensuring that patients are fully informed of their rights and the medical and legal implications of a CTO. Adequate education and training for service providers may also play an important role. In addition, focusing on coercive aspects of CTOs should not take away from a broader discussion and study of daily pressures and leverage applied during treatment of individuals with severe mental illness. Awareness and implementation of these ideas may lead to a reduced perception of coercion among patients receiving mental health treatment and encourage them to be more actively involved in their own care.
Acknowledgments
The authors thank Lorne Tugg, M.D., for help during the initial phase of this project. In addition, this review was greatly aided by Carolyn Ziegler, M.I.S.T., who assisted in the creation and running of the electronic search strategy.
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Information & Authors
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Cover: Landscape, by Louis Comfort Tiffany, ca. 1892. Stained glass. Private Collection. Photo credit: Art Resource, New York City.
History
Received: 24 November 2014
Revision received: 3 April 2015
Accepted: 11 May 2015
Published online: 1 October 2015
Published in print: January 01, 2016
Authors
Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
St. Michael's Hospital, Toronto, Canada
This research was financially supported by the Psychiatric Associates of St. Michael’s Hospital, Toronto, Ontario, Canada.Metrics & Citations
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