What Are Community Treatment Orders (CTOs)?

Legal supports for helping those with severe mental illness comply with treatment.

Reviewed by Margaret Foley

Key points

• Community treatment orders (CTOs) require patients to comply with court-ordered treatment for mental illness.
• Proponents point to decreases in homelessness, decreased hospitalizations and increased compliance with meds.
• Controlled studies often fail to find significant outcome differences when patients are followed long-term.

My intention in writing this blog is to share the experiences that I went through with my son, starting with the first manifestation of his illness and our journey through numerous subsequent episodes. It's also to provide commentary as a parent and psychiatrist on issues that these experiences bring up, such as how the diagnostic process works in mental health and how to work with treatment providers and medication issues. My hope is that reading this may be helpful for people with mental health issues and also their families and friends.

Community treatment order

Because of Bill’s multiple hospitalizations, his psychiatrist at Mendota was finally willing to initiate the extensive paperwork to apply to get him involuntarily committed for mandatory outpatient treatment, termed a “chapter 51” commitment. She documented the multiple inpatient hospital stays, the many issues with noncompliance with medication, and the fact that when he became ill it took a long time to stabilize him, even though the onset of the illness happened with surprising speed.

The process was conducted formally with a hearing in the courthouse in front of a judge. Upon hearing the very long history of his illness, with an emphasis on medicine keeping him well when he was on his medication, the judge granted the order. Because Bill was now not allowed to take medication on his own, he had to live in a community-based residential facility licensed to dispense medicine. He was especially unhappy about this aspect of the treatment plan, even though he acknowledged that he had not done a good job of taking medicine in the past.

Mandatory outpatient treatment, or “outpatient commitment”—also called assisted outpatient treatment (AOT) or community treatment orders (CTO)—refers to a civil court procedure wherein a legal process orders an individual diagnosed with a severe mental disorder to adhere to a specified, individualized treatment plan that has been designed to prevent further relapse and deterioration or recurrence that is harmful to themselves or others. This form of involuntary treatment is distinct from involuntary commitment in that the individual subject to the order continues to live in their home community rather than being detained in a hospital or incarcerated. The individual may be subject to rapid recall to hospital, including medication over objections, if the conditions of the order are broken, or the person's mental health deteriorates.

Complying with the order generally means taking psychiatric medication as directed and may include other forms of treatment as well as attending appointments with a mental health professional. It may also require not using non-prescribed illicit drugs and not associating with certain people or going to certain places deemed to have been linked to a deterioration in mental health in that individual.

Patients are often monitored and assigned to case managers or assertive community treatment (ACT), a community dedicated to treating mental health. This option is available in approximately 70 communities worldwide, limited by the number of communities with legal jurisdiction to issue orders for treatment.

Though the terminology "outpatient commitment" and legal construction often equate outpatient commitment with inpatient commitment, community treatment provides the patient with more freedom. When introducing the bill proposing CTO in the U.K., Lord Warner, then Minister of NHS reform, said, "That modern approach strikes a balance between individual autonomy and protection of the patient and the public." CTOs were first conceived as a less restrictive alternative to involuntary hospital admission. They allowed patients detainable under mental health legislation to be treated outside the hospital and had the same stringent criteria as involuntary admissions. From the perspective of clinicians, patients, and their families, as well as human rights lawyers, "least restrictive" CTOs were considered preferable to hospital detention. Most proponents involved in the outpatient commitment debate made the case based on the quality of life and cost associated with untreated mental illness and recidivism, with patients cycling through hospitalization, treatment and stabilization, release, and decompensation. While the cost of repeated hospitalizations is indisputable, quality-of-life arguments rest on an understanding of mental illness as an undesirable and dangerous state of being. The need for care is balanced against the cost of living on the streets or being held prisoner by terrible delusions and hallucinations.

In one study (Swartz), 74 percent fewer participants experienced homelessness; 77 percent fewer experienced psychiatric hospitalization; 83 percent fewer experienced arrest; 87 percent fewer experienced incarceration; 49 percent fewer abused alcohol; 48 percent fewer abused drugs; and there was a 56 percent reduction in length of hospitalization. Consumer participation and medication compliance improved. The number of individuals exhibiting good adherence to meds increased by 51 percent. The number of individuals exhibiting good service engagement increased by 103 percent. Consumer perceptions were positive: 75 percent reported that CTO helped them gain control over their lives; 81 percent said CTO helped them get and stay well; and 90 percent said CTO made them more likely to keep appointments and take meds.

However, these were based on observational studies of immediate outcomes, whereas in some randomized clinical trials, which have less inherent bias, there was no evidence for superiority in longer-term, 12-month readmission rates (Rugkåsa, 2013). As the authors pointed out, this may have been due in part to patient refusal, attrition, and protocol violations. They concluded that the benefit of CTO may derive more from the intensive community services offered than from the compulsory nature of the treatment. In Bill's case, it seemed clear that these two aspects worked together to keep him well as long as he was on compulsory treatment. In other words, during the time he was living in a facility that monitored his meds or in the next phase of his treatment where he lived on his own but had to report to a crisis center every evening to take the meds while being observed (checking under his tongue), he stayed well and was able to move forward with his life. Had there simply been a court order, without the daily means to implement it, undoubtedly he would have stopped taking his meds and decompensated. In addition, during this time he received more intensive outpatient treatment, including group and individual therapy. He also began to think about the possibility that he might be a good person to help other patients cope with their mental illness since he had experienced so many episodes.