In a report published yesterday the use of Community Treatment Orders (CTOs) was scrutinised for the first time by the Care Quality Commission (CQC), the regulatory body charged with (among other things) overseeing the implementation of the Mental Health Act. CTOs were introduced in November 2008 as a means of addressing the problem of so-called ‘revolving door’ patients: those who were detained for treatment for a mental disorder, then released back into the community, often with little support or after-care, and inevitably ended up back in the system. Such patients often refused to co-operate with community mental health teams and would not take their prescribed medication, which outside of hospital could not be enforced.
“Patients who are detained in hospital for treatment…can be discharged into the community if they still require treatment for mental disorder on the grounds of their own health or safety or for the protection of others, but it is agreed that such treatment can be given outside hospital” (CQC report p.96 available here)
The creation of CTOs was intended to ensure that these patients could be compulsorily treated (a phrase that for the most part means: being compelled to take their medication) in the community rather than having to be detained for a long time in hospital. This extension of compulsory powers beyond the confines of the hospital marked a significant shift in mental health policy and care. The government argued this was a sensible strategy not least because it would free up beds in acute psychiatric wards: patients could be quickly released under the terms of a CTO and only recalled if they did not comply with their treatment plan. This was branded as a way of empowering and freeing individuals who would otherwise be confined to a hospital. (A Foucauldian-minded commentator might consider that the introduction of CTOs hammered the final nail in the coffin of the asylum. However, I would argue that they merely shifted surveillance, monitoring and control to the community rather than the hospital. But that is perhaps another discussion).
CTOs were met with fierce resistance at the time the Mental Health Act (2007) was being debated, particularly by lobbying groups such as the Mental Health Alliance who were extremely concerned that the broad criteria for these exceptional powers would result in large numbers of mental health patients being subjected to excessive coercive controls. It was clear at the time that the government’s agenda was being driven by a concern about risk rather than the health and welfare of the individuals such powers would affect. Nonetheless, strong assurances were given that CTOs would be restricted in their use and applied only to ‘revolving door’ patients for whom no other treatment options seem viable.
It is therefore particularly damning that the CQCs report reveals that in implementing CTOs, their frequency of use far exceeds what was previously anticipated: “… given that CTOs are meant to help ‘revolving door’ patients who would otherwise disengage with services, 30% of the patients in our sample did not have a reported history of non-compliance or disengagement. This suggests that the high use of CTOs – much greater than government estimates at the time the law was passed – could be a result of the powers being applied preventatively beyond the group of patients for whom they were primarily designed.” (CQC report p.99)
I can understand why CTOs might be necessary for some patients who repeatedly relapse and continue to suffer, who would otherwise effectively be institutionalized for life. They might provide a safe halfway house enabling patients to reintegrate back into the wider world whilst maintaining strong links with their mental health team and access to support (I know I’m being idealistic here but it’s an argument ‘in principle’). However, it appears that CTOs are being used with alarming regularity for patients for whom there is no reason to impose any controls or constraints once they are discharged. Having not previously failed to “comply” (in scare quotes because it is an odious term) there is no justification for placing patients under such orders other than the perception that they pose a risk, either to themselves or others, and cannot be trusted to manage their own treatment without being monitored and controlled with the threat of detention. In what world does that enable people to attempt to take control of their own lives, to begin the delicate and tentative process of recovery, and to feel as though they have some say in what happens to them? If anything, this overuse of CTOs is disempowering and disenfranchising: hardly the best route to building much-needed trust between patients and mental health services and enabling people to manage their own lives.