The Otago CTO Study: What Have We Learned?

John Dawson,

Faculty of Law,

University of Otago, Dunedin,

New Zealand

IALMH Conference, Padua,

June 2007

A linked set of studies • qualitative study of views of 42 involuntary

outpatients and carers, including interviews with patients, families and clinicians;

• survey of all NZ psychiatrists concerning their views of the NZ CTO regime;

• comparative analysis of CTO legislation in

NZ, Australia, Canada, England and Scotland.

Papers on:

Views of NZ CTO regime of:• CTO patients: (2005) J Mental Health 357• Clinicians: (2004) ANZJ Psych 836; (2006) Int J L&P 535• Families: (2006) Int J Soc Psych 469 • Maori: (2004) ANZJ Psych 830

CTO legislation: (2006) Int J L&P 482

Theory and Methods: (2002) Medical Law Review 308; (2003) Int J L&P 243

Factors influencing rate of use: (2007) Psychiatry 42

Otago CTO Study

All references on our website:

www.otago.ac.nz/law/otagoCTO/index.html

Google search: “Otago CTO study”

Major Variations in Rate of Use of CTOsPeople under CTOs per 100,000 population

Victoria, Australia (2005) 60District of Columbia (2004) 54New Zealand (2003) 44Queensland (2004) 43Maricopa County, Arizona (2004) 31Western Australia (2004) 10Tennessee (2004) 10Ontario (2003) 2

S Lawton-Smith, A Question of Numbers,King’s Fund, London (2005)

Central Issues

• Scope and design of CTO legislation• Mental health services available:

– structure, intensity, skills• Family support• Links to other social systems:

- housing, welfare, CJ system, reimbursement• The exercise of clinical discretion• Role of community psychiatric nurses

Service delivery context for use of CTOs

• Length of inpatient stays possible

• Co-ordination of inpatient and outpatient care

• Availability and intensity of CMH services,

including supported accommodation

• Attitudes, skills of community psychiatric nurses

• Staff willingness to visit patients in their homes

• Cross-cultural capabilities of CMH staff

• Police assistance with recall to hospital

• Availability of depot (injectable) medication

Features of Australasian CTO Regimes

• Main focus: serious mental illness, not intellectual disability or personality disorder

• Immediate danger not mandatory; seriously diminished capacity for self-care sufficient

• Evidence required that treatment is available • Medication without consent is authorised,

but not ‘forced medication’ in community • Clear powers of entry into private premises• Clear enforcement mechanisms• Discharge at discretion of clinicians• Regular review by courts or tribunals.

The criteria for compulsion under NZ’s MH legislation

'Mental disorder', in relation to any person, means an abnormal state of mind (whether of a continuous or an intermittent nature), characterised by delusions, or by disorders of mood or perception or volition or cognition, of such a degree that it-

(a) Poses a serious danger to the health or safety of that person or of others; or

(b) Seriously diminishes the capacity of that person to take care of himself or herself.

Community Treatment Powers in NZ

• a duty placed on the patient to accept treatment• patient to accept visits and attend appointments • to direct the ‘level’ or place of accommodation

• CMH teams may enter private premises at reasonable times, for treatment purposes

• swiftly recall to hospital care by clinicians• police assistance in that recall process• treatment without consent in a hospital or clinic

• no ‘forced medication’ in community settings

Patients’ metaphors for the CTO

‘an umbrella’ ‘a bridge’ ‘a pathway’ ‘a turning point’ ‘a stepping stone’‘a lifeboat’ ‘a doorway’‘otherwise it would be like being in a boat in the

middle of the ocean without an oar’

‘thumbscrews now on, pull your weight’‘it’s good but there’s handcuffs on it’‘it puts pressure on in a polite way’

‘at their choice and their time - capacity to be cured’

Patients’ Overall View of the CTO

Cohort approached: 103Lacked capacity to participate: 19

Agreed to participate and completed process: 4222 still on the order; 20 recently discharged

Totally for the order (no adverse comment) 8Mostly for the order 19Equally for and against 9Mostly against 3Totally against 3

Gibbs, Dawson, Ansley, Mullen(2005) 14 Journal of Mental Health 365-368

Patients held generally favourable opinions of the CTO regime because:

• assessed it in light of their prior patient career & negative experience of institutions

• allowed more freedom and control over their lives than hospital care

• valued the sense of security and enhanced access to services

• valued the ongoing support of mental health professionals and accommodation providers

• viewed it as a transitional step from a chaotic to a more stable form of life.

Responsible clinicians exercise considerable discretion, when they decide:

• to place a patient on a CTO, on leaving hospital• to discharge a patient from a CTO• to apply to a court or tribunal for its renewal• to advocate strongly for the CTO at the

hearing• to recall the patient to inpatient care, etc

>>> CTOs ‘may’, not ‘must’, be used.

So what determines the rate of use ?

My hypothesis:

It is largely determined by the manner inwhich responsible clinicians exercise their discretion under the scheme.

This depends, in turn, on their perceptions of the balance of advantage in using the scheme.

Clinicians’ Preference for a Mental Health System With or Without a CTO Regime

Responses from a Survey of all NZ Psychiatrists Surveys sent, 362; returned, 202; response: 57%

With CTOs 78.8%Without CTOs 9.3%Unsure 11.9%

For the 55 British-trained psychiatrists in NZ who had worked in both systems:

Preference for a system with CTOs: 76.0%

Key Uses of CTOs: NZ Clinicians' Views

• to ensure contact between patients and professionals

• to ensure compliance with medication• to enhance patients’ insight into their illness • to prevent or identify relapse• to facilitate accommodation and social support• to create a stable situation, so other forms

of therapy, activity, psychological change, have a chance to occur.

NZ clinicians’ views of the impact of CTOs on therapeutic relationships

‘a useful tool in pursuit of core clinical goals for the seriously mentally ill.’

‘binds into place the necessary community service, and facilitates contact with the patient, medication compliance and early identification of relapse.’

‘ may support the involvement of families and other agencies in care and may have a significant impact on a patient's attitude to their illness.’

‘while compulsion can harm relations with patients in the short term, the advantages of continuing treatment usually outweigh this problem, and where greater insight follows treatment, therapeutic relations often improve in the end.’

Romans, Dawson et al (2004) 38 ANZ J Psychiatry 836-841

How might CTOs work 1?What mechanisms ?

Directly: through the enforcement process

Indirectly: through therapeutic relationship

Structurally: – binding into place a ‘structure for care’– committing service providers to the patient– giving the patient priority for care– supporting the family’s insistence on treatment– giving housing providers the confidence to care

How might CTOs Work 2 ? On the psychology of the patient:

– may come to accept the need for treatment

– in light of their prior knowledge and experience

A communication to the patient:

– concerning the severity of their illness

– that others care and will intervene

Clinicians:

– The order ‘persuades the persuadable’. – It is ‘a compulsory contract for care’.– ‘an element in ongoing negotiations about treatment’.

Essential conditions for a useful CTO regime ??

A well-targeted regime: serious mental illness

Sufficient additional authority to treat outpatients

No intolerable administrative burdens

No unreasonable liability concerns

Adequate, available CMH services

Sufficient supported accommodation

Coordination of inpatient and outpatient care

Police assistance with recall process

Support of psychiatrists, families, nurses