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Friday, 17 January 2014

Is it time to call time on Community Treatment Orders?

The Mental Health Act 2007:
Alternatives to hospital or
 curtailments of liberty?
Every so often I come across an article on Community Treatment Orders (CTOs). Usually the view expressed is critical and it always produces a stab of disquiet. More on the bad feelings in a second, but before that, it’s worth just establishing what we’re talking about. The norm that people with mental health problems can be given treatment against their will and detained in hospital is well established.  In the United Kingdom the Mental Health Act 2007 extended this principle by allowing people such compulsory treatment at home (i.e. without admission). The twinge of unease comes because I, in the face of a good deal of criticism from colleagues, thought this change was a good idea.

Let’s leave aside whether such compulsory powers are right or wrong. Feelings run high but there is no sense in which the abandonment of enforced treatment is on the table. Let’s also leave aside the idea of confining compulsory treatment to cases where people lack the capacity to consent. Unlike physical health (where any of us has a right to refuse treatment unless we lack capacity) the UK the Mental Health Act allows treatment on the basis of   mental illness While there are powerful arguments that this situation is unjust, these have struggled to gain traction.  Here I want to focus on the narrower question of whether, in a world were compulsion is established, CTOs have been helpful.

The rationale behind CTOs (introduced in 2008) was to facilitate compulsory treatment and to avoid the potentially distressing and dislocating effects of an admission to hospital.  At the time I was spending my working life in acute mental health wards and the downsides of being in hospital (forced or otherwise) were regularly right in front of me.  Because of this, the alternative of delivering treatment at home rather than in hospital struck me as, if not exactly good, then potentially better than the status quo. However, even after six years it’s clear that uncertainty persists as to whether CTOs are worth retaining.
Assessments of similar provisions across the world have been inconclusive. A range of methodologies have been employed and much of the work is either descriptive or involves comparing admissions before and after the introduction of CTOs. This was the kind of rationale used in a Guardian article arguing that an increase in compulsory admissions between 2008-09 and 2011-12 was proof enough of failure. It is of course, unclear just how many hospitalisations there would have been in 2011-12 without CTOs, so perhaps treating such figures as decisive is overdoing it. A third kind of evidence has been somewhat sparse: controlled trials. These are studies where people have been randomly allocated either to treatment involving CTOs or to treatment without them, At the time of the introduction of CTOs in the UK there were only two such studies (details here and here). Both of these suggested that allocation to CTO or non-CTO- based conditions had little observable effect on hospital admissions. The results were slightly ambiguous though as one of the studies did find that, for people subject to longer-term CTOs, there were fewer hospital admissions.

More recently, in this month’s Psychiatric Bulletin CTOs receive detailed consideration in five articles. This series of pieces features a contribution from researchers on The Oxford Community Treatment Order Trial (OCTET). This project is the largest controlled thus far involving 333 people. For detailed results see here and here . The short version of their findings is that the hope that I, and others, had of a reduction in hospital admissions with CTOs has not been borne out. Both admission rates and length of stay were essentially indistinguishable.

Is the case closed then? Well maybe not quite. In the face of the OCTET evidence, other contributors make three points. Firstly, it is argued that, while OCTET hasn’t shown a reduction in hospital admissions, there may be other indices by which CTOs might be considered helpful. Though you may hear the creak of moving goalposts, there is some merit in this. Readmissions may not necessarily be seen as a treatment failure, something I’ve argued myself in the past. There are cases where a move to hospital (say to try and forestall an intensifying crisis) might be helpful. Indices such as frequency of clinical contact and rates of preventable physical illness are areas where CTOs seem to produce positive effects. Secondly, one potential limitation of the OCTET trial, which lumps together a large and diverse group, is that it does not focus precisely enough on specific sub-groups who may benefit. For example those on CTOs for a protracted time period (as suggested in the study mentioned above). A third point (and one that is likely to raise hackles) is the proposal that the OCTET trial may partly be affected by the participation of clinicians who are lukewarm towards, or outright negative about CTOs. This may affect the appropriateness with which they have been used in the trial. In other words not a fair test. I suspect responses are on their way.

So where are we left? Critics say that OCTET and other controlled trials show that CTOs have failed to meet their intended purposes and should be given the boot. Those taking a more circumspect line argue that the very few controlled trials are insufficient to allow a final decision to be taken and that further work (and perhaps a wider range of outcome measures) is needed: especially to establish more precisely if particular groups benefit. One thing I’m struck by is that inconclusive evidence is seen as a reason to continue with CTOs rather than to abandon, or suspend, them. True, practice in healthcare ultimately must often make policy before the evidence is in. Otherwise innovations would never occur. Nonetheless, the evidence in favour of CTOs, though, has been far less convincing than I (and I suspect many others) expected.  Compulsory powers are not insignificant in their effect on people. Could it be time for a pause?


  1. Sorry, I know you're trying to treat CTOs as separate from basis for compulsion under the mental health act. I just can't separate them myself. The way in which we detain is wrong!

    I know though that you are trying to question CTOs and I do agree with you that it's time to stop. In that spirit it's also worth pointing out that the study in Psych Bulletin (the one that supports CTOs) is really (REALLY) weak compared to the methodology used in OCTET. It's a before and after piece which, as you said in the para above)is not a good test.

  2. 1. Lets start by referring to people as though they were adults, people who may or may not want to interfered with by MH health services. Referring to people as problems that something must be "done with" is a very bad start.

    2. Lets start with the largest group of people who are detained and forcibly treated. The vast majority of people in this position in hospital represent no threat to themselves or anyone else. That they do is largely a fiction. The overwhelming number of people who are detained in hospital are there because they are an inconvenience to someone else.

    3. Psychiatrists who continue to detain people do so on the flimsy and frankly ludicrous premise that they are able to divine the future. They can no more accurately predict future behavior of the people they detain than I can guess next weeks lottery numbers. The general public has a belief that psychiatrists have mystic meg like abilities and while psychiatrists know they don't they are happy to keep the deception going as its what they are paid to do.

    4. You have conveniently ignored the fact that involuntary commitment and forced treatment amount to torture. Their is no reason that stands up in law that allows torture.

    5. People should have the right to an intervention if they want it and the right to refuse, even if that means they might die. Cancer patients have the right to refuse treatment and die, its an outrage that mental health service users do not have the same right. The fact is that what many service users want is the right to turn down "treatments" that are harmful, they aren't even life saving.

    6. If fat people where rounded up by the police and forced to have gastric bands, replete of course with special barbaric surgery courts run and controlled by barbaric surgeons their would be riots in the street.

    7. Not having involuntary commitment and forced treatment is not the same as doing nothing. Services would just have to be put on the same legal footing as all other sorts of interventions.

    8. If voluntary commitment and forced treatment did disappear the fabric of society wouldn't rip. Time for society to right this wrong.


    1. Thanks for taking the time to comment. I'd just like to pick up on a few things above.

      Re point 1. I didn't actually refer to people as 'problems' or say that something should be done with either them or their difficulties.

      Re point 2. As it happens I agree with that. However the in the article I didn't take a position on this issue. The article was explicitly aimed at a narrower point (as set out in para 2).

      Re the remaining points there are plenty of elements I agree with (for example the point about the choice to end one's own life), but again, these are not what the article was about and I, very deliberately, did not take a position on them.

      There are, of course ,discussions to be had about the existence of compulsory powers and about the basis on which they are applied. For example in mental health the basis on which compulsory powers are applied is rather different to that in physical health. (The articles linked in para 2 discuss this in more detail and consider some of the points you make in detail).

      I did not address the wider rights and wrongs of compulsion because I think there is an particular conversation to be had at this stage about the specific extension of of compulsory powers in the UK that are represented by CTOs. I am not sure that as a society we are in a realistic position to contemplate the abandonment of compulsory powers. However, the settings to which such powers can be applied (home, hospital etc) or the basis on which they are employed (capacity or health) may be somewhat more tractable.

      We are planning to feature a piece on the basis of compulsory powers and the differences with physical health (where compulsion such compulsion is based on the absence of capacity rather than state of health). For now though I would really recommend the two links in para 2, on the words 'powerful arguments' and 'struggled' which go into these arguments in a great deal more depth. the second one is of particular interest to me as it describes a previous attempt to shift the basis of the UK Mental Health Act.

      John McGowan

  3. p.s. Involuntary commitment and forced treatment are very much on the table by the way..

    Statement by Mr. Juan E Méndez


    session of the Human Rights Council
    Agenda Item 3

    4 March 2013

  4. As someone who has experienced coercive psychiatry including sectioning, forced ECT and forced meds for a bipolar illness, I find it curious that the debate around CTO's never addresses their psychological impact. Whether or not the treatments I received were in my best interests medically, there is little doubt that they did a huge amount of harm, psychologically. Along with coercion, went assumptions that I was unable to make any sensible choices for myself. This may have been true in the acute stages of my distress, but certainly wasn't true once the crisis had been contained. I found it degrading, punishing and humiliating to be incarcerated, forcibly injected, given ECT and robbed of my right to make decisions for myself, even when there clearly came a point in the treatment proceedings when I was able to do so. The experiences were not only traumatising but created a lasting sense of shame which had implications for my self-esteem and contributed to self-stigma. Those subject to CTO's report similar feelings of degradation and humiliation. Surely, mental health care based on the principle that an individual has the right to make decisions about their treatment where capacity is intact, is surely the only way to go?


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