Introduction

The treatment and control of individuals with severe mental health difficulties in the community has long been positioned as a problem in need of a solution. Community treatment orders (CTOs), enacted under the Mental Health Act (2007) are one recently introduced ‘solution’ in English mental health services. CTOs give mental health professionals the power to impose conditions on how service users live in the community, particularly in regards to medical treatment, and provide a mechanism for hospitalisation and treatment enforcement, called recall, if these conditions are not met or if the service user's mental health has deteriorated to the extent that they are deemed to be a risk to their own health and safety or that of others. CTOs tend to be aimed at particular groups of service users, especially those who have been described as ‘revolving door’, meaning they regularly stop their medication and experience relapse, leading to continuous movement between hospital and the community. The large majority of individuals placed on CTOs have been given a primary diagnosis of a psychosisrelated disorder, and are on antipsychotic medication (Churchill et al, 2007), which the CTO is intended to ensure they adhere to. Although CTOs are regularly reviewed they can be renewed indefinitely, and so the individuals who are placed on them can be under compulsion in the community for an unlimited period of time.

CTOs have spread persistently across different jurisdictions over the last 30 years, and yet remain a much debated addition to the landscape of community mental health wherever they have been enacted. Modern mental health services, both in the community and in hospital, have always contained elements of compulsion and coercion, which can be seen as forming a continuum, from informal persuasion through to formally mandated hospital treatment (Monahan et al, 2001). However, a distinction can be made between the undefined and discretionary use of treatment pressure in the community and the legislatively defined role of CTOs. As Churchill et al (2007: 20, emphasis in original) state, CTOs are qualitatively different from what has gone before in the countries where they have been implemented because they, ‘enforce community treatment outside (and independently) of the hospital, contain specific mechanisms for enforcement and/or revocation and are authorised by statute’.