Community Treatment Orders

Community treatment orders (CTOs) were introduced in Victoria under the Mental Health Act 1986 and remain an option under the Mental Health Act 2014. Compulsory treatment in the community is enabled by mental health acts in other Australian states and territories. Having a CTO means that clinicians can provide treatment without consent for individuals with severe mental health problems who are living ‘in the community’. If a person on a CTO does not follow the treatment then he or she can be forcibly sent to an inpatient unit. 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.

Of the people we spoke to, only seven had experienced being placed on a CTO. Several expressed concerns that being on a CTO, especially for long periods of time, could interfere with recovery because of the negative impact on people’s sense of hope and self-efficacy, both of which have been identified as core aspects of personal recovery. While there were aspects of being on a CTO that people found very upsetting, and most people who had experienced being on a CTO felt that it was wrong to be ‘forced’ to have treatment, it was also recognised that some people could be very unwell and that a CTO could be helpful to them for a period of time.

People described being put on a CTO when they refused to comply with medication prescribed by a doctor. Some people talked about not wanting to take their medication because they didn’t think they needed it, or felt it wasn’t making a difference. Others refused medication because of its actual or perceived side effects (see Medication: Choice and non-compliance and Medication: Effectiveness and side effects).

Cindy had a CTO ‘slapped’ on her when she refused her ‘horrible’ medication.

Luana felt her psychiatrist justified having her on a CTO because she had been angry about the upsetting side effects of her medication and wanted to reduce the dose.

Some participants said they thought they had been placed on a CTO as a way of being punished for being non-compliant with medication. Michelle described taking ‘control’ over her medication by spitting it out or breaking her tablets in half, but said when her psychiatrist ‘cottoned on’ to this, he put her on a CTO.

Being ‘forced to take medication’ was upsetting for people. Jenny, a support worker in the mental health sector, said being forced to have treatment could negatively impact on a person’s ‘sense of who they are’ and could be ‘very bad’ for them. Susana described being given a letter saying she was being put on a CTO by her Crisis Assessment and Treatment (CAT) team after she left hospital but said the meaning of it ‘wasn’t really explained’ to her. She recalled the letter stating that she was a ‘threat to the community’, which Susana said made her feel ‘like a criminal’.

For those who had been in hospital, a CTO could be seen as a way for clinicians to extend their control over the person as they went back into the community. Some people saw it as an extension of their hospital treatment. Simon said, ‘I was involuntary [in hospital]… well, they extended it into a CTO when I left’. The threat of a CTO was also perceived by some people as a way for medical practitioners to exert pressure on them to comply with treatments while in hospital. Chris hadn’t been on a CTO but when he was in hospital, he said his case manager told him, ‘if [you] don’t take [your] medication and follow the plan as prescribed to the most finest detail, [I’m] going to put [you] on a CTO… make [your] life miserable’. Gurvinder agreed to a CTO after he left hospital and said, ‘after you’ve been in the psych ward for six weeks, you’ll agree with anything to just leave for a bit’.

A few people challenged their CTOs after they left hospital. Simon felt he was wrongly given a CTO when he was discharged from hospital. In hospital, he said mental health practitioners had refused to accept he was transgender and told him it was ‘all in [his] head’. They stopped his hormone treatment, certified him and extended that to a CTO on his release. He challenged the decision and the Mental Health Review Board (in 2014 the Board was renamed the Mental Health Tribunal) agreed there was ‘no valid reason’ for keeping him on a CTO.

Some people who experienced feeling very unwell saw the CTO as an important aspect of their treatment and didn’t think it was problematic.

Gurvinder ‘didn’t mind’ being put on a CTO because he didn’t want to experience hearing voices and being suicidal again. He felt the CTO would keep him ‘on the straight and narrow’.

Charlie thought forced medication could be important to get people well again. When she was on a CTO the doctors made treatment decisions for her until she was well again.

Even when people didn’t like taking medication, some acknowledged there could be positive aspects to having regular contact with medical staff or interacting with other patients taking medication. When Susana went for monthly visits to the mental health clinic for an injection under a CTO she was ‘a bit scared’ because she was used to taking tablets and didn’t think she was ‘really sick or should be taking something that’s not good for you’. But when she saw others taking medication she thought it might be ‘a good idea’.

Susana described being given daily tablets as part of the CTO. She didn’t want to take them because she didn’t think they made a difference but she found the daily visits ‘kind of helpful’.

Having some input and control seemed to be important for people even in the context of involuntary treatment when they were under a CTO. They found it beneficial when they felt they were somehow ‘choosing’ to take the medication.

Despite having a CTO, Charlie felt she had some aspects of control over how and when she took her medication.

When they felt a little better, some people wanted the opportunity to alter the dose of their medicines by changing the prescription, or having the final say each day about whether and how much medicine to take. Having some choice about treatment seemed very important. Some people found that medical staff listened to them, but others found that it was a struggle to be heard. Gurvinder saw his choice as between taking the medicine he was prescribed (though depot injection) or being unwell – he didn’t think the doctor would listen to him if he asked to change medication.

Luana agreed that she should have been on a CTO initially to keep her safe, but said she quickly became well and thinks she was on it for ‘far too long’.