Transcript the presentation

The Otago CTO Study:
What Have We Learned?
John Dawson,
Faculty of Law,
University of Otago, Dunedin,
New Zealand
IALMH Conference, Padua,
June 2007
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.
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
Otago CTO Study
All references on our website:
www.otago.ac.nz/law/otagoCTO/index.html
Google search: “Otago CTO study”
Major Variations in Rate of Use of CTOs
People under CTOs per 100,000 population
Victoria, Australia (2005)
District of Columbia (2004)
New Zealand (2003)
Queensland (2004)
Maricopa County, Arizona (2004)
Western Australia (2004)
Tennessee (2004)
Ontario (2003)
60
54
44
43
31
10
10
2
S Lawton-Smith, A Question of Numbers,
King’s Fund, London (2005)
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
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
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.
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(a) 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.
Community Treatment Powers in NZ
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•
•
•
•
•
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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
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’
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)
Mostly for the order
Equally for and against
Mostly against
Totally against
8
19
9
3
3
Gibbs, Dawson, Ansley, Mullen
(2005) 14 Journal of Mental Health 365-368
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.
Responsible clinicians exercise
considerable discretion, 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.
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.
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
Without CTOs
Unsure
78.8%
9.3%
11.9%
For the 55 British-trained psychiatrists in NZ who had
worked in both systems:
Preference for a system with CTOs:
76.0%
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.
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 Psychiatry 836-841
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
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’.
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