The efficacy of what are called Community Treatment Orders (CTOs) - The Agent comments

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15 May

I added this comment the other day to this, a report on the @Mental_Elf web-site (by Kathryn Walsh) called Community treatment orders fail to reduce psychiatric readmissions for people with psychosis :


One of the criteria for the trial is said to be ‘capacity to give consent’.

I wonder whether this is ‘a red herring’, if the seeming legal niceties of ‘putting someone’ (as it is often put) on a Community Treatment Order (CTO) are not actually observed.


From professional experience*, I believe that the legal opinion has been expressed that it is possible under Mental Health Act 1983 (as amended), and without a patient ‘applying for’ it, for him or her to be given section 17 leave to, say, a care home or a non-NHS specialist unit. (I am thinking of someone on s. 3.)

In theory, if hospital authorities needed to, ‘reasonable force’ could be used to oblige him or her to go. Forget how ‘untherapeutic’ that is, because the general regime of psychiatric units (e.g. locked wards, compulsion as to ‘treatment’ under the Act – usually an injection, and the dehumanizing environment and attitudes) can hardly be conceived of as therapeutic – or, when it is not that, it is cajoling, coercing, wheedling and blackmailing to seek (a form of) compliance.


Almost certainly, someone whose consideration for a CTO is ‘triggered’ by the Act (e.g. by application or referral to a First-Tier Tribunal, or at the time of contemplating s. 17 leave) will have been plenty depersonalized and demoralized by all of this already, before one even gets in sniffing distance of a formal meeting ‘to consider’ the Order.

Where the Principle of Least Restraint then (not least if no one cannot work out whether it is the CTO regime or that of s. 17, including the example that I gave above, that amounts to least restraint) ?


Patients who have already been brutalized by a place such as I describe (and will typically lack self-confidence and self-esteem), even if formally given the choice to consent to an Order [I understand that they aren't actually 'Orders', and the question of consent is more honoured 'in the breach', I gather], have no obvious reason to say No, when it means that they can go home.

(I believe that anyone would snatch at going home, whatever they are asked to agree to, because he or she (wrongly, I think, because not informed) assumes that it is that, or staying put.)

No reason obvious to the patients, then. If they were properly and independently advised as to (a) being able to say No, and (b) What, if they did say No, would be the Responsible Clinician’s (RC’s) options then, the position might be different :

If the RC cannot secure agreement from the patient to meet the conditions that are sought and / or the Approved Mental Health Professional (AMHP) won’t countermand the Order, there is still a position to fall back onto, i.e. s. 17 leave, or even discharge (since there no longer is supervised discharge).


But how many patients oppose a CTO ? How many think – more relevantly, are told – what happens, if they state openly that they will not comply with the conditions, rendering the notion of putting them on an Order ‘dead in the water’ ?

The RC has beds ‘to unblock’, considering a CTO is forced by certain events, but, if the patient is patently saying No, what will the RC do ?


So an Order is effectively dangled, and capacity to consent is really falsified : the patient is not allowed to weigh up whether to agree to the conditions for a CTO in compliance with the test under the Mental Capacity Act 2005 (as amended) simply because he or she is almost certainly not given the full information, which, if he or she had, could be understood and applied.

In truth, I think that the real scenario of a CTO coming about is having huge debts, but being marched down to a bank and told that you need a personal loan from that specific bank.


So not told any safeguards, e.g. that :

(a) the bank can advise only on its own products, and there may be other products

(b) even if the borrower won the Lotto that night and could pay back the loan, interest is charged up front;

(c) there are arrangement fees;

(d) the Bank of Mum and Dad is only too willing to help out, etc., etc.


Such a transaction, if challenged, wouldn’t stand up to the Financial Services Authority (FSA). For me, the way that CTOs are ‘secured’ is no better, but there is no adequate FSA, and patients affected are unlikely to have recourse to one, because they just ‘wanted to go home’.



End-notes

* There is a little more about that experience here in relation to mental health advocacy.


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