Community treatment orders: the ethical balancing act in community mental health

Abstract

Community treatment orders (CTOs) are legal mechanisms by which an individual with a mental illness and a history of non-compliance and potential for violence can be mandated (against their will) to undergo psychiatric treatment in an outpatient setting. Although CTOs are increasingly being adopted by governments as a means of protecting both mentally ill persons and society itself, their use continues to stimulate considerable debate. While there is some evidence of their potential benefits in promoting treatment compliance and reducing hospital stays, there is concern that they infringe on the mental health client's human rights and freedoms. Consideration of the ethical and practical implications of the use of CTOs must continue. In this paper, some of the most pressing issues are identified and discussed.

Spinning the revolving door: The governance of non-compliant psychiatric subjects on community treatment orders

“…The law not only promotes medication compliance in order to alleviate risk, it also creates the conditions under which the psychiatric subject can be managed with more intrusive interventions. In keeping with the critical scholarship that suggests that the use of CTOs makes the community no less restrictive than the hospital (Heffern and Austin, 1999;Munetz and Geller, 1993;Segal and Tauber, 2007;Snow and Austin, 2009), I argue that CTOs are de facto forced medication orders.…”

Community treatment orders: exploring the paradox of personalisation under compulsion

“…Arguably such an approach could be ethically justifiable depending on the presence of certain morally ‘relevant facts’ (Szmukler & Appelbaum , p. 240). Nevertheless, this form of paternalism stands at odds with a policy context emphasising personalisation (Snow & Austin ) and may be detrimental to developing trust within therapeutic relationships (Teasdale & Kent , Laugharne & Priebe , Palmieri & Stern ). We would therefore urge practitioners to be mindful of the inherent power issues associated with the holding and sharing of knowledge (Goodyear‐Smith & Buetow ).…”

“…CTO practice could be improved not only in relation to personalisation but also in terms of relational aspects of care. Snow and Austin (, p. 183) note how strong lines of communication with families are essential. Encouragingly, in contrast with findings by Ridley et al .…”

Beyond Balancing Competing Needs: Embedding Involuntary Treatment Within a Recovery Approach to Mental Health Social Work

“…At present, there are no readily available data on the number of people currently subject to such orders in Australia (Brophy & Healy, 2009), but it has been estimated that approximately 950 people are on CTOs at any given time in South Australia (personal communication, South Australian Attorney General's Department). There are rigorous debates about the ethical basis of involuntary community treatment (Brophy & Healy, 2009;Brophy & Ring, 2004), and social workers have been specifically critical of the potentially coercive nature of CTOs, pointing out how treatment compliance and public protection may be emphasised over therapeutic interventions focused on safeguarding client rights (Brophy & Healy, 2009;Brophy & Ring, 2004;Snow & Austin, 2009). More specifically, coercion is often considered inherently detrimental to recovery because of the perception that it undermines individual rights to autonomy and choice (Snow & Austin, 2009), as well as having the potential to negatively affect the working relationship between social workers and clients (Stanhope & Solomon, 2008).…”

“…There are rigorous debates about the ethical basis of involuntary community treatment (Brophy & Healy, 2009;Brophy & Ring, 2004), and social workers have been specifically critical of the potentially coercive nature of CTOs, pointing out how treatment compliance and public protection may be emphasised over therapeutic interventions focused on safeguarding client rights (Brophy & Healy, 2009;Brophy & Ring, 2004;Snow & Austin, 2009). More specifically, coercion is often considered inherently detrimental to recovery because of the perception that it undermines individual rights to autonomy and choice (Snow & Austin, 2009), as well as having the potential to negatively affect the working relationship between social workers and clients (Stanhope & Solomon, 2008). Many within the consumer-led recovery movement are even more explicit in their opposition to involuntary treatment and detention: for example, O'Hagan (2012) argues that it is discriminatory and a human rights violation, representing the single largest barrier to recovery.…”