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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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