Abstract
The mental health laws of many jurisdictions provide an enabling framework for the use of community treatment orders (CTOs), or ‘outpatient commitment’ as it is called in the USA. But the legislation does not usually say when CTOs
must be used: this remains a matter for the discretion of clinicians. So the argument is made here that the rate at which CTOs are used in practice depends on the manner in which clinicians exercise their discretion when implementing the CTO regime. Furthermore, it is suggested that clinicians will exercise that discretion, to place a person on a CTO, when they believe the overall balance of advantage favours that option. Several factors are then identified as relevant to that calculation: the powers provided to treat involuntary outpatients; the threat of liability being imposed on clinicians for the conduct of patients in the community; the structure and quality of the mental health services available; the perceived impact of coercion on therapeutic relationships; the expectations of third parties; and past patterns of involuntary outpatient care. These factors provide a complex network of influences on the exercise of clinical discretion in the use of CTOs. Interaction between these factors produces a dynamic and fluid situation. Widely varying rates of use of CTOs can therefore develop in different jurisdictions with otherwise similar legal traditions, and rapid changes can occur in the rate of use of CTOs, over time, even within a single jurisdiction, without any change occurring in the law.