William* was 22 when was first hospitalised in Victoria for a suspected mental illness. Two years later, he was diagnosed with schizophrenia, a diagnosis with which he did not agree. At the age of 30, he was made an involuntary patient under the Mental Health Act.
This meant that he had to take the medication prescribed to him by his treating psychiatrists, first as an inpatient and then at home, after he was released on what is known as a ‘community treatment order’.
In essence, a community treatment order is made under mental health legislation and compels a person with a mental illness to comply with treatment for that mental illness, even if they do not want it. If they do not comply with treatment then they can be admitted to hospital as an involuntary patient. An investigation into this process found that it is common and can lead to considerable distress when police and other emergency and crisis services become involved.
Community treatment orders have been a hidden part of the mental health system since their introduction first in Victoria in 1987 and then in other states.
Being treated with medication without consent raises issues concerning personal choice and liberty. It can only be done if certain legislative criteria are met including that there is no less restrictive option available.
William was willing to be treated for depression, but didn’t want to take anti-psychotic drugs, which can have severe side-effects. For the next 16 years, he tried to challenge being treated as an involuntary patient to no avail. The community treatment order he was on was renewed each year and upheld by the then Victorian Mental Health Review Board.
Despite new mental health legislation being introduced in Victoria in 2014 which emphasised voluntary treatment, rights and recovery, in August 2015, a community treatment order was made for William by the newly constituted Mental Health Tribunal.
William, with the support of Victorian Legal Aid, sought a review by the Victorian Civil and Administrative Tribunal (VCAT). VCAT found that he did not meet three of the four criteria needed for a community treatment order to be put in place and the order was revoked.
William’s story raises questions about the use of community treatment orders to control a person’s treatment for mental health issues: are they being used as a safety net? Are they effective?
Three large randomised control trials, two epidemiological studies as well as a systematic review of all previous literature indicate that community treatment orders (CTOs) don’t seem to work. Why, then, does Australia, and Victoria in particular, continue to have the highest rate of community treatment order usage in the world?
Collectively, Australian mental health consumers are compelled to undergo over a million involuntary community mental health services each year, yet there is very little publicly available information about government policy principles and objectives related to CTOs. As Edwina Light and her colleagues state in their article ‘Out of Sight, out of mind’ :
“The ‘invisibility’ of CTOs in mental health policy raises questions about the transparency and accountability of the mental health system, and about whether this policy silence ultimately entrenches the marginalisation of, and discrimination against, people living with mental illness.”
In Victoria, which has the highest rate of usage in the world, there are over 5000 people compelled by community treatment orders at any one point in time. Like William, some of these people have been under compulsory orders for many years.
Community treatment orders can have a devastating effect on the people subjected to them. According to research with people on CTOs, being under the control of an order is associated with distress, feelings of loss, grief, isolation and disempowerment. Cheryl describes her experience of being treated with medication as an involuntary patient as akin to a ‘chemical lobotomy’ that forced her to stay on her couch with her mind in a perpetual medicated fog.
Just how many people are in situations similar to Cheryl and William is difficult to determine.
Hearings held by mental health tribunals are closed to the public and data collection varies between states and the territories.
Dr Edwina Light and Professor Steve Kisely are experts in the field of research into community treatment orders and are the authors of two of the articles referred to above. They, along with other academics, policymakers and persons with lived experience of mental health problems took part in a Melbourne Social Equity Institute symposium on May 27, aiming to assess the efficacy of CTOs. A report is now being compiled with a view to developing a national research agenda.
The report approaches this national issue by starting with an important, too often overlooked question: what do people with mental illness want?
*Some names in this article have been changed.
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