The Otago CTO Study: What Have We Learned?

1. The Otago CTO Study:What Have We Learned? John Dawson, Faculty of Law, University of Otago, Dunedin, New Zealand IALMH Conference, Padua, June 2007

2. 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.

3. 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

4. Otago CTO Study All references on our website: www.otago.ac.nz/law/otagoCTO/index.html Google search: “Otago CTO study”

5. Major Variations in Rate of Use of CTOs People under CTOs per 100,000 population Victoria, Australia (2005) 60 District of Columbia (2004) 54 New Zealand (2003) 44 Queensland (2004) 43 Maricopa County, Arizona (2004) 31 Western Australia (2004) 10 Tennessee (2004) 10 Ontario (2003) 2 S Lawton-Smith, A Question of Numbers, King’s Fund, London (2005)

6. 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

7. 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

8. 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.

9. 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- • 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.

10. 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

11. 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’

12. Patients’ Overall View of the CTO Cohort approached: 103 Lacked capacity to participate: 19 Agreed to participate and completed process: 42 22 still on the order; 20 recently discharged Totally for the order (no adverse comment) 8 Mostly for the order 19 Equally for and against 9 Mostly against 3 Totally against 3 Gibbs, Dawson, Ansley, Mullen (2005) 14 Journal of Mental Health 365-368

13. 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.

14. Responsible clinicians exerciseconsiderablediscretion, 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.

15. So what determines the rate of use ? My hypothesis: It is largely determined by the manner in which responsible clinicians exercise their discretion under the scheme. This depends, in turn, on their perceptions of the balance of advantage in using the scheme.

16. 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%

17. 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.

18. 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 Psychiatry836-841

19. 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

20. 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’.

21. 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