Perception of Coercion Among Patients With a Psychiatric Community Treatment Order: A Literature Review

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.

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.