Community Treatment Order

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This could undermine the goal of deinstitutionalisation[37], that seeks to implement integral and flexible attendance services supporting psychosocial reintegration and rehabilitation. In any case, ensuring human care and effective mental health treatment for everyone, and especially for those most in need, such as some patients with SMI, seems, as a last resort, a responsibility for the State. Discussion on CTOs and deinstitutionalisation has occurred at the interface of ethical values and contexts in conflict This interface affects political, judicial, executive, police, healthcare and professional association powers.

Section 51 Mental Health Act 2007

As far as legislation is concerned and with regards to CTOs, it is necessary to wonder whether we are talking about providing ill-prepared and opportunistic legal answers to the social pressure of public opinion, the media and pressure groups of civil society. In no way should this be answered, since society has the right and duty to exercise democratic constructive pressures that seem appropriate to influence the legislator, and the State has the duty to implement appropriate and coherent criminal and civil policies.

Health protection is proposed as a guiding principle of social policy In the inevitable tension between individual care and defending the public good it is necessary, for utilitarian and pragmatic consequentialism, to maintain equity in an environment governed by efficiency Similarly, for principlist-deontological personalism what is fair is identified with the common good, which is not identical for all, but rather proportional 13, The concept of health does not coincide with welfare or it is not necessarily contrary to suffering.

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Therefore, it rejects the medicalisation of everyday life, that is, the treatment of non-medical problems as if they were medical problems. With justice understood in this sense, for public health a fair distribution of resources and economic budgets will result in a fair, suitable and correct treatment for people with SMI with or without a CTO program. A number of these patients would have to receive a costly integrated care program for SMIs, which are generally lacking or insufficient in many other Western countries.

There is, however, a clear clash of interests between the majority of patients with less severe mental disorders such as adjustment disorder and the minority with SMI such as schizophrenic disorder. The first of these claim their right to be assisted by community mental health services satisfactorily in terms of time and manner, and have more weight as they are more numerous. The second group tend not to have any other defenders apart from the associations of mentally ill patients whose weight in the community is relative.

The crucial, unresolved issue is, therefore, the management of psychiatric community care based on equitable distribution Yet, without the proper implementation of less restrictive community treatment programs, CTOs contribute to the forced equity, we might say, of community care resources. Understood properly, it is not a question, as accepted by the fallacious argument, of replacing low-cost integrated care programs for SMIs, but to supplement them or even to force their establishment.

As we have seen, the goodness of CTO is entirely assumed also from pragmatic consequentialism and, therefore, from its extreme position, utilitarianism. In effect, its implementation and developmental costs are perfectly acceptable for any community and its overall outcome is sufficiently positive, that is, it is fair and correct.

In any case, the utilitarian argument requires an ethical normativism, the utilitarianism of the rule which should promote laws to ensure a fair state of affairs. Therefore, the author's view on ethical utilitarianism supports the development of a specific law on mental health and CTOs, which is currently lacking in many Western countries.

For ontological personalist bioethics, on the other hand, everything which does not hurt the individual is licit, and everything which suppresses or hurts him or her is illicit. So, for this bioethical approach, the care of the incapable patient is an end in itself, not a means. The eminent dignity of the patient as a subject of rights requires their effective guardianship at all times. The personal dimension is a continuum which is independent from the mental state of the individual, so they do not lose a shred of their dignity from any disease or disorder, even if this disorder severely impinges on affectivity or judgment as happens with SMI.

Consequently, a duty of respect towards the incapable patient is imposed, which has to provide the necessary action as far as society is concerned in order to safeguard the incapable patient's integrity. A CTO also appears here, then, as an obligation of bioethical justice. Finally, to arrange hierarchically the four main principles or duties in a higher rank non-maleficence and justice and in a lower rank beneficence and autonomy from the perspective of moderate principlism 26 is not important for the purpose we have seen from the bioethical foundation of CTOs, since we could not find a substantial conflict between them in connection with CTOs.

We have reported frictions between the two principles of lower rank, which rather than repel each other, can merge or join regarding the important aspects. Upon the basis of the results of this work and the bioethical discussion of them, CTOs are presented, as far as the author is concerned, as a method of therapeutic intervention with a bioethical foundation resistant to criticism.

A CTO is an extraordinary means of intervention, applicable only in the absence of less restrictive care alternatives and when the patient's self-governance is severely compromised, whether or not there is court-ordered incapacity to act. It has been considered that CTOs are consistent firstly with the deontologist-principlist dominant paradigm of practical reason, respecting its four general categories of basic principles.

When prescribing a CTO, open communication between the clinician, the patient and the family or legal guardian is crucial. This prescription must ultimately be based on a bioethical exercise of responsibility by the psychiatrist, judiciously weighing up the classic principal prima facie duties which must necessarily be translated into a real duty referring to a specific patient and context. The author declares that there are no financial or non-financial competing interests in this work. Intervenciones no voluntarias en salud mental. Rehabil Psicosoc ; 4: Vol II. Madrid: Litofinder; Resource document on mandatory outpatient treatment.

J Am Acad Psychiatry Law ; New York State assisted outpatient treatment program evaluation. Outcomes of patients in a low-intensity, short-duration involuntary outpatient commitment program. Psychiatr Serv ; Involuntary outpatient commitment, community treatment orders, and assisted outpatient treatment: What's in the data?

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Can J Psychiatry ; Erickson SK. A retrospective examination of outpatient commitment in New York. Behav Sci Law ; The effectiveness and ethical justification of psychiatric outpatient commitment. Am J Bioeth ; 7: Cullen-Drill M, Schilling K.

Mental Health Act - What is a Community Treatment Order?

The case for mandatory outpatient treatment. Effectiveness of community treatment orders for treatment of schizophrenia with oral or depot antipsychotic medication: changes in problem behaviours and social functioning. Aust N Z J Psychiatry ; O'Reilly R. Why are community treatment orders controversial?

Community Treatment Order

Burns T, Dawson J. Community treatment orders: how ethical without experimental evidence? Psychol Med ; Principles of biomedical ethics. New York: Oxford University Press; Madrid: Triacastela; Begley AM. Facilitating the development of moral insight in practice: teaching ethics and teaching virtue.

Nurs Philos ;7: Generalitat de Catalunya. Tests of competency to consent to treatment. Am J Psychiatry ; Dickenson D. Ethical issues in long-term psychiatric management. J Med Ethics ; Drane JF. Competency to give an informed consent. A model for making clinical assessments. JAMA ; Szasz T.


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Psychiatry and the control of dangerousness: on the apotropaic function of the term "mental illness". Asclepio ; XLV: Szmukler G. The philosophical basis of psychiatric ethics. Psychiatric ethics. Callahan JC. Liberty, beneficence, and involuntary confinement. J Med Philos ; 9: Pressure and coercion in the care for the addicted: ethical perspectives. Dresser R. Involuntary confinement: legal and psychiatric perspectives. J Med Philosophy ; 9: Autonomy, religion and clinical decisions: findings from a national physician survey.

Verkerk MA. The care perspective and autonomy. Med Health Care Philos ; 4: Can we justify eliminating coercive measures in psychiatry? Como arqueros al blanco. Guardianship of people with mental disorders. Soc Sci Med ; Widdershoven G, Berghmans R. Coercion and pressure in psychiatry: lessons from Ulysses. The Nicomachean ethics. Chicharro Lezcano F.

Tratamiento ambulatorio involuntario. Norte Salud Ment ; The justificatory power of moral experience. Physicians' silent decisions: because patient autonomy does not always come first. Mental health legislation and human rights. Peele R, Chodoff P. Involuntary hospitalization and deinstitutionalization. Santos Urbaneja F. Derecho y salud mental. Cuad Psiquiatr Comunitar ; 6: Green AS. Maybe so, for some. Perhaps CTOs have been used too liberally, an unjustified knee-jerk reaction to scaremongering about dangerous patients with psychosis or as a long-leash substitute for proper care.

And we know that when used randomly, they do not seem to be effective. Maybe however there is another side to this? I work as a consultant psychiatrist in an Assertive Outreach Team. Sadly, a dwindling service model in these austere times, we exist to support those with severe mental illness who suffer with psychotic symptoms. We see those patients who, at least when we first meet them, often do not think they have any illness at all. As a consequence they see no place in their lives for treatment or contact with services.

How can this be? Imagine that you hear voices, day and night, as clear as yours or mine; hurling abhorrent insults and inciting brutal acts of harm. There are no secrets from your psychosis. So, your most intimate fears become a reality. Imagine living with relentless perceived threats of torture, or worse, at the hands of your loved ones or imagined assailants wherever you go. But the most important thing is that for you, all of this is completely real.

Community Treatment Orders

Why trust them? Why accept the poison they pretend to be medicine? And even if it does not kill you, it has crippling side effects which slow you down and make you all the more vulnerable. The most frequently-quoted research evidencing the apparent ineffectiveness of CTOs did not fully capture this population. It excluded those too ill to consent to taking part and also those who refused.

Some would say that this group is the very population that CTOs were intended for. Our experience is that for most within this group, the use of a CTO has allowed us to maintain contact with them, to gain their trust over time and to collaboratively find compromises around treatment. The framework has certainly reduced the time they have spent in hospital and the risks they pose to themselves and others, which usually arise very directly from their psychosis.

There is much stigma relating to the erroneous perception of violence risk from those with mental illness. However, whilst it is true that this is a very damaging stereotype, in my particular field of Assertive Outreach we see people who have multiple and complex needs which may well include a risk of violence when unwell.

Community Treatment Orders | Alberta Health Services

I do not think of them as dangerous people, though: their violence arises from fear, which in turn arises from illness. For most within this group, the use of a CTO has allowed us to maintain contact with them, to gain their trust over time and to collaboratively find compromises around treatment. So, as their doctor, do I have a duty to treat them to prevent this harm when very clear patterns of risk associated with relapse are present?

As a psychiatrist I am always mindful of the power imbalance between professionals and patients which reaches its uncomfortable peak when we use the Mental Health Act.

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