Correspondence

Marie-Hélène Goulet

Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada

Research Center of the Institut universitaire en santé mentale de Montréal, Montreal, Quebec, Canada

[email protected]

Keywords

Community treatment order, involuntary treatment, qualitative study, mental disorder, patient engagement

Abstract

Introduction

There has been a surge in the use of CTOs around the world with now more than 75 countries using them. In the province of Quebec (Canada), a CTO is a legal mechanism used to constrain people with a mental disorder, incapable of giving consent and who categorically refuse care, to undergo psychiatric treatment when required by their mental health state. In different jurisdictions, CTOs may refer to an obligation of care during and after hospitalization or be used exclusively in the community (Rugkåsa & Burns, 2017). In Quebec, the use of CTOs has increased by nearly 50% between 2015 and 2020 (Ministère de la Justice, 2021). This raises significant questions, given studies have not clearly demonstrated CTOs’ clinical effectiveness.

A meta-analysis revealed no significant difference compared to voluntary treatment approaches on indicators of rehospitalization, decreased psychiatric symptoms, global functioning, and quality of life (Kisely et al., 2017). Furthermore, although CTOs were initially perceived as a less restrictive alternative to hospitalization, significant ethical questions remain about their legitimacy. A CTO is meant as an exceptional measure, given the restriction on individuals’ fundamental rights and freedoms. For some it is simply an extension of social control (Guerra, 2022). Given the lack of convincing results on CTOs’ effectiveness and the associated ethical issues, the consequences of this coercive measure on the person and their relatives must be explored by examining the perspective of the various stakeholders involved in their use.

In general, CTOs are perceived more positively by mental health care providers and relatives than by persons with mental illness themselves (de Waardt et al., 2022). Although all stakeholders express some ambivalence toward CTOs, patients report more negative experiences in the both short- and long-term. These include stigma, feelings of humiliation, and fear, as well as barriers to social and professional life and recovery (Edan et al., 2019; Francombe Pridham et al., 2018; Goulet et al., 2019). Health care providers tend to have a more positive appreciation of CTOs as tools to facilitate delivery of mental health services (de Waardt et al., 2022) and promote treatment adherence (Corring et al., 2018). Nonetheless, one of the key concerns is the degree to which they can promote patients’ self-determination given they are being forced into treatment (Corring et al., 2018). The relatives of the people under CTOs convey often feeling isolated from the treatment process by health care providers (Stensrud et al., 2015) but still perceive CTOs as having a positive effect for their loved one, themselves, and their family’s relationships. For example, they report CTOs increase adherence to treatment and the feeling of safety, while decreasing stress (Canvin et al., 2014; Corring et al., 2019; Mullen et al., 2006).

Among these different stakeholders, the literature shows consensus regarding the goal of promoting adherence to treatment; however, there is considerable variability in the understanding and enforcement of the legislative framework, and perceived overall benefits. In a global context that promotes partnership with the person living with a mental disorder and aims to reduce the use of coercion, it is essential to understand the different perspectives of the key stakeholders regarding the clinical, ethical, safety, and recovery issues surrounding the use of CTOs. Thus, this study explores the experience of CTOs among persons with a history of CTO, their relatives, mental health care providers, and psychiatrists in hospital and community settings.

Materials and methods

Study design

This qualitative descriptive study was based on a participatory approach. A qualitative methodology was used to capture the complexity of the phenomenon by emphasizing the subjective nature of the research participants' experience (Lincoln et al., 2011). The Montreal Model was used as a participatory approach (Pomey et al., 2015), a theoretical framework of the continuum of patient engagement along the different components of care: direct care, organization and governance of services, health policy development, as well as teaching and research. The main premise of patient partnership is valuing and recognizing experiential knowledge as complementary to scientific and professional knowledge (Jouet, Flora, & Las Vergnas, 2010). A peer worker with a lived CTO experience was involved in the various phases of the study: protocol co-construction, interview guides, and interviewing of the patient-participants. Since the participatory approach was based on a patient partnership model, no families or clinicians were involved in the project.

Setting

This study was conducted in one forensic and two civil mental health hospitals in Quebec (Canada). In Quebec, in exceptional circumstances, a CTO may require a person to submit to care when they are deemed unfit and categorically refuse the care considered necessary by their physician or their treatment team (C.C.Q., art. 16). Accordingly, the physician must file a motion with the Québec Superior Court for an autorisation de soins (CTO). The judge rules based on the presence of two necessary criteria: the incapacity to consent to care and the necessity of the proposed treatment (Bernheim et al., 2015). Unlike many other jurisdictions, CTO in Québec is a distinct legal procedure from civil commitment. The person can be hospitalized unwillingly but can still consent or refuse care; thus, in a hospital setting, a treatment order must be obtained to administer care without consent.

Sample

This study included three populations: individuals who are or have been under a CTO, relatives and mental health care providers. Overall, 35 participants were recruited using a convenience sampling method. The patient-participants were initially approached by a familiar health care provider to then, if interested, meet the researcher or research assistant. The relatives were recruited through a non-profit organization that supports the loved-ones of individuals living with a mental disorder. The mental health care providers (including nurses, criminologists, social workers, occupational therapist, specialized educator, and psychiatrists) were recruited with the assistance of health care managers from different settings. For all groups, participants had to be adults capable of giving consent and to communicate in English or French. Patients had a mental disorder diagnosis and experience of a CTO in the past two years. Relatives had to be a significant person of a person with a mental disorder who had experienced a CTO in the past two years. Mental health care provider had to have experience in the care trajectory of a person under a CTO within the last six months.

Data collection

Semi-structured interview guides were developed for the different group categories based on the Montreal Model (Pomey et al., 2015) and a meta-synthesis on CTOs (Goulet et al., 2020), in order to explore both the general CTO experience and concepts related to partnership in care between the mental health care providers and patients. The 60 to 90 minutes interviews were conducted individually with each participant by the first author, the peer support worker, or a research assistant.

Data analysis

The interview recordings were transcribed verbatim and integrated into the QDAMiner software (version 6.0.2). A deductive thematic analysis was conducted by following Miles et al.'s (2020) (17) methodology. First, each interview was coded using a codebook derived from the subthemes identified in Goulet et al.'s (2020) meta-synthesis (e.g. CTO as legal leverage, playing the game), and by allowing new codes to emerge from the data. Matrices were then created for each participant group to classify data analyzed from the verbatim into themes. A global matrix was created to integrate the groups and reveal the most common and significant themes, as well as inter-group differences.

Ethical considerations

Ethics certificates were obtained from the three participating health institute research ethics boards. All participants signed an information and consent form. The data collected were de-nominalized and protected with a password accessible only by the research team.

Results

Thirty-five participants were recruited across in and outpatient settings. The six persons who experienced a CTO had a mean age of 44 years, had been on an CTO for 1–20 years, and their self-reported diagnoses included schizophrenia, bipolar disorder and schizoaffective disorder. Five participants were hospitalized during the interview and only one was not currently under an CTO. Five relatives were recruited, 4 of them were mothers and the other one a father, for a mean age of 65 years. The mental health providers (n=24) included nine nurses, eight psychiatrists, three social workers, two criminologists, one specialized educator, and one physical therapist. The average number of years working in mental health was 24 for the psychiatrists and 12 for all other mental health care providers.

Analyses revealed three themes and seven sub-themes discussed in the following section and provide a comprehensive and nuanced picture of the various stakeholders’ experiences.

Theme 1: Differential positions as a function of meaning conferred to CTOs

The acceptability of CTOs was influenced by the relative importance attributed to positive and negative impacts. In general, two strong positions emerged among the different participant groups. Mental health care providers and relatives agreed on the necessity and benefits of CTOs, while also acknowledging their downsides. In contrast, participants from the patient group perceived CTOs extremely negatively.

CTOs as a “necessary evil”

Except for patients, all other participants believed the positive aspects associated with CTOs outweighed their negative consequences. Both relatives and mental health care providers identified the benefits associated with CTOs—their subjective evaluation of the improvement in the quality of life and mental status of the person under a CTO being the most discussed. Decrease in illness relapse and its associated consequences, support for treatment adherence, and the opportunity to work on the other essential aspects of a person’s recovery and reintegration were also mentioned. For families, the prospects of their loved-one getting better through a CTO usually outweighed the risks of broken communication bridges and family conflicts.

“I would say that as a parent, it is definitely very negative for me, in the sense that, once again, it breaks the bond of trust that I have with my son. However, if I agreed with the doctors on this decision, it was because the most important thing for me is the recovery of my son. I am doing it for him at the risk of him not speaking to me for the rest of his life.” (Relative 2)

Similar to families, some psychiatrists perceived CTOs as a measure to support recovery and increase a person’s independence, by presenting mental illness as the primary source of loss of freedom. Psychiatrists perceived CTOs as acceptable and good medical practice, in order for them to treat a sick person, for relapse prevention and associated consequences. Psychiatrists were more likely to use this measure, even going so far as to denounce the under-use of CTOs by some colleagues.

“I would say that the younger colleagues and I do more CTOs than the older ones. I do not see any reason to wait. The patient truly has no insight; he is rotting in the psychiatric ward, and his life is terrible. He is losing his family and contact with his children; furthermore, he cannot return to work. To stop just because I am afraid that the patient would be a little angry? Thus, we go ahead and waste less time.” (Psychiatrist 11)

Participants having experienced a CTO did not discuss any benefits associated with it. When asked about this, one participant said that he was now more knowledgeable about CTOs, while another mentioned having made it through a difficult time.

CTOs as a social and relational rupture

The majority of the patients reported an exclusively negative experience of CTOs, along with emotions such as anger and helplessness. Most explained that the hardest aspects were the side-effects of the medications and the feelings of losing freedom and control over their lives: “I am now in some kind of a prison, I think. This treatment is a type of a prison.” (Service user 5)

The health care providers were aware of CTOs’ negative effects on the patients that may contribute to the difficulty that many report when enforcing CTOs in their clinical practice. One problem was associated with the duality of their role (“enforcer” vs. “caregiver”) when negotiating the enforcement of CTOs.

“It is extremely painful because as doctors, we do not choose this to bother our patients. We are not their enemy. Furthermore, any adversarial system places us as if we are the enemy of our patients. However, wait a minute. I am neither a police officer, a judge, nor an agent of social control. I refuse to do that. I am here to try to serve someone who is experiencing difficulty and does not even have the capacity to ask for help anymore.” (Psychiatrist 2)

This seemed to particularly affect the nurses who were responsible for applying the measure. It appeared that many health care providers shared the idea that a nurse’s role is the most difficult. For example, a social worker stated:

“The patient is enraged, and he blames us. I think, sometimes, my team has told me that the clients have a better therapeutic relationship with me because I did not get involved in that side of things, like the psychiatrist, who asked for the CTO, and it is the nurse who has to push to give the injection. Once, we had a client who had a therapeutic alliance with me, and the nurse asked me to go with her to give the injection; since then, the client lost her trust in me. We never regained the same situation and trust.” (Social worker 16)

For families, not feeling involved in the CTO process was a particularly difficult aspect. Indeed, the majority expressed feeling sidelined by the treatment team and lacking information, thus resulting in an insufficient understanding of the process surrounding the CTO. This was often justified by the treating team by the need to respect confidentiality.

“I would like the healthcare team to take us aside in the absence of the patient to explain certain decisions to us: why we are going there and doing this. I ask a lot of questions, and they cannot answer because it is confidential. Why not allow for an improved understanding to provide even better support... If I had a magic wand, that is probably what I would do... to be able to sit down with the people who are treating our loved ones. It is being excluded that is extremely challenging... tremendously difficult.” (Relative 2)

Theme 2: A risk management tool

When asked about the use of CTOs, most mental health care providers stated the criterion of dangerousness, precisely as a criteria necessary to initiate them and as a safety net.

Initiation of a CTO

Although dangerousness is not a criterion in the Quebec legislation for initiating a CTO, the risk of a person acting violent toward themselves or others, as well as unhealthy behaviors that may lead to medical emergencies, were perceived by the majority of the participants, except for the psychiatrists, as a central element influencing the decision-making process.

“If he is aggressive, violent, suicidal, not eating, and has not eaten for a while, depending on the clinical picture... Evidently, the risks are really what is at the root of it. For someone who does not take his medication, but who is at no risk when he does not take his medication, to go and tell the judge: ‘Yes, this person really needs to take his medication.’ It is going to be harder to prove because there is not necessarily any risk.” (Nurse 14)

All the psychiatrists had knowledge of the legal criteria necessary for the application and implementation of a CTO. This could be explained by the fact that they were responsible for the process surrounding a CTO, such as assessing the person, writing the report, and testifying in court. Interestingly, however, the dangerousness of the person also emerged from the psychiatrists’ arguments. This suggested that dangerousness may be an implicit and informal criterion motivating the implementation of CTOs, occasionally presented as a possible consequence of not treating the person deemed unfit. The implicit nature of the dangerousness criterion seemed to influence the experience of the patients who believed it to be the reason for their CTO.

“In my opinion, the reason is that they present danger for themselves or for the public. However, I am neither a threat to the public nor myself.” (Service user 5)

A safety net for support systems

With the exception of patients, all other participants present CTOs as a safety net that allows both the health care providers and caregivers to feel secure. This was interpreted in two ways: first, by forcing treatment on people who are perceived as potentially dangerous, and second, because it offers a form of protection/soothing while facilitating the work of the treatment teams.

The CTOs were described as beneficial by all the relatives. Once a CTO was issued by the judge, they reported feeling relieved because they no longer had to act as a safety net for their loved one because of the assurance that a treatment team would formally provide the necessary care.

Although not explicitly addressed by the patients, three psychiatrists explained that the CTOs can be reassuring to some of the more resistant patients by providing limits and guidelines to follow. According to them, the CTOs would allow the patients to improve their condition without having to admit they are ill.

“I have seen patients who just could not break the self-image: ‘I am not sick. I do not need medication. However, if you go get a court order for it, I will take it...’ Actually, they are relieved that we are going to get it because they are slightly ambivalent; nevertheless, they are definitely not able to give up on their point, which is, ‘No. I do not need medication.’ However, deep down, they know they need it.” (Psychiatrist 1)

For the health care providers, CTOs are a reassuring measure guaranteeing them a certain level of safety and professional protection, allowing them to do their work, that is, to follow up on and treat the person. They are described as leverage for “treating” the person especially with medication, despite the absence of consent, and thus decreasing the behaviors that are perceived as difficult by others. Once the person’s mental state is stabilized, the health care providers say that they are better able to work with the person and invest in other aspects of rehabilitation and support recovery.

This perception seemed to be associated with the fact that the mental health care providers feel responsible, even accountable, for maintaining the safety of the individual and the public. The decision-making process leading to the implementation of a CTO, as well as the treatments imposed on the individual, are medico-centric and medication-oriented. Thus, psychiatrists are at the center of the decision, wherein a process of rationalizing the CTO seems to occur because of their responsibility to ensure both the safety of the patient and that of the public.

“How to tolerate risks as a team and as a reflection on our responsibilities as well, because it is to avoid harm that it is sometimes put in place or maintained. Occasionally, it is because it is necessary and other times... Basically, each person can integrate a notion of responsibility that belongs to them. I have to manage all the risks as an institution. Thus, for this risk management, sometimes, it is maintained and then—wait, where is our role in this? Do we have to go to that point? Has it been there for a few years? Are there still tangible dangers?” (Social worker 10)

Theme 3: Coping strategies used to deal with CTOs

Different reactions to CTOs led to mobilizing various coping strategies for service users, ranging from playing along to resistance. For mental health care providers, different approaches were discussed in order to mitigate the consequences of CTOs.

Playing along

Some persons who underwent a CTO seemed resigned to the situation. Among several of them, a coping mechanism emerged: “playing along,” that is, by complying with the health care providers' expectations. Thus, they were found objecting to the CTO, albeit passively. Indeed, they all seemed to feel powerless toward it, or, more precisely, toward the professionals. Most expressed compliance with the expectations of being able to regain their freedom, while others attempted to be more prepared to advocate for their cause in the eventual renewal of the CTO.

“I saw that it was useless to discuss and argue with them. Like a waste of time. (...) It is useless. (...) They want to know... what they want to hear, what they want to have, that is what they want to have, you get it? They do not care what I think or say. They are the ones who have to be right and that is it. […] You cannot argue with them because you are the one who is going to lose. (...) Because if I try to demonstrate, like show or say something that I disagree with, then they will not listen to me.” (Service user 3)

On the opposite side of the spectrum, the mental health care providers tended to believe that the patients accepted this situation. The majority of the psychiatrists said little about the coercive dimension of the CTOs, with some even stating that they “happen without much coercion” (Psychiatrist 11). This results in a seeming normalization of this experience in daily clinical practice.

“Usually we give them treatment, they get better, and eventually, it does not cause a problem or a conflict. Because even the patients can see that they were very uncomfortable and now they are less uncomfortable… that the CTO was not the end of the world.” (Psychiatrist 12)

CTO is a powerful legal tool that evoke a “coping mechanism” in most patients, who develop strategies to navigate through coercion. These approaches may be perceived by the health care providers as an acceptance of the CTO, or as a form of deception.

“He knows the game. He knows what to and what not to say. At some point, we will question him and he will avoid them. He will give us a flat answer. He even refuses to do a follow-up at home. We know that it is a fake speech, a kind of a superficial acknowledgment.” (Criminologist 4)

Resistance

None of the patients expressed having shown active resistance to CTOs, even if they did not agree with the decision. Although all patients reported being opposed to the CTO, only one explicitly mentioned a form of resistance:

“I will wait three years, go back to the judge, and I will have built my case.” (Service user 2)

However, according to the health care providers, some patients were actively resistant. This could be presented by their absence in the follow-up appointments, physical and verbal aggression, negotiating, denying the presence of a CTO, or the need for systematic calls to the police to enforce the CTO.

“There are even some who are never compliant with their treatment orders, we always have to go and get them with the police.” (Nurse 14)

Attempt to mitigate the negative consequences

The mental health care providers used different approaches to minimize the impact of a CTO, demonstrating their sensitivity to the coercive aspect of this measure by seeking to avoid the need to “activate” CTOs as much as possible or use it as a leverage. They aimed to make the experience as acceptable and supportive as possible for the patient despite the coercive context. Moreover, different strategies were named by the mental health care providers: negotiation, flexibility, providing choices, allowing time, respect, teaching, and working on the therapeutic relationship.

“In the past, we saw that: the first injection, they are resistant, they do not want it; hence, code white... It is a shame because you jump on the patient. We do not see that anymore because we take the time. If it takes one or two hours, we take the time. However, often, we manage to negotiate and take time too.” (Specialized educator 15)

The importance of treating the patient with respect was also emphasized.

“What is the most important in a patients’ perception... I have talked to them considerably about this; do they feel they were respected in the way it was performed? Of all the coercive measures, whatever they are, what stands out is the feeling that they were treated with respect, not that something was imposed on them when they lack abilities and judgment. Therefore, I am quite careful before getting a CTO… to take the time to document my things, talk to the patient, explain the need and reasons for the treatment, and give them the opportunity to defend themselves.” (Psychiatrist 4)

Discussion

This study explored the experience of CTOs among patients, relatives, mental health care providers, and psychiatrists in hospital and community settings. Despite some variations, overall, the perspectives of the relatives and mental health care providers were contrary to those who underwent a CTO.

The patients’ coping mechanisms with CTOs ranged from resignation to resistance. The insufficient acceptance of the CTOs, and thus consent, was consistent in that refusing treatment was a criterion of the CTOs. However, there was certainly a gap between the perception of patients and that of practitioners and psychiatrists, who felt that the patients accepted it over time. The mental health care providers explained an acceptance of CTOs by the reduction of psychiatric symptoms; nevertheless, patients described it more as a matter of “playing the game” to negotiate the imbalance in the power relationship inherent to CTOs. Thus, although our results did not support the two profiles (active acceptance and resistance) proposed by Jobling (2014), they indicate a continuum from resignation to resistance. This lack of acceptance leads once again to the question of whether it is possible to develop a true therapeutic relationship regarding coercion where the association is by definition tainted by an imbalance of power, as the caregiver always has the option of evoking a CTO, like a sword of Damocles ready to break the link—often tenuous—of the trust relationship. It is worth mentioning that five of the six participants who had an experience of being subjected to a CTO were hospitalized at the time of the interview, which could have influenced their experience negatively.

However, it should be noted that the majority of the stakeholders discussed ethical issues related to the restriction of human rights and that it is in this spirit that strategies were being deployed to mitigate the effects. The desire to improve CTO implementation, without always influencing the outcomes, is similar to the concept of procedural justice by Lind and Tyler (1988), according to whom a person will have a better experience if they feel treated with respect and fairness. For example, mental health care providers' concern in terms of taking the time to listen to the person and negotiating their treatment could reduce the impacts associated with the coercive aspect of this measure. However, in the present study, persons who underwent a CTO did not report having been exposed to any interventions or approaches targeting the development of therapeutic alliances. In the context of formal coercion such as CTOs, the possibility of negotiation, whether it be the nature or dosage of the medication, or even the follow-up context, is perceived by patients as a way of making their voices heard. This can be a way for mental health care providers to demonstrate their intention to encourage the persons’ involvement and respect for their perspective. However, some authors associate negotiation with informal coercion (Hotzy et Jaeger, 2016). Indeed, Brophy and McDermott (2013) have suggested a human rights approach to CTOs and a focus on the quality of care, including questions about the goals and desired outcomes. A CTO is perceived as coercion by the patients; contrariwise, the psychiatrists leverage CTOs to help patients regain a certain autonomy that would make it a practice anchored in recovery. Here, the ethical values that are central to the field of care are in conflict: prioritizing charity, however, reproduces the historically established power relationship between the patient and care team.

Furthermore, from the perspective of those primarily affected, the symbolic violence associated with a CTO is palpable. This study’s results suggest that this violence is related to a denial of legal and social recognition (Houston, 2016). Beyond the suspension of several human rights, including the right to consent to one’s care, the denial of legal recognition is apparent when the CTOs are compared to prison. It is also apparent when the person is disqualified from planned care. The nature of this care, which is mostly limited to medication with no other alternative, also evokes a strictly biomedical reading of the treatment possibilities that contribute to a person’s recovery. The person is maintained, at least temporarily, in a zone of non-citizenship in which care is then dictated by the intersection of judicial and medical powers. Some findings in this study also indicate a denial of social recognition of patients. First, the amplification of the power imbalance can lead to the exclusion of their voice and experience. Nonetheless, these exclusionary mechanisms can, in the sense of recognition theories, lead to self-forgetfulness and significant violations of the human dignity (Honneth et Rusch, 2013; Houston, 2016).

From the relatives' perspective, two observations emerge. First, as their involvement follows not only the trajectory of care but also the person's life, the relatives feel relieved of formal care, while simultaneously experiencing exclusion, thus confirming the findings in the literature (Corring et al., 2010; Stensrud et al., 2015; Rugkåsa & Canvin, 2017). In addition, certain respondents, such as caregivers and psychiatrists, mentioned a desire to increase the use of this coercive lever in the hope that the patient would receive the care that they need. This observation, first made by O'Reilly et al. in 2006 (26), raises questions about the use of judicialization to ensure an appropriate intensity of services in psychiatry.

An implicit criterion for a CTO is dangerousness. Although the primary purpose of CTOs is to provide care for people with mental health problems who require it, “dangerousness” is a factor that also influences this decision; however, it is not a criterion in Quebec’s legislation (Bernheim et al., 2016; Frank et al., 2020). The results of the current study indicate that dangerousness is perceived as a legal criterion by all but psychiatrists who support their argument based on risk management for which a CTO becomes the last resort. Therefore, Quebec is in a class of its own regarding legislation. After reviewing the CTO legislation in the Commonwealth, Dawson (2016) proposed four general principles: the presence of a mental disorder, the presence of risk, necessity/proportionality, and the possibility of community-based treatment. Nonetheless, it appears that the CTO experience is intimately linked to risk, notwithstanding the legislation that frames the practice. This is why it is often discussed as a safety net to manage risk (Goulet et al., 2019). However, our study’s findings have revealed that it is also a safety net for mental health care providers, whether related to their professional responsibility or a role similar to that of a family member.

This study’s limitations are primarily related to the specific Quebec legislation, as presented above, which may affect its generalizability. Other usual limitations for this type of studies are the sample size and social desirability. Conducting individual interviews with people who had previously experienced CTOs by a research partner patient was a strategy to decrease this bias. It is possible that the participants produced a reconstruction of the facts that deviated from the reality; thus, the interval of a CTO experiment was set at a maximum of two years to reduce this bias. The inclusion of several categories of clinicians (nurses, criminologists, social workers, occupational therapist, specialized educator, and psychiatrists), resulted in a much larger sample of clinicians than those who had been on a CTO. In addition, recruitment of persons who had been on a CTO was difficult and had to be stopped early due to the COVID pandemic, further limiting the number of participants for this group. The review of the results by a patient partner helped to promote the perspective of this category of participant. Lastly, considering the participatory nature of the project, the different stages of the study could have benefited not only from the participation of a patient partner, but also from that of clinicians and family members. The participation of different categories of individuals involved in CTO should be sought in future studies wishing to employ a participatory approach.

Conclusion

The current context of care is strongly influenced by the recovery and patient engagement movement. How can we reconcile the position wherein the patient is considered the expert in the experience of their illness with a context of crisis that deprives the person of their fundamental right to autonomy? Does the association of a CTO with dangerousness impact the social acceptability of its inherently coercive nature? Unlike coercion in other formal forms such as seclusion and restraint, which are targeted by international policies supported by the World Health Organization that aim at their reduction or even elimination, this is not the case for CTOs. The coercion associated with treatment—therefore, with a therapeutic intention—is instead targeted as a desirable practice owing to the argument that it facilitates early treatment, thus decreasing the long-term sequelae of the absence of treatment. Wyder et al. (2015) have proposed that it is possible to aim for a humanist approach—even a partnership of care—within a CTO. Further studies will be needed to identify strategies to reconcile the stakeholder perspectives regarding CTOs, which, by virtue of their inherent nature, is a difficult proposition.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

MHG has received research grants from the Canadian Institutes of Health Research and Fonds de recherche du Québec - Santé.

Acknowledgments

The authors acknowledge the contribution of all participants of the study.

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