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Community Treatment Orders, Ontario
Definition
Criticism
Report
Legislation
Recent News
Definition: Community Treatment
Orders (CTOs) in Ontario allow a physician or psychiatrist
to legally compel a patient to take psychiatric treatments
after leaving a psychiatric ward. A CTO allows a psychiatrist
to call police to bring patients in for an assessment if they
fail to comply with the treatment plan that goes with the
Order. CTOs are supposed to be applied only if a patient agrees
to abide by the Order and if they meet the criteria (e.g.,
have been admitted to hospital twice or more, for 30 days
or more, etc.; see notes
for more detail). The CTO lasts 6 months and is supposed to
come with rights advice (unless it is being renewed–
see Recent News below).
Criticism: CTOs have been criticized
as a way to discharge people to save money without providing
sufficient supports like housing in the community. The coercive
nature of CTOs makes treatment seem draconian to some patients,
who complain they feel like prisoners in their own homes (families
can be asked to monitor patients, for example). Therapeutic
relationships suffer. As for the right to choose or refuse
a CTO, it is very easy for a psychiatrist to declare the patient
legally 'incapable' regarding treatment choices because mental
illness causes 'lack of insight'. While a treatment may seem
to work from a psychiatrist's perspective, major negative
effects and lack of real life improvement feels like treatment
failure to some patients, and has led to patients refusing
treatment. Ironically, treatment 'compliance' is often required
for them to be given housing or other services. Legally, any
arrangement can constitute a 'treatment' under the law, including
relocation to another address, having to take routine pregnancy
tests, and other lifestyle changes.
Report: Many of these critiques
are corroborated in the anecdotal and literature review evidence
made public by the legislated Ontario government's
report on CTOs. It also reports incidents of abuse, rights
violations, negligence, and problematic care arrangements.
Despite evidence in quantitative studies that compulsory community
treatment does no better than outpatient services on the whole
in keeping people on treatments, the report says CTOs were
widely accepted and successful based on anecdotal evidence.
The legislated report was supposed to be finished and made
public by 2003, and subsequent reports were scheduled in 2008
and every five years after. However, it was only made public
after the government received a Freedom of Information Act
request by psychiatric survivor activist Lucy Costa in May
2007. There seems to be no plan to conduct a follow up review.
Legislation: CTOs were put
into Ontario's Mental Health Act on December 1, 2000, to address
public fears that mental patients were going off their meds
and causing harm to others (this scenario was forcefully brought
to the attention of Ontario law makers by the Schizophrenia
Society of Ontario, which is an organization partially funded
by drug companies; for references please consult Fabris's
thesis on CTOs). In fact
the Law to amend the Act was named in honour of a victim of
'mad' violence, Brian Smith. The assailant, Jeffrey Arenburg,
was only deemed 'schizophrenic' after the attack. When he
was released 10 years later, he was not expected to take medication
or put on a CTO. Brian's Law also broadened the criteria for
psychiatrists to detain and forcibly treat individuals. In
the past detention required evidence of immanent danger; the
new Act expands this to include the appearance of incapacity
and lack of self-care. As the report shows, the results of
this legislative change have not curbed violence, have not
improved treatment adherence, and have only arguably improved
some dischrage planning. About 1000 CTOs are applied every
year (though data needs to be kept more rigorously).
Recent News: New developments
regarding CTOs under Bill 16 can be viewed at the CMHA website.
And new developments in Ontario's mental health and addictions
policies
can be viewed at a government website. In both cases, the
government seems intent on streamlining coercive measures
while giving non-coercive services including 'peer' based
approaches a secondary role.
Related
research on the chemical management of youth in Canadian institutional
settings can be viewed here.
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