Mental Health Standards for Involuntary Community Treatment Orders
In Australia there are currently over 600,000 people living with severe mental illnesses such as psychotic disorders and debilitating forms of anxiety and depression (Light, Kerridge, Robertson, Boyce, Carney, Rosen, Cleary, Hunt, O’Connor, & Christopher, 2015). Many of these individuals are incapable of or resistant to, taking prescribed medications, or participating in treatment (Rolfe, 2001).
Following deinstitutionalisation of psychiatric services, people who live with persistent and severe mental illness deemed of harm to themselves or others, are often required to receive treatment of mental health services in a community setting through a Community Treatment Order (CTO) in order to avoid involuntary hospitalisation (Light et al., 2015).
Although it can only be enacted when legislative criteria are met and there are no less restrictive options available, being treated without consent raises significant issues around individual choice and liberty (Campbell, 2010). Investigations into these processes has found considerable distress and harm caused from forced treatment with evidence suggesting CTOs in fact hinder recovery from ill mental health and in some even cases exacerbate it (Vrklevski, Eljiz, & Greenfield, 2017).
Despite contentious debates, around the value and efficacy of CTOs and their significant prevalence and alarming rate of increase, information about government policy principles and objectives in relation to CTOs is scarce with very little information made publically available. As such, it is believed by many to be a major area of concern (Light, Kerridge, Ryan, & Robertson, 2012).
This submission will consider the social problem of severe mental health and the impact of involuntary community treatment orders on people experiencing mental health issues, along with the consequences of these orders on society. Current legislation and policies will be presented and evaluated in regards to this restrictive practice, including the ideological frameworks upon which they are based. Potential changes to Mental Health policies and standards will be outlined for consideration and assessment in the next review scheduled for 2020 for their inclusion in the Mental Health Acts across all Australian jurisdictions.
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Considered the leading cause of disability and ill health world-wide (World Health Organisation, 2001), mental illness is considered one of Australia’s National health and social policy priority areas (Parliament of Australia, 2000).AIHW estimates 1 in 5, equating to approximately 3.2 million Australians, experience a mental disorder each year with severe mental illness impacting approximately 690,000. It is reported that less than half of those living with ill mental health seek treatment incurring significant individual suffering and social and economic costs (Department of Health, 2016). Along with risk of individual, negative economic and social problem outcomes including for example poverty, housing instability, homelessness and unemployment, those living with mental illness are also subjected to significant stigma and discrimination (Light et al. 2015). The social and economic costs have been shown to extend into society, costing the economy an estimated $60 billion per year in expenditure, personal cost and lost productivity (National Mental Health Commission, 2016).
In response to the impact of this on the country, political agendas and policy strategies that aim to prevent mental illness have been implemented with the intention of addressing these social and economic costs and achieving better mental health outcomes for Australians (Parham, 2007).
The differences in the mental health acts between the jurisdictions are significant, not only in the content but in the way in which the laws are processed, resulting in a substantial lack of coordination or consistency in the approach to Mental Health across the country (Barnett, 2012).
A National Mental Health Policy was adopted in 1992 by Commonwealth, state and territory Governments to encourage a consistent approach to the care, treatment and control of people living with mental illness. In 1996 National Standards for Mental Health Services were introduced to guide implementation and quality of mental health policy, service and practice (Mental Health Standing Committee, 2010). Australian Governments have since developed and regularly reform their respective Mental Health Acts and the legislations and policies in line with these to support the appropriate provision of services for those living with mental health issues these include involuntary treatment (Australian Law Reform Commission, 2014).
Involuntary and oppressive practices are believed to have begun in the early 1800s with the introduction of ‘insane’ asylums in Tasmania and NSW (Rosen, 2006). These practices were influenced by an underlying fear, still largely prevalent and influential in society and government policy today, that people with mental illness were dangerous, posed a risk to society and needed to be controlled Due however to political pressures to respond to facility scandals of abuse and neglect in asylums, the development of anti-psychotic medications, and the changing social attitudes on people’s rights, Australia entered a trend towards deinstitutionalisation from asylums to hospitals in the 1960s (Rosen, 2006). Following inquiries into social justice and human rights issues with mentally ill people living and dying hungry and un-medicated in the streets, a National Mental Health Policy was established. Subsequent strategies that followed aimed to shift and mainstream, mental health services away from psychiatric hospitals and into the community (Light et al. 2012). Critics however suggest that this is not representative of social progression as sold by governments, but rather a ‘long leash approach to the surveillance and control of non-compliant patients outside of hospital’ and are reflective of custodial frameworks of the past where the aberrant in society who posed a risk the wider community, where punished through detention and the deprivation of liberty (Rogers & Pilgram, 2014, p.166).
Significantly differing rates of and reasons for use between the jurisdictions, has exposed that there is a significant lack of government knowledge with regards to the needs and treatment of those living with mental health issues (Mental Health Standing Committee, 2010). Understandings and treatment of mental illnesses by health care providers, especially in the field of psychiatry, are often based on treatment ideologies that incorporate the often strict beliefs around the aetiology of mental illness and the effectiveness of varied interventions and treatments, including those against a person’s wishes (Scheid, 1994). Psychiatric ideologies lie at the core of involuntary treatment policy initiates and legislation within each state or territories’ Mental Health Acts, which allow psychiatrists and health care professionals to implement legislative powers to use CTOs (Power, 2008).
However as reported in the 1993 National Inquiry into Human Rights of the Mentally Ill, psychiatry lacks clarity about the cause of illness and its treatment due to being under conflicting and often contradictory influences of ideologies including social or environmental versus biological or genetic explanations (Australian Human Rights Commission, 1993). Despite this, governments have however allowed policy and legislation in the area of mental health to be led by experts in psychiatry. This has ultimately resulted in a prevailing but relatively well- hidden ideology of control through forced treatments that eliminates individual autonomy in personal decision making to those deemed to not be ‘sane’ enough to deserve that basic human right (Rosen, 2006).
Although there are arguments for forcing non-compliant patients to accept necessary medication or treatment considered to be in their best interest, the counter arguments are significant. These include: insufficient evidence of efficacy; patient relapses under CTOs; less adherence to treatment than when not on CTOs; no reduction on hospital admissions (as aimed and expected); increased demand on health services including time consuming bureaucratic CTO administrative systems that reduce patient-centred care; human rights and ethical violations from coercion; social control and the deprivation of patient’s freedom and liberty; and the stigmatising of people with acute mental health issues (Heun, Dave & Rowlands, 2016). Phenomenological studies into CTOs that probe and offer insight into the personal experience and perception found patients also experienced; excessive fear of inadvertently violating conditions; a belief that their speech and freedom was limited; disempowerment due to the coercive nature of treatment and an unwillingness to seek help for their mental illness; or ill health due to fear of the imposition of further control in their lives (Rogers & Pilgram, 2014). With important aspects of personal recovery such as their sense of hope and self-efficacy also negatively impacted, research show CTOs significantly interfere with a person’s mental rehabilitation. It is suggested that CTOs in fact exacerbate mental illness and further it’s social and economic impact on society (Power, 2008).
Community treatment orders were first introduced into the mental health system in Victoria in 1986 under the mental health act 1986 before being adopted by the rest of states and territories. Justification for their implementation lay in the rationale of ‘parens patriae’ and ‘police powers’ which empower the state the obligation to act in the best interest of those with compromised capacities to do so for themselves, and to restrict their freedom in order to protect and ensure social order (Rolfe, 2001).
Enforced under mental health legislation in Australia, enabling enforcement of those diagnosed with mental illness to comply, even against their wishes with treatment of their condition, CTOS can be implemented when less restrictive practices are deemed to not protect either the individual health and safety or other members of the public (Light et al., 2012).
The authorisation of compulsory treatment has been justified by policy makers as being a continuation of deinstitutionalisation through the provision of less restrictive services compared to that of inpatient psychiatric services (Brophy, 2018).
As well as aiming to provide an alternative to restrictive detention and contributing to freeing up resources within the health system, the logic is that CTOs will support people to achieve stability in their mental health through consistent treatment and therefore prevent repeated relapse know to leads to frequent readmission (Mental Health Review Tribunal, 2018). Forced treatment that is deemed necessary by health professionals is also championed as reducing the suffering or even death of those experiencing severe mental health conditions, and as a result can improve patient’s quality of life (Department of Health, 2016).
However, implementation of CTOs are recognised as challenging human rights frameworks and have instigated recommendations from the United Nations Committee on the Convention on the Rights of Persons with Disabilities to repeal legislation (Brophy, 2018). Calls for reforms to policy by human rights advocacy groups such as Justice Action are also not uncommon with CTO’s considered to be inefficient, ineffective and a challenge to privacy, autonomy, self-determination, human rights and social justice (Campbell, 2010). Although significant changes and been made to involuntary treatment of inpatients, CTOs have largely remained untouched, and the power to make CTOs has been retained by the Mental Health Acts enacted in all jurisdictions. Policy information around CTOs, principles and objectives are also hidden from information publically available. The seeming invisibility found within policies highlights issues with not only transparency but the accountability of mental health systems. It is also believed to contribute to entrenching further the discrimination and marginalisation of those living with mental illness and as such counter social justice and rights? (Vrklevski, Eljiz, & Greenfield, 2017).
In Australia there are over a million involuntary services recorded each year with 45% of these out in the community. With rates increasing in all jurisdictions, figures suggest that the system is failing in the early and/or effective intervention of mental distress (NSW Mental Health Commission, 2015). Advocacy, social Justice, human rights organisations will continue to advocate on this area of policy and support recommended policy changes in standards for CTO made by this submission.
Recommended policy changes
With mounting evidence of the failure of Community Treatment Orders in meeting objectives alongside the violation of rights and the negative impact they have on the mental health and recovery of patients subjected to them, the importance of policy revision is paramount.
Recommended policy changes for consideration:
1) Clarity regulation and compliance within the standards
In light of the lack of transparency in CTO policies and their implementation, the most basic recommendation is to clarify the terminology, expectations and use of CTOs as well as the inclusion and awareness of social justice principles so that the policy and legislation truly works to protect individual rights, advance empowerment, and provide all necessary resources for full access and participation to be achieved. Consistent and socially just CTO assessment, implementation and use can be developed across jurisdictions through appropriate obligation to adherence, monitoring and management of CTO standards and principles.
2) Inclusion of greater critical holistic consideration of the person
This strategy involves the critical holistic consideration of the person and their circumstances by specifically and appropriately trained professionals. This will support improved delineation of patients, separating those that will benefit from coercion from those that will relapse or be treatment resistant when coercion is enforced and would benefit more from alternative support services. Greater transparency of this process and appropriate standards should be shared across all jurisdictions to support greater consistency and bring down excessively high and or/unnecessary CTO use (Brophy, 2018).
3) Inclusion of less restrictive models
Further considerations need to be assessed with regards to the opportunities for, and potential benefits of, less restrictive models such as assertive community treatment and case management for those assessed to not benefit from CTO coercion. The involves the development of more collaborative approaches within a team of specifically trained CTO support services and health professionals, that work alongside patients in the ongoing, tailored management of their ill mental health (Heun, Dave & Rowlands, 2016).
4) Improvement of Mental Health Services
The use of involuntary treatment orders would be substantially reduced through the increase and improvement of mental health services that provide effective early access to to community based mental health services for individuals and families. These will be focused on recovery and not just management of symptoms as well as essential long term planning support services for care in the community (NSW Mental Health Commission,, 2015).
The development and use of streamlined, holistic care that promotes service delivery that is tailored, recovery-orientated and achieves consumer empowerment (Brophy, 2015) will embody social justice principles and objectives and ultimately support personal recovery from mental illness and therefore reduce demand on the health system.
Summary and Conclusion
This submission has presented the relevant history and influences surrounding the development and implementation of Community Treatment Orders in Australian mental health policies. These include These influences can explain the inclusion of restrictive involuntary practices similar to institutional treatments of the past, but not justify them when infringement on a human rights and social justice principles are considered (Light et al. 2012), Due to the removal of personal agency and self-determination, alongside the added stigma and discrimination, CTOs believed to in fact be a hindrance to recovery and well-being. Overall CTOs have been found to be ineffective in achieving the championed social or economic benefits aimed for in their implementation. As such recommendations presented within this submission would support the development of a system that is considerate of both rights and needs and as a result, drastically improve the treatment and outcomes from those with severe mental health issues.
1) Clarity within the standards
2) Inclusion of greater critical holistic consideration of the person
3) Inclusion of less restrictive models
4) Improvement of Mental Health Services
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