Following orders?

For many people with serious mental health problems, a stay on a psychiatric hospital ward is preferable to compulsory treatment at home, an option the government seems hellbent on introducing.

Few people are happy with the idea of community treatment orders (CTOs), officially known as “non-residential” orders because the person is not resident in a hospital. But they form a key plank of the government’s mental health reform in England and Wales and are unlikely to go away.

Under current mental health law, individuals can be forced into treatment only if they are hospital in-patients. Many believe that it should stay this way and, when you consider the arguments, their scepticism is understandable.

First, there is concern that, if community-based orders are introduced, more people will become subject to compulsory treatment – because numbers will not be restricted by available hospital space. On the contrary, pressure on psychiatric beds could result in doctors discharging patients on to CTOs when they need to stay in hospital.

Second, enforcing treatment in the community may drive people away from mental health services out of fear of coercion. For example, many service users, because of intolerable side effects, already prefer to suffer the symptoms than take medication.

Third, the effectiveness of community-based orders has proved inconclusive, raising questions as to whether they are ethical or worthwhile. One review based on their use in the US estimated that to prevent one readmission to hospital 85 orders would be needed on average while 238 would be needed to prevent one arrest.(1)

There is also a worry that people will be left on orders for longer than necessary. For example, a service user with a chaotic mental health history may improve when treated in the community. The dilemma is then whether they stay on an order indefinitely to maintain the stability or, because they have improved, whether to discharge them from the order and risk deterioration?

As yet, mental health professionals in the UK can only go on evidence from other countries which use community treatment – also known as mandatory or involuntary outpatient treatment. These include New Zealand, Canada, Australia, the US and Israel. Scotland will have its system soon.

In New Zealand, involuntary community treatment was introduced by the Mental Health (Compulsory Assessment and Treatment) Act 1992. Typical conditions require service users to accept visits from community health professionals, and accept treatment, including medication. Where a person lives may be specified but they may be limited on how far they can travel from home. Breaching the conditions can result in being taken to a clinic for treatment or returned to hospital, which may include the police and reasonable force.

Of all the countries with compulsory community treatment, New Zealand has the highest rate of use, at about 40 to 60 people in 100,000, with the number climbing steadily, from 1,207 in 1998 to 1,769 in 2003.(2) Data suggest that more men than women are placed on orders, and they tend to be people with diagnoses of schizophrenia or affective or schizo-affective psychosis, with a history of hospital admission and non-compliance with medication. Many also have a history of aggression, self-harm and substance misuse.

One study found that in Otago, on New Zealand’s south island, two-thirds of service users on CTOs were either wholly or generally favourable and only 7 per cent were totally opposed. Some said that an order had saved their life through preventing suicide or self-harm; others that it was like a security net when they became unwell. They talked about having improved access to mental health services and greater freedom than being in hospital. But even those who were favourable identified negative aspects saying things such as “I have to do what they say” and being “under control, supervision and surveillance”. One person said that he was restricted to travelling within 50km of his house, which meant he could not visit his father 55km away.(3)

Anita Gibbs, a senior lecturer at the University of Otago who carried out the research, says in most cases the orders work well. “But for the small group of clients who hate the orders you wonder whether it was worth bothering as they saw no advantages other than being controlled. Having said that, the families of these clients are still really supportive of the orders.”

Indeed, her study found that relatives felt that CTOs helped them to share the burden of care with mental health professionals and strengthened the support and resources available. On the downside, family members were not always kept informed, to the extent that some did not know their relative was about to be discharged off an order.

Mental health professionals were also positive about the orders. They found them useful in maintaining contact with service users, monitoring their conditions and increasing compliance – some even admitted to using the threat of returning a service user to hospital at times. Few considered the orders intrusive or unnecessary.

Gibbs says: “The practice does not seem as bad as the legislation. New Zealand’s mental health act looks like a coercive piece of legislation but has in practice rarely been used to force people to do things they don’t want to in the community. In most cases, where people refuse community treatment they still go to hospital, and it is rare they are put on a CTO without having been in hospital.”

In contrast, Canada has the lowest use of CTOs, with just two people in 100,000 in Ontario and Saskatchewan, the two provinces where it is most established, subjected to compulsory community treatment. The low usage may be due to the tight criteria used. In Saskatchewan, where CTOs have been used since 1995, in order to qualify a person must have had three admissions or spent a total of 60 days in hospital in the previous two years.

Richard O’Reilly, a practising psychiatrist and professor of psychiatry at the University of Western Ontario, says psychiatrists have been “very judicious” in imposing community treatment. His 2001 survey in Saskatchewan found that at any one time just 15 to 20 people out of a population of one million would be on CTOs. He believes that the bureaucracy involved is resulting in their under use, particularly when you consider that in Saskatchewan a CTO lasts for just three months.

“By the time it is signed it needs to be renewed,” he says.

In Ontario, if a patient is brought back into hospital using the powers of the CTO that CTO ends and the process has to start again. Also, in Saskatchewan two psychiatrists must see the patient in the community for each renewal, which is a problem given the shortage of psychiatrists.

A review of CTOs in Ontario has been sent to the health minister but has yet to be published. But O’Reilly believes that the debate needs to move on. “In every jurisdiction CTOs are used for only a few individuals so the fears that people will be swept off the streets are unrealistic. As we treat people with increasingly complex disorders we need some form of the CTO. It is more helpful to move the debate from whether CTOs are good or bad to looking at the criteria for and operation of CTOs.”

Which is a good idea in countries where the orders are used but, until CTOs are on the statute books in England and Wales, arguments for and against them are likely to reach fever pitch – with many hoping that there’s still time to scupper them.

(1) Compulsory Community and Involuntary Out-patient Treatment for People with Severe Mental Disorders, The Cochrane Collaboration, 2005
(2) A Question of Numbers: The Potential Impact of Community-based Treatment Orders in England and Wales, King’s Fund, 2005
(3) Community Treatment Orders for People with Serious Mental Illness: A New Zealand Study, University of Otago, accepted for forthcoming publication in British Journal of Social Work

What service users think

Nasa Begum
“If community treatment orders formalise and provide a clear framework for treatment in the community then they may be of some value.
“At the moment, community teams can put pressure on service users to agree to so-called ‘voluntary treatment plans’ (often related to medication regimes) but there are no safeguards or rights to independent advice or advocacy.
“I have concerns that compulsory treatment within the confines of one’s home crosses a boundary – one’s home should be a private space of refuge. Being forced to accept treatment at home would be hard, particularly if you had to let professionals in or take medication you don’t want. If you have adverse side effects then
back-up support will not be as readily available as in hospital. Being on a locked ward can be very distressing but at least when you are on the road to recovery you can leave the difficult period behind you at the hospital. It is much harder to feel positive about your home if that is the place where you have been through a crisis.”

Moira Urquhart
“My main fear is that, by forcing people to co-operate, it could make their condition more unstable and increase the risk of them becoming aggressive.
“I feel that the government doesn’t care and is treating patients more as criminals than as people who are ill. The old system was better as there was more help in hospital. The contacts patients made often resulted in long-term friendships, and the hospitals had social activities and events, such as bingo teas and dances. This care in the community is making people lonely and isolated.”

What professionals think

British Association of Social Workers
The organisation says CTOs “may have a value but only in very precisely defined circumstances”.
But Roger Hargreaves, its lead on the mental health bill, says although he was originally positive about the orders he now has second thoughts. The association originally proposed the idea of CTOs – or community care orders as they were known then – in the late 1970s. But times have changed.
Hargreaves says: “Psychiatrists were reluctant to discharge and we saw community care orders as a way of getting people out of hospital who would otherwise be there for a very long time. It’s a different matter now when beds are in short supply.
“There’s a great danger of CTOs being misused to impose compulsion on people who really need to be in hospital but can’t because there isn’t a bed.”

Royal College of Psychiatrists
Tony Zigmond, vice-president, says: “They have a part to play so long as the conditions necessary for compulsion are correct and that, even when people meet the general conditions for compulsion, this is targeted at ‘revolving door’ patients.”
He says that in Australia and New Zealand the conditions for making someone subject to compulsion are narrower than in the draft mental health bill for England and Wales, and adds that he would welcome strict conditions for CTOs.
“The danger at the moment is that [our bill] is so pervasive. You could have anyone on them, which will swamp the system and drive people away from services,” he added.


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