Carers and Community Treatment Orders

Victoria’s Mental Health Act 2014 (the Act) regulates the use of Community Treatment Orders (CTOs) and the duration of these orders. A psychiatrist may make a temporary treatment order for up to 28 days (sections 45 through to 51). Within that 28 day period, an independent Mental Health Tribunal (MHT) can hear an application from the psychiatrist for the Tribunal to make an Inpatient Treatment Order for a period of up to six months or a Community Treatment Order for a period of up to 12 months (sections 52 through to 57). Under the former Mental Health Act 1986, treatment orders were made by psychiatrists and reviewed by the (now defunct) Mental Health Review Board (MHRB) within eight weeks of their being made. The Act has also introduced new provisions such as Advance Statements (section 20) and Nominated Persons (section 24) in order to facilitate more choice in treatment decisions for those subject to compulsory treatment orders. These changes are in line with the Act’s underlying principles that those receiving compulsory treatment should be ‘provided assessment and treatment in the least restrictive way possible with voluntary assessment and treatment preferred’ (section 11(1)(a)) and ‘should be allowed to make decisions about their assessment, treatment and recovery that involve a degree of risk’ (section 11(1)(d)).

Although CTOs are used throughout the world (including the United States, some Canadian provinces, New Zealand, Israel and England, Scotland and Wales), CTO use in Australia is high by international standards. There have been concerns about the particularly high rate of CTO use in Victoria, especially in the context of insufficient evidence about the effectiveness of CTOs and because arguably they do not conform with human rights obligations under the United Nations Convention on the Rights of Persons with Disabilities.

This Talking Point is about carers’ experiences of being able or unable to support the person being cared for to participate in or make decisions about their treatment and life while he or she was on a CTO. (See also Community Treatment Orders on our companion website on the experiences of people with severe mental health problems of CTOs.)

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Carers’ views on benefits of Community Treatment Orders
Carers’ concerns about processes around CTOs pre-Victorian Mental Health Act 2014
Carers’ views on changes to CTO legislation post-Victorian Mental Health Act 2014

Elena, a carer consultant, discussed her understanding of the changes to the use of CTOs introduced by the Victorian Mental Health Act 2014*.

Community Treatment Orders (CTOs) provide a legal framework that require a person to comply with treatment, usually medication in the community, as an alternative to treatment in the more restrictive environment of an inpatient unit. Available in Victoria for over twenty years, the criteria for imposing a CTO typically include the presence of a diagnosis of ‘mental illness’, an assessment that treatment is needed, and a judgement that there is a risk of harm to self or others. Before 2014, the Mental Health Review Board had the responsibility to continue or discharge a person from a CTO. Since 2014, a psychiatrist can make a Temporary Treatment Order for up to 28 days, but the MHT (which has replaced the MHRB) has responsibility for making Treatment Orders which may either be Inpatient Treatment Orders (where the person stays in hospital) or Community Treatment Orders after an application is made by a mental health service. The Tribunal also hears appeals from patients about their compulsory status.

Carers’ views on benefits of Community Treatment Orders

Some carers interviewed described times when having the person being cared for on a CTO brought emotional ‘relief’, as Dianne put it. This could be a result of knowing the person cared for would receive medication, or emotional release from worrying about the person cared for relapsing because he or she had stopped taking their medication. For Ballagh this meant that when her son was on a CTO, she experienced a feeling of ‘respite’.

Sasha said if her son did not ‘agree’ to take his medication then she thought he probably ‘would need’ to be put on a Community Treatment Order.

In the past, when Dianne’s son had been on CTOs, she said he had ‘stuck’ to them. This provided her and her husband with ‘a bit of relief’.

Carers’ concerns about processes around CTOs pre-Victorian Mental Health Act 2014

One carer, Alex, said the process around CTO hearings under the MHRB had been ‘flawed’ because it ‘cut carers out’. He thought there ought to be a process whereby carers were ‘automatically invited’ to attend hearings. Some described how they had been unable to support decision making around the person cared for’s treatment when the person being cared for was taken off a CTO because they did not receive support from the treating team to prevent the person cared for from becoming ‘unwell’ and needing to go back into hospital. A few carers expressed concern about the impact on the person cared for’s wellbeing and recovery prospects of experiencing a relapse following being taken off CTOs: ‘each time he has an episode, I’m sure it’s worse for his brain’, said Sasha. Alexia described how her son’s ‘cycle’ of ‘hitting rock bottom’ had affected her own quality of life: ‘every time he relapses I lose a bit of my son mentally. He’s not the same anymore. So it’s just the fear: what’s going to happen to him when I die? Now I’m still alive I’m trying to fight and work collaboratively with the treating team. I’ve been ignored. When he doesn’t have anyone around, what’s going to happen?’

Other carers talked about times when they thought mental health practitioners had used CTOs to achieve aims that carers thought were non-therapeutic and which had decreased carers’ capacity to participate in supporting treatment decisions for the person being cared for. Based on her experience of caring for her brother, Lisa said she felt that CTOs had sometimes been used as a means of ‘punishing’ the person experiencing severe mental health problems. Some other carers talked about CTOs being used as a long-term alternative to a structured treatment plan. Alexia described how in the past ten years her son had been placed on eight CTOs, which she said she did not regard as ‘proper’ treatment: ‘It’s just keeping him hanging from relapsing. Until he gets discharged from the CTO he’ll stop the medication then he’ll relapse’.

After Lisa’s brother had a relapse after he tried ‘going off’ his medication unsupervised, practitioners suggested he needed to go on a CTO.

When Alexia’s son told her he had been discharged from his CTO without a plan in place for therapeutic support, she said it hit her like a ‘bucket’ of ‘ice’ cold water.

A few carers talked about how the person being cared for had received medical treatment in a compulsory context that they felt had undermined the person cared for’s confidence to make decisions about his or her medication. George described how his son was once treated during a ‘crisis’ episode in a centre that was like a ‘prison’ where he had ‘had no freedom’, which had a ‘traumatic effect’ on him. His son became ‘fearful’ of being treated there again should another crisis eventuate, which George said he thought was a main factor in his son’s reluctance to get his medication reassessed. For George’s son, the threat of again being made subject to compulsory treatment acted as a significant deterrent to his willingness to make the kind of decisions about medication involving a degree of risk.

Carers’ views on changes to CTO legislation post-Victorian Mental Health Act 2014

Some carers, including Ballagh and Marta, were concerned about some of the changes the new mental health legislation had brought in. They worried that an unintended outcome of the underlying principle for people diagnosed with ‘mental illness’ to make decisions that could involve a ‘degree of risk’, could be the reduction of the capacity of carers to support the person being cared for to take his or her medication when he or she came home from hospital. As Marta said, ‘There is less we can do as carers because even my daughter said to me, “Oh my case worker told me I have the right, if I don’t want to take my medication, that’s all right”‘.

By contrast, Ebony agreed with the principle that people diagnosed with ‘mental illness’ should be able to make decisions involving ‘risk’: ‘I guess life is a risky business and so people need to be able to take their own calculated risks’. However, she felt she and other carers lacked the support they needed to be able to assist the person being cared for to make the kind of decisions involving ‘risk’ which the Act sought to promote: ‘I don’t really have anyone that I can go to that I know of that I can access that can help me help him through this period’.

Ballagh said she thought CTOs should be used as a ‘short-term’ form of ‘crisis intervention’.

Elena described the changes that had been made with the establishment of the new Mental Health Tribunal as ‘huge’. She was optimistic that it would be easier for carers to access information and attend CTO hearings.