Psychiatrists' perceptions of mandatory treatment orders in Singapore: a qualitative study.

Abstract

Mandatory Treatment Orders (MTOs) are used in Singapore to manage offenders whose culpability is diminished by mental illness, yet guidance on their optimal application remains limited. This qualitative study explored psychiatrists' perspectives on the use of MTOs and their role within the broader mental healthcare and justice system. Semi-structured interviews were conducted with 21 practicing psychiatrists at a tertiary mental health institution, and data were analyzed thematically. Participants described substantial variability in MTO practice, shaped by clinical experience and levels of forensic involvement. Three overarching themes emerged: determining appropriate MTO duration, distinguishing between criminal and civil use of MTOs, and balancing forensic assessor continuity with independence. Longer MTOs were generally favored for individuals with psychotic disorders and histories of non-adherence, while shorter MTOs were viewed as sufficient for milder conditions, minor offences, and individuals with established engagement and insight. Many participants expressed ethical concerns about extending MTOs to civil contexts, citing risks of coercion, weaker enforcement mechanisms, and prioritization of social control over therapeutic benefit. Although continuity of the forensic assessor was often preferred for clinical and practical reasons, concerns regarding impartiality were also raised. Overall, psychiatrists viewed MTOs as occupying a dual therapeutic-justice role, generating tensions that contribute to variability in practice. Clarifying policy objectives, strengthening training and operational supports, and defining assessor roles may help improve fairness, consistency, and treatment outcomes.