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Insight and use of community treatment orders

Background: Judgments about insight and compulsory treatment are routine, though contentious, aspects of psychiatric practice. But how should judgments about patients' insight inform involuntary treatment decisions? Aims: To explore the role played by judgments about patients' insight in reasoning concerning the use of community treatment orders (CTOs) in New Zealand. Method: Interviews were conducted with 42 patients treated on CTOs, their clinicians, and carers, concerning reasons for involuntary outpatient care. Their comments concerning patients' insight were analysed to investigate how they used the concept in reasoning about involuntary care. Results: Lack of insight was viewed as an important indicator for compulsory outpatient treatment, due to the perceived link with treatment compliance. There was also a common perception that outpatients could progressively gain insight during sustained treatment on a CTO. Obtaining good insight was not necessarily viewed as an indicator for discharge from a CTO, however, if the patient posed continuing risks of harm, or had a rapid or severe relapse profile. Conclusion: The patient's potential for treatment compliance appeared to be the primary focus of involuntary treatment decisions. Improved insight acted as one important indicator that such compliance would occur.