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*.
> Click here to view the transcript
How do you understand the differences with the Community Treatment Order, post-mental health changes?
There’s not as many people on them. There’s that, I think, is it three months? I know the time spent between having a tribunal or the hearing has been shortened. I think it could be 12 months in the community. I think it’s down to three, could be six, months, but I mean, the hospital … it has to be within six weeks I think, that there has to be a hearing, for them to remain involuntary. So they’ve tightened up, and the decision to put them on an assessment order is made by the psychiatrist.
But the decision to keep them on a treatment order is made by the tribunal. That’s a change. Because they would only hear to … for them to remain on it. The treatment, the assessment orders only last a certain amount of time. And then they either have to discharge them to be voluntary or they have to have – the tribunal will state whether they’re on an order for whatever length of time, it could be two weeks, six weeks, one year, three months, two … whatever they decide. And then they have to have another hearing or it lapses.
Note: This website does not endorse this account of the procedure for the use of CTOs, which was this carer’s understanding of the procedure at the time of the interview. Following the introduction of the Victorian Mental Health Act 2014, the Tribunal hearing must be heard within 28 days of a Temporary Treatment Order being made by a psychiatrist. Under s 57, the Tribunal can then make an Inpatient Treatment Order for up to 26 weeks or a CTO of up to 52 weeks. It is the Tribunal that makes a Treatment Order rather than keeping a person on a Temporary Treatment Order, which is the correct term for what is referred to above as an ‘assessment order’.
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.
> Click here to view the transcript
Oh, well naturally I would prefer it to be his own choice and actually do it, you know, because he sees that he needs it. But if he doesn’t choose to do it I would, yeah, think that that would be not as good an option but it still would be necessary for him to function. I think he would need it to function reasonably well instead of these, you know, sailing along and then just falling in because each time he has an episode, I’m sure it’s worse for his brain. So I think overall for his better health.
We certainly don’t want him to be drugged up and one of the reasons he didn’t want to take the medication at times is because he said it made him feel dopey and sort of just not with it. But I mean, and certainly I don’t want him to feel like that and I certainly don’t want him to be doped up. But it just seems to be the only option for him to function reasonably, at a reasonable level.
That is, his medication?
Yes, yeah. So, if that was, if he didn’t agree to it, you know, I would probably, yeah, would agree that he would need one of those orders, yeah.
Can you tell when he’s on medication and when he’s not?
Oh absolutely, yes.
What are the differences?
Just the way he talks, like when he’s on medication he’s just talking normally, you know, rings up and, and oh we just have a talk. It might be an issue he wants to invest some money [in], or he’ll talk to my husband about that and, you know, he gives him a bit, or he wants to take out something and buy something. So he always asks for advice and he usually takes it and it doesn’t matter if he doesn’t, but at least he asks.
If he’s not on medication you get really abusive texts, like nonsensical type of texts, not emails, an actual phone call or he’s ringing, I think it’s him or saying something strange on the phone and putting the phone down. So oh, yes, I can tell immediately when he’s off it and he’s obviously been off it for a while now.
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’.
> Click here to view the transcript
I wondered, has your son been on a CTO?
Lots of times, he’s been on everything, yes lots of Community Treatment Orders yes, and he does stick by them when he’s on them. Which is good, because you know that he’s going to take his medication, and you’re going to have a bit of relief for a while. So, but then they don’t last forever, and then he goes off them, so.
So CTOs from your perspective have been?
Good, I like them.
And has he been often in involuntary …
Yes, he’s been [an] involuntary patient a few times as well.
What’s your perspective on that?
Oh well you need to be [an] involuntary patient sometimes because he’s been quite aggressive and very unwell. And I hadn’t actually seen him really aggressive until I went to visit him, at one stage. I think it might have been at [city], oh might have been [city], I’m not sure which. And he was in the locked part, when I went in to see him and, oh boy, I’d never seen him like that, and I couldn’t stay there, he was just too, too aggressive. And, yes, you couldn’t have them in the open part when they’re they’re like that. So they do need that bit.
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.
> Click here to view the transcript
I really don’t like it when clinicians talk about non-compliance. Because it feels very much like they’re affixing blame. So if a consumer stops taking their medication, or forgets to take it, or has patchy adherence, or whatever, they label that as non-compliance. And it feels like, should there be any ramifications from that happening, it just gets put into this blame box, rather than perhaps teasing out why that’s been happening in the first place.
Like, are they not comfortable with the medication? Are the side effects really bad? Have they not, has it not been explained to them properly? Whatever it may be. But it just feels like a pretty inappropriate and dismissive way to talk about drugs that are really quite debilitating sometimes. I think I’m lucky, because my brother has been ‘compliant’ for most of his condition.
But that period I spoke about earlier, in 2010, when he’d been well for 15, and well-managed for 15 years and wanted to try going off his medication. And, okay, he didn’t do that the ‘right’ way, in that he didn’t consult with a psychiatrist, or taper down, or anything like that. He had a few months off them where he was well and then an episode was triggered, by what, I’m not entirely sure.
But that was the first thing that they kind of latched onto, this issue of non-compliance. And I just think, you know, that’s not really fair. Like, I think if I had been taking something for 15 years and I was feeling really well and didn’t like the way that those drugs made me feel, I can’t say that, you know, I wouldn’t want to experiment with life without them. Anyway, I just think it’s not, talking about non-compliance isn’t necessarily helpful in a clinical setting. I think it just makes the consumer feel like crap in a situation where they probably already are feeling like crap. So I think if there is a new way to talk about that, it’s worth exploring.
I think also it leads to patients being either threatened or at least having the suggestion made that perhaps they need to go on a Community Treatment Order, if it’s in the context of an involuntary admission. Again, I just don’t see the dots as easily connected as some clinicians seem to. Like, I don’t think that non-compliance should necessarily equate to, “You need to go on a Community Treatment Order”. I think, you know, there are so many factors that go into an episode and, you know, people are just a lot more complex than drawing a straight line between those two things.
So in my brother’s case, when he’s had, you know, 15 years of good compliance, became unwell and then it was suggested that he go on a Community Treatment Order. We had to fight really hard for that to not happen, rather than them kind of trusting my knowledge of my brother and my brother’s word that he will stay on the medication. So I think again, you know, clinicians and clinical staff just fall into the trap of, “I’ve seen this before, we better do this”. Rather than taking each situation on its, you know, uniqueness.
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.
> Click here to view the transcript
I remember my son was discharged early [last year] from the CTO in February. Before he was discharged from the CTO, I contacted the case manager and I said to him, “Please before discharging my son from the CTO, could you please prepare him? Talk to the psychiatrist. He needs support. He needs to acknowledge that he’s got mental health issue. He needs to acknowledge that he’s got addiction issue as well. And my son, he’s into this cycle where new friends, new drugs and soon he’s going to be in trouble with the police”.
I said to him, “If you go back to his file, you will see the cycle I’m talking about. He’s neglecting his hygiene, he’s smiling and laughing to himself, he’s doing more drugs, not sleeping and [has] new friends”. “Yes, I know what you’re talking about. I will talk to the psychiatrist and we’ll get back to you”. I said, “Please arrange for a family meeting before the discharge”. “I will get back to you”.
The minute my son showed up for his meeting, they wanted to discharge him from the CTO. The minute he showed up, it was only the case manager and the treating psychiatrist, which is the one who’s still there, his psychiatrist. Fifteen minutes later my son ran to the car and he said, “Wow, I’m off the hook. They discharged me from the CTO”. And I felt like, it’s like you hit me with a cold, with ice bucket. I said, “Oh that’s good. I’m so proud. I know you’re doing very well”. He said, “You’re laughing at me”. I said, “No no no, I’m not laughing at you. You’re doing very well. Yeah, you don’t need to be on a CTO”.
On the way home at the lights here, he opened the door. The light was red while I was approaching the light. I saw that. He said, “I want to go and celebrate”. I said, “Don’t open the car, don’t open the door”. He said, “Stop stop”. I said, “I can’t stop. The light is turning green. It’s orange turning green. There’s cars behind me, cars in front of me. It’s a busy road”. He didn’t care. He opened the door, I braked, he jumped from the car. He crossed the road without looking and went to his friend to celebrate.
In February [he was discharged] and in June he relapsed, [which is] when we called the police. He had the knife and he walked off [out of] the house. He wanted to kill the treating team. He wanted to kill the police. He was admitted. About 40 police squads surrounded the area where he was. [They had to] drive him to the hospital because he stopped the medication and they didn’t listen to me. When he was relapsing if the case manager [had taken] me seriously, he would’ve seen that yes, this woman is right. That’s a cycle.
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’.
> Click here to view the transcript
We’ve given people too many rights and responsibilities and a person who’s sick, as sick as what [son] gets and as sick as many other people get … I’ve seen lots of really, really sick people in my years of visiting [son], you know, in these places that he ends up in the public system. Not the private system, the public system. And they, unless they’re on a CTO, they still are but not as much, they’re given total control over their treatment, and, you know, maybe five times out of 10 or half the time they’re not well enough to be able to say what treatment they want or what treatment they’ll agree to.
And it’s hard to get a person on a CTO now. It’s harder than it ever was before. I think instead of practitioners and providers listening to the client and making their decision based on just what they say, they need to take everybody that, everybody who’s involved in their care, into consideration. Mind you, sorry, if you can get somebody on to a CTO when they need to be on to a CTO, I think CTOs need to be more flexible.
A CTO at the moment seems to be in place for an extended period of time, where I think they shouldn’t be so frightened about placing people on a CTO for a short period of time. It would be like crisis intervention. A person’s put on a CTO because there’s a crisis. At the end of the crisis when everything’s under control they’re discharged from the CTO. Does that make sense? They don’t do that at the moment. So I think they need to think more short-term rather than long-term. Crisis care, crisis management.
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.
> Click here to view the transcript
I’ve got a feeling that it’s meant to be easier for carers to have access to the information, for them to have an opportunity to attend the hearing. I haven’t seen that fully because there’s a, you know, they’ve had to train a lot of tribunal members as well, because it’s huge, the changes that are made. I, look to be quite honest I don’t think, just a knowledge of the different orders that are, you know, the assessment and treatment and you know, when they can be voluntary and when they’re not, and the terminology sometimes helps. I think staff and clinicians need to talk in a way that carers understand, but you know, as a carer it’s good to learn some of the terminology so that, you know, you have more understanding of the system, I suppose.
That might be part of an education for carers and we were talking about another part of that [education for carers].
Yeah, definitely. Yeah and because there’s things change. It’s in continual change. Things are changing all the time.
