Review
of Policy Positions of Relevant Stakeholder Organizations
To
place the Centre's 'Best Advice' in context, a brief review of internal and external
policy positions will illustrate that the field has adopted different positions based
on differing values, assumptions and analyses of the issue.
CAMH Medical Advisory Committee (MAC)
MAC reviewed the literature, described the limitations of current legislation and
discussed the arguments for and against CTOs. It views CTOs as a specific mechanism
to compel severely mentally ill people, who do not appreciate their need for treatment,
to take medication to both prevent relapse and a return to dangerous behaviour. It
assumes that CTOs would only apply to those individuals who had previously demonstrated
a favourable response to medication. The individuals likely to be considered for
CTOs have the following characteristics: repeated relapses, risk of violent and/or
suicidal behaviour, non-compliance with treatment, ongoing incapacity to consent
to treatment even as an outpatient, and frequent hospitalizations.
MAC
stresses the need for the appropriate community services to be in place to support
the implementation of CTOs and believes that CTOs cannot be seen as a solution to
the problems associated with homelessness, unemployment, stigma and social isolation.
The MAC concludes that:
-- CTOs should become part of a continuum of supports/options available to clients
and service providers
-- CTOs may reduce impairment and dysfunction
-- clinicians should accept responsibility to provide treatment without direct
consent of the client under special circumstances where substitute consent is provided
and the client is incapable of making treatment decisions
-- only a small number of clients would be candidates for CTOs
-- the implementation of CTOs should include their systematic evaluation from
the individual and system perspectives
Queen Street Patient's Council
The
Council opposes CTOs and advocates for affordable housing, more supports, liveable
levels of income support, jobs and accountability of services to those receiving
them.
To view the QSPC's entire position, visit their website at http://www.icomm.ca/patientsco/council/positions/ctopcpos.html
CMHA Ontario Division
The
position of CMHA/Ontario Division is that the Mental Health Act should not be amended
to include CTOs, since the current legislation, including the Health Care Consent
Act and the Substitute Decisions Act, permits treatment where the person is incapable
of consent. CMHA supports the development of a comprehensive community mental health
system that includes attention to quality of life issues, housing, income and work.
It supports the idea of service agreements for clients being discharged as a mechanism
for outlining the expectations of the client and provider and for identifying clients
who may represent a danger to themselves and others.
OMA Psychiatry sub-section
The
OMA Psychiatry sub-section position on CTOs is as follows:
-- CTOs are a necessary tool to ensure appropriate treatment for a small group
of patients only, namely the 'hard to treat' who lack capacity and who are likely
to become a risk to themselves or others or are at imminent risk of serious physical
impairment
-- current legislation has no viable alternatives in Advanced Directives, Guardianship
and Leaves of Absence
-- deinstitutionalization is driving the movement and it is important to be able
to guarantee appropriate treatment in the community
-- CTOs must be integrated with a comprehensive package of community-based treatment
and support services
-- CTOs must be accompanied by procedures for monitoring and appeal similar to
involuntary inpatients, such as a mandatory Review Board
Schizophrenia Society of Ontario
The
Schizophrenia Society stresses that too many untreated mentally ill are ending up
in the criminal justice system and on the streets rather than getting the treatment
they need. In their analysis of the issue, the Mental Health Act is too limited to
address the full scope of the problem because it only applies to psychiatric facilities
and it is too narrow in terms of criteria for involuntary hospitalization. They propose
it be amended as follows:
-- the phrase 'imminent and serious physical impairment of the person' should
be changed to read: 'serious physical or mental deterioration or impairment of the
person'
-- the leave-of-absence provision should be changed to extend to those people
whom the physician does not anticipate will return to hospital
-- amend the Mental Health Act to provide for outpatient committal and to have
it serve as an alternative to hospital, with hospitalization as the consequence for
non-compliance
In
addition to changes in the Mental Health Act, the Society states there is consensus
around crucial issues pertaining to mental illness and treatment. They argue for
a better coordinated system that extends to the community, more outreach to those
not receiving treatment, a comprehensive system of housing and employment options,
a system that 'minimizes' the need for involuntary hospitalization and a lessening
of the 'factionalization' within the mental health community. The ethical principles
identified as essential guidelines for the assessment of mental health policy are:
-- compassion for those with schizophrenia
-- mental capacity, i.e., anyone capable of making decisions should do so and
those incapable should 'not be denied treatment'
-- liberty, which means the individual should have the right to challenge the
decision before an arbiter
-- public safety, i.e., fear from harm
CMHA, BC Division
CMHA,
BC Division recommends against CTOs. It identifies the PACT model as an approach
which shows results superior to those of CTOs. It also views treatment compliance
as only one of several factors contributing to relapse in addition to social and
system factors, medication efficacy and lack of client education. It holds that CTOs
may prevent people from learning about the consequences of their illness. They conclude
that the system needs more accountability and more services in line with what clients
say they want. They have voted in favour of 'non-coercive' solutions for the 'most
difficult to treat' such as court diversion programs, assertive community treatment,
'no reject care,' better strategies for early intervention, better crisis intervention
and finally, an accountable system that places high expectations for recovery on
those in need.
CMHA National
CMHA
National takes the position that, although the case for community committal has compelling
arguments on both sides, rather than continuing the debate, it is preferable to shift
the argument to positive alternatives on which there is agreement. In their draft
policy statement they make three recommendations:
-- support for development of a comprehensive community mental health system as
the 'first line of defense'
-- mental health systems must provide active support and consistent care based
on consumer needs and which go beyond treatment to include quality of life factors
-- more resources are needed for family and consumer organizations
Mental Health Legal Committee (MHLC)
The
MHLC takes the position that the 'frustration' leading CTO advocates to recommend
them is a result of a 'lack of appreciation for the existing ways in which informed
consent to treatment on behalf of incapable persons can be obtained.' The problem
as defined by them is the under, and inappropriate, use of current legislation.
They
criticize the underfunded inpatient system, the inadequacy of community supports
and believe the thrust should be towards consensual care based on therapeutic engagement
of the client. Quality of life factors are seen as being crucial to the well being
of mental health clients.
Family Mental Health Alliance (FMHA)
The
FMHA has taken a position against CTOs on the grounds that it sees the entire issue
as a symptom of a larger problem rather than a solution to the problem. They argue
that, while there is a problem with untreated mentally ill in the community who are
often aggressive, the underlying problem is the lack of resources available to 'all
stakeholders.' The FMHA opposes CTOs because they represent an involuntary interference
that does 'violence' to an individual. Also, they see the issue of non-compliance
as multi-dimensional, with many of the reasons having to do with inadequacies in
medications and the service system. The FMHA endorses a review of the MHA with a
view to broadening the definition of harm, along with the creation of an adequate
service base, possibly with mental health legislation.
Mood Disorders Association (MDA)
The
MDA of Ontario and Toronto opposes CTOs and states that the real issue of concern
is the 'failure of the MoH to build a comprehensive community-based system of care
for those with mental illness while closing psychiatric treatment beds.' It contends
that the MHA is robust enough to safeguard public safety and the rights of people
with mental illness.
National Association for the Mentally Ill (NAMI)
NAMI's
position is summarized as follows:
-- availability of effective comprehensive community treatment will diminish the
need for involuntary commitment (inpatient and outpatient)
-- methods for facilitating communication regarding treatment preferences among
clients, families, and providers should be adopted
-- involuntary commitment decisions should be made expeditiously and simultaneously
so individuals can receive treatment in a timely manner
-- involuntary commitment should be used as a last resort
-- independent review must be guaranteed in all involuntary commitment cases
Summary
There
is no consensus among these organizations on whether CTOs are a good thing or not.
Organizations opposing CTOs emphasize different aspects of the issue from those advocating
for CTO legislation. The advocates appear to agree that CTOs are likely to benefit
only a small number of people with psychiatric illnesses and that appropriate services
are needed to ensure CTO effectiveness.
Regardless
of the position taken on CTOs, all groups speak to the need for a comprehensive mental
health service and support system. Some groups supporting CTOs see a comprehensive
mental health system as a necessary condition for CTOs to be effective. This interdependency
is well-described by Applebaum (1986):
"If
states are more interested in discharging patients than in ascertaining what happens
to them after discharge, if mental health centres are not willing to accept responsibility
for these patients, and if most mental health professionals avoid involvement in
monitoring compliance, then it (CTO) will not be effective."
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