Availability and restrictiveness of community treatment orders across 33 European countries

Community treatment orders (CTOs) permit compulsory mental healthcare outside hospital. Such orders have become part of an increasing number of mental health laws, even if there is a lack of consensus on their effects, negative personal experiences, diverging ethical positions and expectations that governments should reduce or abandon coercive practices. It is therefore surprising that there is limited research describing the availability and restrictiveness of CTO legislation, and we found no comprehensive European study. Such studies could contribute to clarification of differing positions and, through that, informing further research and discussions of how to promote voluntary options in clinical practice.

To establish the availability of CTO legislation across Europe, and how regimes in different ways restrict the person.

Data were collected from 33 European countries through a network of researchers and practitioners, and links to relevant legislation were provided.

We found 13 CTO regimes across the 33 countries: two-thirds therefore managed without them. Despite some variation, most law texts specified restrictions related to legal criteria, enforcement mechanisms and safeguards. Restrictions on the person were often specified in separate tailored plans, and most regimes permitted indefinite renewals, which means that the duration of restrictions can be ascertained only in retrospect.

CTO law texts preclude scrutiny of overall restrictiveness, which might add to current uncertainties regarding the proportionality of CTOs and their role in balancing individuals' rights to both autonomy and care. The current policy drive towards community care should not automatically lead to new CTO regimes until their effectiveness and de facto restrictiveness are established.