Community Treatment Orders: Can coercive measures ever have a positive impact?
By Dr Nuwan Dissanayaka
On a daily basis we face a barrage of alarming headlines about crises in our mental health services. There is a rising clamour for desperately needed funding. However, many also hold out hope that these ills will be remedied by truly restorative reform of the Mental Health Act, the main piece of legislation we use to treat patients detained “on sections” in hospital and also those subject to the heavily criticised Community Treatment Orders.
The Community Treatment Order (CTO) is possibly the most controversial “section” within the Mental Health Act. Introduced in November 2008, it was designed to maintain the treatment of those community patients who don’t take the medication professionals feel they need to remain well, who disengage from services and who, as a consequence, are repeatedly hospitalised against their will. CTOs do not permit enforced treatment in the community but instead confer the authority to recall the patient to hospital.
There is no escaping the fact that they are, at their heart, a deeply coercive measure. Some argue that they were introduced due to failures in community care. Additionally, the public perception of the grave risks that can be associated with untreated psychosis and a number of high profile inquiries, most notably the Ritchie Inquiry into the Care and Treatment of Christopher Clunis, were undoubtedly influential in their introduction.
There is no escaping the fact that CTOs are, at their heart, a deeply coercive measure.
But have CTOs worked? Many would say not. Dubbed “Psychiatric Asbos” by their critics, the term evokes a sense of punishment rather than protection, of custody instead of care. A more elegant, yet equally merciless metaphor is that of a lobster pot - an inescapable prison, entered into innocently by the hapless victim, little knowing that they have no hope of release.
But are these characterisations fair? Maybe so, for some. Perhaps CTOs have been used too liberally, an unjustified knee-jerk reaction to scaremongering about dangerous patients with psychosis or as a long-leash substitute for proper care. And we know that when used randomly, they do not seem to be effective.
Dubbed “Psychiatric Asbos” by their critics, the term evokes a sense of punishment rather than protection, of custody instead of care.
Maybe however there is another side to this? I work as a consultant psychiatrist in an Assertive Outreach Team. Sadly, a dwindling service model in these austere times, we exist to support those with severe mental illness who suffer with psychotic symptoms. We see those patients who, at least when we first meet them, often do not think they have any illness at all. As a consequence they see no place in their lives for treatment or contact with services.
How can this be? Imagine that you hear voices, day and night, as clear as yours or mine; hurling abhorrent insults and inciting brutal acts of harm. There are no secrets from your psychosis. So, your most intimate fears become a reality. Imagine living with relentless perceived threats of torture, or worse, at the hands of your loved ones or imagined assailants wherever you go. But the most important thing is that for you, all of this is completely real.
Of course the doctors, nurses and social workers try to convince you that it isn’t really happening but aren’t they part of the conspiracy too? Why trust them? All they’ve ever done is lock you up. Why accept the poison they pretend to be medicine? And even if it does not kill you, it has crippling side effects which slow you down and make you all the more vulnerable.
Imagine living with relentless perceived threats of torture, or worse, at the hands of your loved ones or imagined assailants wherever you go
This is by no means everyone’s experience of psychosis, but to our team it is a very familiar story. The most frequently-quoted research evidencing the apparent ineffectiveness of CTOs did not fully capture this population. It excluded those too ill to consent to taking part and also those who refused. Some would say that this group is the very population that CTOs were intended for.
Our experience is that for most within this group, the use of a CTO has allowed us to maintain contact with them, to gain their trust over time and to collaboratively find compromises around treatment. The framework has certainly reduced the time they have spent in hospital and the risks they pose to themselves and others, which usually arise very directly from their psychosis.
There is much stigma relating to the erroneous perception of violence risk from those with mental illness. However, whilst it is true that this is a very damaging stereotype, in my particular field of Assertive Outreach we see people who have multiple and complex needs which may well include a risk of violence when unwell. I do not think of them as dangerous people, though: their violence arises from fear, which in turn arises from illness.
For most within this group, the use of a CTO has allowed us to maintain contact with them, to gain their trust over time and to collaboratively find compromises around treatment
So, as their doctor, do I have a duty to treat them to prevent this harm when very clear patterns of risk associated with relapse are present? To slightly misquote a famous case this becomes a matter of “striking a fair balance between the competing interests emanating on the one hand from society’s responsibility to the individual, and on the other hand from that individual’s inalienable right to self-determination which includes his or her 'right to be ill'”.
As a psychiatrist I am always mindful of the power imbalance between professionals and patients which reaches its uncomfortable peak when we use the Mental Health Act. This certainly holds true of CTOs, and is why they should not be used unless all other options have been exhausted. I practice this and teach it to the next generation of psychiatrists who attend the Section 12 training I deliver.
But if it is true that the Mental Health Act is a last resort, then how can we possibly rely upon a randomised trial of detained patients with psychosis for evidence? Most of the studies arguing against CTOs I have seen include a small caveat in their conclusion. Perhaps there is a group of patients for whom the use of a Community Treatment Order is appropriate? A group so unwell that they may sometimes lack capacity to recognise their need for support and treatment, and for whom this framework represents the least restrictive option to help them reclaim their lives.
I am always mindful of the power imbalance between professionals and patients which reaches its uncomfortable peak when we use the Mental Health Act
I agree with much of the criticism levelled at CTOs. They are an ethical minefield and an administrative nightmare. They are poorly understood and therefore often poorly applied. I understand the argument for their abolition, but if this is done without due caution on the basis of the current research, then this will be to the detriment of a small but hugely important group of patients. The review of CTOs must therefore be properly informed by patients who have been subject to them on the basis of appropriate clinical need, their outcomes, the views of their loved ones and of those professionals who have the most extensive experience of using them. Because as unpopular as this view may be, if used appropriately, for some patients Community Treatment Orders can be truly transformative.
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