Notes on Community Treatment Orders by Andrew Hughes, December 11th 2003, from our conference Whose choice? What choice?

1 Will they reduce violence?

One of the reasons given for needing new powers is the alleged problem of violence by people with mental health problems. In general psychiatric patients are not a significant danger to the public. A review article in the British Journal of Psychiatry has shown that whilst overall there was a fivefold increase in homicide in the UK from 1957 to 1995 there was a decline of 3% per annum in the contribution to these figures by people with mental illness. Even in cases where homicide has tragically occurred failure to take medication has rarely been the most important issue. Independent research commissioned by Mind found that the importance of non-compliance with medication in homicides is overstated. The most common contributing factors were found to be poor risk management, communications problems, inadequate care planning and lack of inter agency working. Introducing CTOs rather than addressing these issues fails to tackle the root of the problem. The Government’s own National Inquiry into Homicides and Suicides also found that CTOs would have only a small effect on numbers of homicides. If they deter people from using services (see question 2), CTOs could in fact increase violence, by leaving those most likely to commit violent acts without support.

2 Will they help engage people in treatment and support?

Government and public concern is focussed particularly on people who do not wish to engage with services now – often because they have had bad experiences in the past. If users feel CTOs have made compulsion more likely they will be deterred from using services. In a survey carried out by the Manic Depression Fellowship in December 1998 almost 1 in 5 of respondents thought that CTOs would either make users too frightened of the consequences to contact services or discourage them from seeking help. This cuts people off from the very services which should provide help and support, thus making a deterioration of their condition more likely.

3 Will they increase compulsion?

There are occasions where compulsory intervention is necessary as a last resort. However, compulsion can be counterproductive, removing people’s self-determination and dignity, and possibly deterring them from future contact with services. The aim of legislation should therefore be to reduce the use of compulsory powers. There is a strong risk however that extending compulsion to the community setting will have the opposite effect.

4 Will they focus only on medication?

Medication is the easiest treatment to administer compulsorily. CTOs will be unable to deal with people who require services such as counselling which require voluntary participation. In some cases medication can be unhelpful. Where medication is helpful, it needs to be combined with access to a variety of services, support, adequate housing and employment. If CTOs focus only on medication they will be ineffective. Treatment needs to be defined to incorporate a wider range of therapeutic interventions.

5 Will they be enforceable?

If CTOs are intended to update mental health legislation in the light of increased treatment in the community, how will they achieve this? If a person refuses to accept the treatment detailed in their CTO, they will have to be taken to a clinical setting and detained there to allow forcible treatment. Will this be done by the police or by health professionals? Is it then appropriate to release someone immediately after they have been injected with a powerful drug against their will, when they may be in a distressed or disoriented state? If not, how is the CTO an improvement on the current situation?

6 Will they be applied disproportionately to black people?

In the aftermath of the Lawrence Inquiry, the Government made a commitment to tackle institutional racism in all public services. The current Mental Health Act has been used to oppress black people who are more likely to be in locked wards, more likely to be diagnosed with schizophrenia, receiving higher doses of medication and are less likely to receive talking treatments than their white counterparts. What safeguards will be put in place to ensure that all groups are treated equally?

7 Will they change the role of health professionals?

Implementing and enforcing CTOs will change the nature of the relationship between service users and health professionals from a therapeutic relationship to one based on coercion.

8 Will the interests of users be protected?

By their nature CTOs would be implemented at times when users are least able to express their own preferences. Any proposal that imposes new constraints on them should be matched by an enhancement of their rights to guard against abuse of CTOs. This should include the right to independent advocacy, and to make an “advance directive”, detailing how they want to be treated if they become ill. In addition, the views and experiences of individuals should be an important factor in deciding on treatment options. Treatment should aim to improve the quality of life for the individual concerned, not simply to remove symptoms. What procedures will exist to take account of the needs and wishes of the people who will be subject to CTOs? Will they be negotiated or imposed?

9 Will they be compatible with European Convention on Human Rights?

It seems likely that CTOs themselves would comply with the European Convention. However, if CTOs are to be enforced as described above, by forcible detention, the Convention would only allow this if at the time the person suffers from a mental disorder of a kind or degree warranting compulsory confinement. Any proposal to allow forcible detention of people who are not suffering from such mental disorder could conflict with the Convention.

10 Are there any alternatives?

There are plenty of alternatives which would help preserve self-determination, autonomy and dignity and be just as effective as CTOs. Many people have the experience of asking for treatment, not receiving it and subsequently having to be compulsorily detained. Providing attractive services, using assertive outreach to engage with people, and giving people the right to receive the treatment they need, when they need it would reduce the need for compulsory powers. The home treatment service in Birmingham, for example, has successfully reduced the need for compulsory treatment and increased compliance.

Parker, C and McCulloch, A (1999) ‘Key Issues from Homicide Inquiries’ Mind.

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