Mapping the psychiatric circuit: Mental health law and psychiatric carcerality in the ‘post-institutional’ era

Abstract

This paper theorises psychiatric carcerality after the shift in the locus of control from incarceration in large-scale institutions to psychiatric treatment in ‘the community’. It draws on the findings of an Australian study into experiences of Community Treatment Orders, civil orders under mental health legislation authoring forced psychiatric treatment in the home. It conceptualises Community Treatment Orders as a node within a broader psychiatric circuit, in which patients constructed as ‘risky’ are governed through enlistment into routinised, coerced movements across the circuit. I explore how psychiatric carcerality in the ‘post-institutional’ era operates through both immobility and movement across the psychiatric circuit, and the circuit's role as a threshold to other carceral systems and spaces.

Keywords

mental health disability psychiatry community treatment order

Introduction

The centrality of madness and disability to the carceral state is often under-explored and poorly understood. Foundational texts in carceral studies have analysed historic psychiatric institutionalisation, in asylums and mental hospitals, as both a form of incarceration and social control (Foucault, 1961; Goffman, 1968). More recent scholarship and activist accounts (particularly within the psychiatric survivor and abolition movement) have sought to broaden understandings of incarceration to include the vast array of contemporary spaces and systems in which mad/disabled people are detained (Ben-Moshe et al., 2014; Chamberlin, 1978). The ‘institutional archipelago’, Ben-Moshe et al., 2014 write in their ground-breaking edited collection, includes the assortment of community-based services for disabled people established after the introduction of deinstitutionalisation policies in the West, such as residential facilities, group homes, and day hospitals, as well as prisons. Since the nineteenth century, mental health law has functioned to codify the practice of non-consensual psychiatric treatment and involuntary hospitalisation (Ellard, 1990). This paper offers a conceptual framework that seeks to shed light on the role that present-day mental health legislation plays in the functioning of the carceral state apparatus in the ‘post-institutional’ era, in the aftermath of deinstitutionalisation reforms (Altermark, 2017). It does so by drawing on the findings of research into experiences and perceptions of Community Treatment Orders (‘CTOs’) under mental health legislation in the Australian state of Victoria. CTOs, sometimes known as ‘assisted outpatient treatment’ or ‘mandatory outpatient committal’, authorise the forced use of psychotropic drugs, most commonly in the form of long-acting, slow-release depot injections, without informed consent for people living in the community (Patel et al., 2011). Victoria provides a pertinent case study, as the second most populous Australian state has some of the highest rates of CTO use globally (Light, 2019; Light et al., 2012; Rains et al., 2019).

I begin by providing an outline of the conceptual background, followed by a description of the basic features of CTOs and the context for their introduction into law and psychiatric practice. I then outline the study's methodological approach and develop the conceptual frame of the psychiatric circuit through an analysis of interviews exploring the experiences of patients, independent advocates, lawyers, mental health peer workers, and university-based mental health researchers.¹ Themes and findings from interviews included that participants identified ways that CTOs can confine individuals within their homes and in the community; that CTOs function as a mechanism for surveillance from both police and ‘helping institutions’; and that CTOs can lead to the transfer of individuals to other intersecting carceral circuits (such as police, courts, and the family policing system). I argue that CTOs epitomise the form of psychiatric carcerality in the neoliberal era, relying on coerced movement across a dispersed network or loop of ‘community-based’ psy-system settings, laws and practices, enlisting patients into both punitive movement and immobilisation, in order to achieve the same confining objectives of institutional era. This is what I refer to as the ‘psychiatric circuit’.

Towards an analysis of the psychiatric circuit

Emerging in carceral geography scholarship, ‘carceral circuits’ has been developed as a conceptual window for understanding the multiplicity of interconnected institutions within the carceral state (Gill et al., 2018). Carceral circuitry describes how carceral space is created through a multiplicity of sites, institutions and laws, and highlights the importance of mobility and movement in maintaining carceral space (Russell et al., 2022; Turnbull and Moore, 2024; Turner and Peters, 2016). Gill et al. conceptualise the enrolment of mobility and the compulsory circulation of people, objects and practices ‘between and around carceral spaces’ as carceral circuitry's central ontological features (2018: 4). In a similar vein, Norton-Hawk and Sered (2018) describe an ‘institutional circuit’ constructed from the diffuse circle of agencies, programs, and facilities for providing services to people who are homeless, or who have been labelled with ‘mental illness’ or ‘addiction disorders’ (such as homeless shelters, rehabilitation and detoxification facilities, welfare offices and parenting classes). Instead of sequestering ‘institutional captives’ in physical structures, the power of the institutional circuit is ‘everywhere, rather than confined to particular buildings’ (Norton-Hawk and Sered, 2018: 265). In this paper, I attempt to respond to the call from Gill et al. to map and expose carceral circuits, by bringing hidden carceral techniques and practices in the psy-system to public knowledge (2018: 193).

I conceptualise both the coerced movement and immobilisation of patients subjected to CTOs as part of a wider psychiatric circuit. Once individuals are categorised and sorted by those who are charged with performing functions under mental health legislation (and related practices, guidelines and policy directives) as both ‘mentally ill’ and ‘a risk to self or others’, individuals can be drawn into the psychiatric circuit. To illustrate the circuit's central features, I focus on CTOs, as they exemplify the state's reliance on enrolling patients into both punitive mobility and immobility in the management of ‘surplus populations’. Several key features of psychiatric circuits include their reliance on (1) psychotropic medication to immobilise, constrain movement and ensure ‘compliance’; (2) the deployment of surveillance and the routine movement (or ‘churning’) of patients across multiple institutional sites and systems within the circuit (such as supported residential services, hospital psychiatric units, short-stay psychiatric facilities, ‘secure extended stay’ psychiatric facilities, outpatient clinics, outreach team workers and guardianship orders); and (3) transcarcerality, through the transfer of patients to other intersecting carceral institutions and legal settings at multiple points along the circuit (such as police, courts and the family policing system). The temporal and spatial dynamics of the psychiatric circuit are usually described by individuals themselves, families, clinicians, and researchers through the imagery of being ‘shuffled’ through a ‘revolving door’ of services, while receiving a lack of, or poor quality, ‘care’ (Klassen, 2017; Schliehe, 2014). Risk-management and containment practices propel the movement of patients viewed as ‘high risk’ across the circuit, with those who seek system entry, but are assessed as being a ‘low’ or ‘moderate’ risk, often being denied support, excluded from service eligibility and subjected to abandonment in the community (Bhui, 1999; Epstein, 2005; Sawyer, 2005). Rather than positioning psychiatric carcerality as originating within, and flowing out from, fixed institutional sites and structures, the psychiatric circuit relies on the circulation and reach of mental health legislation, and the practices it codifies and authorises, across a broader network of spaces, including the home and ‘the community’.

Community treatment orders (CTOs) in Australian mental health legislation

Until the latter half of the twentieth century, those considered mad could be institutionalised in standalone psychiatric institutions for extended periods (Coleborne and MacKinnon, 2003). During this period, Australian psychiatric hospitals were increasingly subjected to scrutiny (Bromberger et al., 1992). The development of modern psychopharmacology in the 1950s assisted in the reorganisation of long-term institutionalisation, providing a low-cost and efficient way for the state to manage ‘problem populations’ in places deemed ‘less restrictive’ than psychiatric hospitals (Fabris, 2011; Hatch, 2019). From the 1970s onward, Western governments began decommissioning psychiatric hospitals, shifting the locus of control from large institutions to a more dispersed network of services in ‘the community’ (Robson, 2008). Nikolas Rose has described deinstitutionalisation as signalling the emergence of a new ‘institutional topography’ for psychiatry, as the focus shifted to a system of outpatient management through the establishment of outpatient clinics, mobile treatment teams, day programs and social housing (1998: 179). The insufficient resourcing of community-based services since the deinstitutionalisation period reflects broader neoliberal trends, involving retractions in state welfare spending, economic deregulation and heightening social insecurity (Wacquant, 2009). Today, average periods of hospitalisation in mental health facilities in Australia have shortened, as the system has re-orientated towards community-based services which are largely under-resourced, narrowly focused on clinical treatments and governed by practices of risk assessment and containment (Australian Institute of Health and Welfare, 2024; Tseris et al., 2024).

Australian state and territory-level mental health legislation² regulates public mental health services, authorising the use of involuntary assessment, detention in psychiatric facilities and involuntary psychiatric treatment (including use of electroconvulsive ‘therapy’). Mental health legislation also regulates the use of ‘restrictive practices’, which encompass the use of mechanical restraints (i.e., strapping people to fixtures, such as beds or wheelchairs), physical restraints (the use of physical force), and the use of seclusion (the confinement of a person to an area they cannot leave) in mental health services (Lawrence et al., 2018; Maker and McSherry, 2019). Chemical restraining is also a widespread practice (McSherry and Tellez, 2016). Generally, these practices are legally permitted when it is deemed necessary to prevent harm to an individual or others, and where no ‘less restrictive’ intervention is deemed possible or available. The ‘risk to self and others’ criterion in mental health legislation has been critiqued on the basis that its true function is to protect the community, with psychiatrists employed as arbiters of public safety, sharing the ‘social control responsibilities of the criminal justice system’ (Appelbaum, 1988: 779). From the 1970s-1990s CTOs were progressively introduced into mental health legislation, often as part of deinstitutionalisation reforms. In the United Kingdom, the United States and Canada, CTOs were introduced into mental health legislation in connection with fear-based politics surrounding deinstitutionalisation (Behnke, 1999; Grob, 1966; Muijen, 1996). CTOs have since been introduced into mental health statutes in all states and territories of Australia, as well as New Zealand, across the United States, Canada and the United Kingdom (Kisely and Campbell, 2007). Today, CTOs are a common feature of mental health laws and psychiatric practice, such that CTOs have been described as the ‘default’ means by which community-based public mental health services are ‘accessed’ (Rees, 2009: 80).

CTOs require individuals to comply with medication treatment plans in order to live in the community. In Australia, CTOs are made in the first instance by mental health services and are subsequently reviewed and made by Mental Health Tribunals, with limited mechanisms for appeal (Carney, 2012). Patients are typically discharged from a period of hospitalisation onto CTOs and are commonly mandated to receive long-acting, slow-release depot injections of psychotropic medications as part of their treatment plan (Brophy et al., 2006; Patel et al., 2011). Patients are also required to accept visits from psy-system workers in their home and/or attend appointments as outpatients. In some jurisdictions and circumstances, CTO treatment plans can involve conditions regarding social activity, can specify the location a person must live, and can be used when a person is homeless (Brophy et al., 2006; Dawson and O’Reilly, 2015; Mental Health Review Tribunal, 2018). CTOs may also involve mandatory blood testing to monitor medication levels, urine drug screening, or mandate additional, non-psychiatric medications, such as contraceptive and libidinal medications³ (Klassen, 2017; Mental Health Review Tribunal, 2018). If a patient is deemed non-compliant with their treatment plan, mental health services can rely on police to exercise force to transport patients for involuntarily assessment, treatment and hospitalisation (often referred to in CTO literature as the ‘recall’ or ‘CTO revocation’ process) (Owens and Brophy, 2013).

CTOs are usually granted for periods of six or 12 months; however, there are generally no limits to the number of times a CTO can be extended, and in some jurisdictions, a ‘perpetual order’ can be made after a number of consecutive orders are given (Callaghan and Newton-Howes, 2017). This means that CTOs can be long-term: one recent case in New South Wales involved a person who was successful in securing legal support to overturn consecutive CTOs they had been subjected to for 47 years (Gregoire, 2020). Those who voluntarily seek to access mental health services in the community also report experiences of coercion, in the form of threats from staff that they will be subjected to a CTO (O’Donoghue et al., 2014). While proponents of CTOs argue they ‘free up’ resources, are ‘less restrictive’ than involuntary hospitalisation, or protect individuals from criminalisation and placement into the forensic system, the evidence behind CTOs outcomes is poor (Burns et al., 2013; Churchill et al., 2007; Heun et al., 2016). Some evidence suggests involuntary psychiatric treatment may increase the likelihood of death by suicide and crimalisation in some circumstances (Emanuel et al., 2025; Jordan and McNiel, 2020). Crucially, subjection to involuntary psychiatric treatment orders is unevenly spread across the population, and their application is racialised. People subjected to involuntary psychiatric treatment are disproportionately Indigenous, from racialised communities, or otherwise from socially or economically disadvantaged backgrounds (Corderoy et al., 2024; Kisely and Xiao, 2018). Factors such as non-white ethnicity, male gender and unemployment have consistently been shown to raise the risk of being subjected to a CTO (Barnett et al., 2019; Kisely et al., 2025). In Australia, people from ethnic minority backgrounds are 47% more likely to be subjected to a CTO; in New Zealand, CTOs rates for Māori are more than three times those of the general population (Kisely et al., 2023; Lees et al., 2023). The racialised dimensions of psychiatric coercion, in which racialised and Indigenous people are more readily perceived as ‘dangerous’, and thus deemed at risk of harming themselves or others, has been observed across the United States, Canada, New Zealand and the United Kingdom (Gajwani et al., 2016; Gibbs et al., 2004; Joseph, 2019). CTOs are controversial and the evidence base for their use remains weak and highly contested. Despite their high rates of use in countries such as Australia and New Zealand, and similarity with community-based orders in criminal law, CTOs have largely evaded scrutiny in carceral and abolition studies (for notable exceptions, see: Fabris, 2011; Klassen, 2017). Given the centrality of coercion, restriction and control to the operation and function of CTOs, and the uneven, racialised nature of their application, they urgently require deeper examination.

Methodology

The research sought to investigate the experiences and perceptions held about CTOs in Victoria, Australia. The study involved the analysis of semi-structured interviews with fifteen participants from a variety of perspectives, including people who had a been subject to a CTO (or had been threatened with being subjected to a CTO), members of the mental health peer workforce, independent mental health advocates (who are employed to provide advocacy support to patients), lawyers, and university-based researchers in the field of mental health. The research sought to make space for constructing knowledge about CTOs outside of the methods of knowledge production most common in ‘mental health research’, prioritising critical perspectives that are often systematically excluded from traditional research approaches. As I grappled with how to ethically engage with people's experiences and stories about CTOs, I concluded that it was not fair to turn the research gaze on first-person narratives alone. In seeking to explore a range of critical perspectives on the topic, the research included participants who drew upon insights from situated, experiential knowledge, as well as (and sometimes in addition to), insights derived from mental health peer work, providing legal representation, independent advocacy, or involvement in traditional research on CTOs. In doing so, I sought to avoid replicating approaches that treat psychiatrised people as mere ‘data sources’ and the over-reliance on inviting those who self-identify as people with ‘lived experience’ to share their personal narratives and stories for the consumption of others, including as part of qualitative research (for an overview of these ethical tensions in survivor-controlled research, see: Costa et al., 2012; Russo, 2016).

The study was approved by the La Trobe University Human Research Ethics Committee (HEC20238). Participants were recruited by sharing the study advertisement with member-based organisations for people who use mental health services, with staff in the state's independent mental health advocacy service and in online mental health support groups. All participants provided written informed consent prior to participating. Interviews were conducted online due to COVID-19 lockdown restrictions over three months in 2021. The interviews were recorded, audio files were transcribed, and data were coded using NVivo 12 software to enable thematic analysis. All participants who had first-person experiences of CTOs were reimbursed for their participation. An insider research approach was adopted, using the author's own standpoint as a psychiatric survivor as an epistemic resource in the research process (Nelson, 2020; Sweeney, 2016). This approach was informed by mad epistemologies, the collective experience and knowledge generated by those with first-person knowledges of the psy-system (Menzies et al., 2013; Rose, 2022). The knowledge generated by mad people is indispensable to the critical interrogation of Western psychocentric worldviews, which understand common human phenomena, such as suicidality, self-injury, intense emotions, unusual beliefs and hearing voices, as the product of inherent genetic vulnerabilities or abnormal neurochemical processes of the brain (Rimke, 2018). These conceptual frameworks, mad epistemologies and the values of survivor research, informed the approach to conducting interviews, the process of data analysis, and the overall research framing and design. To protect confidentiality, all participants have been referred to using pseudonyms.

Sedation and psychopharmaceutical confinement

The administration of psychotropic medications is a widely used and routine practice in public psychiatric practice. Psychotropic medications are used to chemically restrain, sedate and fatigue patients as part of a carceral strategy, aimed at rendering patients passive, compliant and immobile, by limiting speech, delaying cognition and restricting movement. Psychotropic medications are a class of pharmaceuticals intended to alter ‘mood, perception and behaviour’ (Flore et al., 2019: 66). The use of prescription psychotropic medications for the means of behaviour control, without a medical or therapeutic purpose (‘chemical restraint’), has been widely documented in the context of criminalised and formerly incarcerated women, for people with intellectual disability, in residential facilities for people with dementia, in refugee detention, as well as in psychiatric settings (Cain et al., 2023; Kilty, 2012; Turnbull and Moore, 2024; Weightman et al., 2020). The widespread use of psychotropic drugs for the purpose of restraint has long been a focus of mad-identified scholars and activists, who have previously critiqued this technique as ‘chemical straitjacketing’ or ‘chemical incarceration’ (Chamberlin, 1978; Fabris, 2011). For CTO patients, psychotropic medications are most often administered through long-acting, slow-release depot injections (Patel et al., 2011). While this particular method of administering medication is preferred by clinicians, as it provides an efficient and convenient way of ensuring the compliance of patients (Fabris, 2011; Klassen, 2017), it is often distressing for patients. Rose, who works at an advocacy service supporting patients subjected to involuntary treatment orders (or who are at risk of being subjected), explains that mental health services prefer long-acting injections for CTO patients because it makes them easier to control and manage:

A lot of people don’t like the depot because it's long acting, so it usually lasts fortnightly to monthly, or three-monthly in some cases. People usually will argue that oral medication is less restrictive because it means if they stop taking it, it doesn’t linger, whereas once you’ve had the injection, it's in you for a month. A lot of hospitals won’t discharge people into the community now unless they’ve had a depot, so they know that for a month that person will be ‘protected’ and have an antipsychotic in their system (Rose, advocate).

Hayley, who was discharged from hospital onto a CTO, describes how she was given little choice in how she would receive her medication as part of the CTO and was frightened about being injected:

They come to your house, and they have to supervise you taking medication. I was in the hospital one time, and I think they said, a nurse, or a doctor, she goes: ‘Do you want an injection’? I go: ‘I don’t really’. I was scared, I didn’t want to take the injection. But, then eventually later on they changed it to an injection anyway (Hayley, CTO patient).

Psychotropic medications can lead to both short-term and long-term physical health complications, including weight gain, kidney disease, diabetes, strokes, sexual dysfunction and bodily tremors (Flore et al., 2019). These health impacts, which are rarely fully disclosed to patients, are associated with lower life expectancies and poorer health outcomes (Suggett et al., 2021). These ‘side’-effects, along with the impacts of delayed cognition and communication, fatigue and sedation, accumulate to confine patients to the home, or certain spaces within the home. Carla illustrates the way that the effects of prescription psychiatric medications confined to her couch, restricting her movement and ability to communicate with others:

I was on the CTO, and I couldn’t get off the couch. I had restless leg syndrome. I was agitated, I couldn’t stop twitching and I didn’t shower. I would stay on the couch 24 h a day. I’d sleep on the couch, and I couldn’t move … I got to the point where I forgot how to speak because I wasn’t speaking to anyone and I had to think about, before I spoke, how to speak and what words to say. I was that heavily medicated, that I forgot how to speak (Carla, CTO patient).

In Carla's experience of being observed and monitored under a CTO, she describes her understanding of the purpose of CTOs as a way for psy-complex workers to ensure patients are not presenting in ways that would appear they have become more ‘high-risk’:

They review your medication and that's all they care about is you not presenting as unwell, having symptoms. All they care about is that you’re not hearing voices, or you’re not manic or whatever (Carla, CTO patient).

Participants described how heavy sedation and lack of control over treatment plans can be a punitive experience, restraining movement, cognition and speech, sometimes resulting in the confinement of individuals to limited sections of the home, such as a bed or couch. Through forcibly medicating patients, patients are immobilised and constrained through both the sedative and debilitating effects of the medication, as participants described the way that psychotropic drugs lead to a range of health complications, such as involuntary bodily tremors. Over the long term, health-related impacts and complications as a result of long-term psychotropic drug use can lead to bodily debility (Puar, 2017). Through the routine, strategic use of sedating psychopharmaceutical drugs, psychiatric circuits (im)mobilise and enforce compliance, reconstituting patients as governable subjects, more readily managed, subdued and controlled.

Surveillance and routine movement

Once on the psychiatric circuit, patients are made available for heightened surveillance, visibility and coerced movement. Movement is essential to the maintenance of the circuit, with community-based mental health services and crisis outreach teams responsible for the ongoing monitoring of patients while they live in the community. While these community-based services have been introduced as part of a shift towards deinstitutionalisation, they have been critiqued by abolitionists and survivors as failing to represent a ‘separate episteme’ to institutionalisation and for remaining governed by the same custodial and institutional logics (Ben-Moshe, 2011: 243; Altermark, 2017). For those on CTOs, movement across the circuit includes compulsory attendance at appointments at mental health services and monitoring from mental health service workers in the home. CTO conditions typically enforce either attendance at appointments, or require patients to have staff attend and enter their homes for administering medication and/or monitoring that their CTO treatment plans are being adhered to:

People on Community Treatment [Orders] don’t get to decide about a whole range of things in life. Particularly medication, they’re compelled to have medication. They’re compelled to have it in a particular way … They’re compelled to attend a service to have that happen, or they’re compelled to have people come into their homes to do that, or to monitor them (Emily, advocate).

As Rose explains, drawing on her practice experience as an advocate, attendance at compulsory appointments and observations in services can have punitive impacts:

They [mental health services] tell you when your appointments are. You don’t get to say, ‘I’m free on Friday at three o’clock, I’ll come in for my depot shot then’, it's: ‘The consultant is free at this time, you need to come in for your depot’ … You can’t have a hobby, or a job or go back to study if every five minutes you’re going to be called by a mental health treating team and be told to come into the clinic (Rose, advocate).

Carmen details the additional punitive aspects for some patients, who are made to incur the costs of loss of work, or are required to purchase medications:

Some people on Community Treatment Orders actually have to go to the pharmacy and purchase the depot that then is delivered to them without their consent. People ought to be exempt from any costs associated with attending their appointments […] they shouldn’t be obliged to come to their appointments during work hours (Carmen, researcher).

Observation from mobile psy-system workers keeps CTO patients hyper-visible, as Lisa explains, mental health services insist on the need to have ongoing, physical sight over CTO patients:

Somebody very recently had that feeling of ‘Why do I have to keep coming into the clinic on this day, on this time? Why’? The clinic would say ‘Well, we need to have sight of you.’ They were like ‘But why? I can pick up the phone and have a conversation with you’ (Lisa, advocate).

The mobility of community mental health workers in monitoring patients in the community has been assisted through the introduction of Crisis Assessment and Treatment Teams (‘CATT’). These mobile services were established in Australia as part of deinstitutionalisation reforms, with the stated aim of providing crisis intervention services in the community. CATTs are an example of ‘assertive community treatment’, a model which generally involves clinicians engaging in outreach through mobile vans, often with police attending alongside (Evangelista et al., 2016; Van Veen et al., 2018). Upon arrival, CATT clinicians will generally review the person's clinical history, conduct a risk assessment and formulate a ‘management plan’ corresponding to the person's perceived level of risk (Savy and Sawyer, 2008). Rose recounted an experience of a CTO patient who experienced ongoing surveillance at the hands of their local area mental health service's CATT workers:

I worked with one person, their relative lived about an hour away by car and they almost never could go and visit because the CATT would come around at various points during the week and if they weren’t there, they’d call the police. They would call and leave messages for the case manager, and they [CATT] would come anyway and then police would be called and they would be taken to the hospital for an [involuntary] assessment (Rose, advocate).

CTOs make patients more visible to services, available for surveillance, both through home visits and mandatory appointments. The psychiatric circuit relies on both the coerced, circuital movement of people across the landscape, for attendance at appointments under the guise of patient monitoring and the routine surveillance of subjects who have (at one point) been deemed a ‘risk’. As will be explored in the following section, failure to move across the circuit when required can have dire consequences, including police involvement and involuntary (re)hospitalisation.

Carceral thresholds

Participants also described experiencing (or witnessing) transcarceral transfers, as patients can be moved sideways from CTOs into other carceral settings and systems. Carla described being detained in a high dependency unit (a section of the psychiatric ward that involves a higher level of observation and additional locked spaces), in which she had experienced both restraint and seclusion. When discharged, Carla was subjected to a CTO for a year. Upon discharge, she was referred by the mental health service to a child welfare system agency, who removed her child:

That was one of the stipulations [from child welfare agency] that I had to attend all appointments at the mental health service and abide by my CTO to get my child back. I felt like I was bound to do what they told me, and I had no rights or no choice (Carla, CTO patient).

Now in contact with the family policing system, Carla's mental health deteriorated further. As a single mother, her experiences of trauma and distress were dismissed by psy-system workers, as she describes being “a drug user [back then], so they just put it all down to drug presentation instead of being unwell and just labelled me.” Carla described becoming increasingly isolated in this period, faced with a lack of support and being coerced into complying with the conditions of her CTO:

I was totally alone. My mother lives interstate, she didn’t understand I was unwell. My child wasn’t in my care. I was on the couch by myself, seven days a week. Unless the worker came once a fortnight, or the nurse came, they were the only people I saw. I couldn’t function (Carla, CTO patient).

Women report fears of disclosing mental health issues and family violence in mental health services due to the prospect of involvement from the family policing system (Tseris et al., 2022, 2024). The family policing system is represented by the state as supportive of families, despite the system's systemic engagement in ‘benevolent terror’, particularly within Indigenous and racialised communities, engaging in family separation and child removal (Battle et al., 2024; Roberts, 2002). In Australia, this is disproportionately experienced by Indigenous women, as child welfare regimes have engaged in the targeted forced removal of Aboriginal children since their inception (Ashton and Wilson, 2014; Cripps, 2012; Wilson, 2013). In mental health services, psy-system workers are routinely tasked with conducting predictive risk assessments to assess a person's level of future risk of suicide and self-harm (Repo, 2020; Slemon et al., 2017). Risk assessment practices are widely used across a number of carceral settings, including prisons and youth out-of-home care (McCausland and Dowse, 2022). The ascendancy of risk management and containment as the basis of psychiatric practice has also informed the introduction of surveillance technologies such as ‘video assisted patient monitoring’, the expanded use of CCTV, and the use of body worn cameras in psychiatric units (Barrera et al., 2020; Desai, 2009; Simpson, 2023). The use of video sensors and algorithmic software to enable nurses to make remote observations is also increasing in the context of services for the elderly and for people with disability, as well as in acute psychiatric settings, and is likely to also be used in home-based care (Gooding and Clifford, 2021; Stop Oxevision, 2025).

The routine use of risk assessment practices and the coercive responses they engender, disproportionately subjects women (as well as queer, trans, and gender diverse people) to gendered, patriarchal judgements, which hinge upon presumptions of inherent irrationality or hyper-sexuality, which can proceed denials of legal capacity and reproduce the trauma associated with gender-based violence (Arstein-Kerslake, 2019; Tseris et al., 2022). Perceptions of women as risky and unruly subjects are transmuted into punitive practices that transfer women (and their children) into the family policing system. Once enmeshed within the psychiatric circuit and assessed by staff as ‘high risk’, this can become a difficult designation for individuals to escape. Carmen explained how the categorisation of individuals as ‘high-risk’ can persist, travelling with the individual, and animating further punitive responses:

I think about someone who had slept with a knife under their pillow. They thought that they were at risk and that they needed to have something [to protect themselves]. The fact that that was known to the mental health services, it just follows them, it's repeated in their next report and discharge summary […] These things continue to follow people around (Carmen, researcher).

Medicalisation and criminalisation, despite having ‘ostensibly different mandates’, act as ‘complementary devices’ (Norton-Hawk and Sered, 2018: 279), as attributions of disability and psychiatric labels travel with individuals across settings and space, animating carceral and coercive interventions across a number of legal and institutional settings (Steele, 2017, 2020). In addition to the cascading risk categorisations that animate the transfer of patients, particularly mothers, into the family policing system for further carceral control and management, participants also described ways that CTOs embedded the potential for future contact with police. If patients are found to breach their CTO, police are generally authorised under mental health legislation to use ‘reasonable force’ to apprehend and transport individuals to mental health services. In Victoria, 25–30 per cent of people on CTOs are re-admitted to mental health services involuntarily every year (State of Victoria, 2023). This process, sometimes described as the CTO ‘revocation’ or ‘recall’ process, relies on the threat of police contact and use of force as an enforcement mechanism. Although there is ‘widespread agreement’ among clinicians that the threat of police use of force and involuntary hospital readmission is ‘essential’ to the operation of CTOs and their ability to enforce ‘compliance’, police intervention under CTOs has rarely been fully interrogated (Dawson, 2006: 491; Owens and Brophy, 2013: 46). Emily and Rose, reflect on their understanding of the usual circumstances for police intervention and the use of force on patients:

It's usually when [the person] has not showed up to have a depot, or they’ve not shown up at an appointment with a case manager. It's not always immediate, but sometimes it is. Then crisis teams are at the person's door with police … or otherwise being forcibly removed from their homes and taken into an inpatient unit to be assessed (Emily, advocate).

[Breaching a CTO is] really dependent on the conditions of the CTO. The treating team will then develop a treatment plan and if that plan isn’t adhered to, that's when the CTO could be varied to an inpatient involuntary treatment order and that's usually what people are wanting to avoid (Rose, advocate).

When asked about the ways people on CTOs could experience revocation of their CTO (and police involvement as a result), Justine, a member of the mental health peer workforce, reflected on an experience from their time spent working in mental health services.

[A] person was living in a caravan park and the case manager didn’t want to go out there because they didn’t feel safe, so they revoked the CTO so that the police would go and pick the person up and bring them into the mental health service. That sort of revocation happens when, for whatever reason, the case manager has some concerns or doesn’t themselves feel safe going to that environment. It is not common, but it shouldn’t be possible (Justine, peer worker and consultant).

A significant number of people in contact with public mental health services in Australia are homeless and are discharged from inpatient settings back into rooming houses, motels and into other forms of homelessness (Productivity Commission, 2020). This example recalled by Justine demonstrates how ‘riskiness’ can be ascribed to individuals, through associations with homelessness and insecure housing, poverty and unsafe living conditions. Such ascriptions can place individuals at heightened risk of coercive and punitive responses, such as, in this case, the request for police deployment (the ‘revocation’ of the CTO), informed by risk containment frameworks that emphasise ‘safety’ and the prediction of risk before it occurs.

People who experience mental health issues are disproportionately at risk of criminalisation, through the application of charges, fines and arrests by police (Thom et al., 2024). Research on experiences of police apprehension in connection with mental health legislation has documented experiences of excessive police use of force including handcuffing, pepper spraying, use of restraint holds and tasering (Randall et al., 2024; Thom et al., 2024). There have also been numerous injuries, near-misses and fatalities sustained by people experiencing distress in the context of mental health-related police apprehension, contributing to Aboriginal deaths in custody (Dodd et al., 2024; Thomas, 2021). In addition to the risk of death, trauma and serious injury, police contact can act as a criminalisable event, with ‘welfare checks’ forming part of the systematic criminalisation and over-policing of people with disability and mental health issues (McCausland and Baldry, 2017; Morris, 2000). Routine practices within services, focused on neoliberal risk-containment paradigms, push patients into further carceral contact, such as management through family policing system or criminalisation through police involvement. Movement along the psychiatric circuit can produce heightened visibility to other state agencies and punitive systems of social control, transferring individuals laterally into other carceral systems and spaces.

Conclusion: Breaking the psychiatric circuit

This paper has drawn upon the framework of carceral circuits to interrogate the role of both immobilisation and movement in contemporary psychiatric carcerality, drawing on perspectives of Community Treatment Orders in the Australian context. I have described some central analytical and ontological features of the psychiatric circuit, its reliance on psychopharmaceuticals to sedate as a carceral technique; surveillance and coerced mobility across a multiplicity of sites across the circuit; and their transcarceral nature, intersecting with other legal regimes and systems of carceral control. Participants described how CTOs, by enforcing mandatory psychotropic drug treatment, deploy psychotropic medication regimes as part of a carceral strategy, a technique that sedates and debilitates patients, restricting movement and confining patients to the home, or spaces within the home. While patients are permitted to live in the community, they remain subjected to surveillance from mental health services, through clinical outreach and ‘monitoring’ and face the risk of police involvement if viewed as being ‘non-compliant’ with treatment, or do not attend mandatory appointments at outpatient clinics. Participants described how cascading risk designations can animate movement laterally into the family policing system or make individuals available for police intervention. The psychiatric circuit, and its connections to the carceral state, remains largely hidden and obscured due to perceptions that laws and spaces associated with the ‘helping professions’ are therapeutic, supportive, non-punitive and have the potential to divert individuals from the criminal legal system. As one participant put it, their experiences of being restrained, forcibly medicated in a psychiatric ward, and subjected to a CTO post-admission “don’t fit neatly into the public's idea on what it means to be treated in a hospital.”

Since deinstitutionalisation heralded a shift towards the management of patients in the community, the adoption of psychiatric risk-based containment practices, reductions of expenditure on social safety nets and increased funding for repressive state agencies have fostered the construction of a dispersed loop of agencies and services that churn psychiatric subjects through short stays in psychiatric units and onto CTOs. Psychiatric carcerality in the era of medicalised and risk-focused community-based mental health services relies on the ability to coerce movement across a multiplicity of institutional and legal settings, alongside immobilisation and abandonment. As I have aimed to demonstrate, the psychiatric circuit plays a pivotal role in the wider carceral landscape and acts as a threshold to the criminalisation and policing of people deemed ‘mentally ill’. Contemporary mental health legislation has not been subjected to sustained scrutiny in carceral and abolition studies. There has been insufficient consideration in abolition scholarship of the involuntary treatment orders nested within mental health legislation, with the role of mental health courts and tribunals, and guardianship orders – the full breadth and depth of practices, laws, policies and spaces that constitute the wider psychiatric circuit – which replicate and sustain carceral state power. This omission is striking considering recent trends in the North American context involving the expansion of involuntary psychiatric treatment (through expanding the categories of workers who have the authority to initiate involuntary orders and the widening of legal criteria). From the recent directives given to New York City workers to rely on police and involuntary psychiatric treatment powers under mental health legislation in order to conduct sweeps of homeless encampments, to the increased rhetoric from right-wing politicians about the need to ‘return to the asylum’, there is an urgent need for a deeper engagement with the politics of madness and the contours of carceral laws, policy and practices that govern the psy-system. ‘Psychiatric circuits’ is my offering to abolitionist knowledge and discourse that seeks to understand and resist the full spectrum carceral violence, including that which occurs within systems that exist to ostensibly to deliver treatment and care.

Footnotes

Acknowledgments

Thank you to the participants for their insights and reflections. Thank you to Emma Russell, Tarryn Phillips and Anne-Maree Sawyer at La Trobe University for their thoughtful feedback on early drafts of this article. Thank you also to Liat Ben-Moshe at the University of Illinois and Linda Steele at the University of Technology Sydney for early feedback and contributions that assisted with the preparation of this article.

ORCID iD

Panos Karanikolas

Ethical approval and informed consent statements

The study was approved by the La Trobe University Human Research Ethics Committee (reference number: HEC20238) on July 20, 2020. All participants provided written informed consent prior to participating.

Consent for publication

Informed consent for publication was provided by the participant(s).

Funding

This research was supported by an Australian Government Research Training Program Scholarship, a La Trobe University Graduate Research Scholarship and the La Trobe Internal Research Grant Scheme for Graduate Researchers.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The author confirms that the data supporting the findings of this study are available within the article and its supplementary materials.

Notes

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