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Sir: The issue of community treatment orders (CTOs) continues to create difference within the College, but Moncrieff & Smyth (Psychiatric Bulletin, November 1999, 23, 644-646) have added nothing new to the debate. Rather, by drawing the issue away from the practical question of how to help a small group of vulnerable people, towards vaguely defined issues of social control, they may be doing psychiatry a disservice. They have been selective in their references, avoiding the many articles evaluating CTOs in other countries, for example the USA and Australia. Most of their arguments are as relevant to any kind of compulsory treatment as to that specifically located in the community.

The notion, furthermore, that it was “concern for patient rights that underscored the move away from the asylums” is only partially true. There were certainly concerns about institutionalisation, recognised by numerous hospital inquiries, but the impacts of modern medication and of the resource implications of an ageing real estate were just as powerful. The rising demand for medium secure unit beds reflects the way in which the asylums are returning, in another form, while the rising level of Mental Health Act sections reflects the distress of a number of chaotic, relapsing individuals for whom current community provision is simply inadequate.

One of us recalls a rather angry argument in the 1970s, about the introduction of car seat-belts, in which a senior physician suggested that it was a gross infringement of personal rights to be ordered to wear a belt. Yet the impact of a seat-belt law, in terms of reduced head injury and general morbidity and reduced mortality, has been immense. With the appropriate legal safeguards, the use of enhanced tribunals or other legal agencies to monitor community treatment, and reversion of psychiatrists to their proper role (as therapists rather than turnkeys), it would seem to us that history can inform the usefulness of the CTO approach.

We strongly concur with Burns (Psychiatric Bulletin, November 1999, 23, 647-648) that these orders are not about bad behaviour, but about therapy and treatment for people with limited insight who have a right to such treatment. The challenge to psychiatry lies in educating the public that untoward behaviour will always occur, even with CTOs in place. The problem with the language of ‘social control’ is that it makes it very easy to be a bad Samaritan.