A Critical Analysis of a Mental Health Act Assessment

This essay will critically analyse mental health assessment of the Community treatment order (CTO). The research method is explained, along with the critiques of the CTO.

The Mental Health Act 1983 sets out strict parameters, stating when and how those suffering with severe mental health can be detained and treated against their wishes in hospital and in the communities of the England and Wales (The Mental Health Act 1983: The code of practice). At the same time, the Mental Health Act, as a piece of legislation, must also comply with human rights legislation. Mental health approaches and treatments are constantly changing, so it is crucial to constantly renew (update) the Act in order to keep it current with 21st century psychiatric practice (Lepping, 2007).

The Community Treatment Order has been developed to treat people who has been on section 2 or 3 under the mental health Act 2007 following widespread deinstitutionalisation (Burns et al., 2013).

The local community mental health team requested to have joint assessment for renewal of the Community Treatment order under section 17A of the Mental Health ACT for Michael. Michael (this is a pseudonym in order for his identity to remain anonymous). Introduction was completed and Michael was informed about the purpose of the Interview/meeting. He communicated in English and was interviewed in a suitable manner.

Michael is 53-year-old gentlemen; he has been with the mental health service since 2008 and has been diagnosed with treatment of resistant paranoid schizophrenia. In the past, Michael has endured several long admissions and has a history of a lack of compliance with the treatment and he is known to neglect himself. In the community, he was supported by his mother and siblings. He also had allocated care coordinator, who visits him once a week.

Michael arrived at CTO meeting place alone, under Section 17 A of the Mental Health Act. Before the meeting, notes were read to familiarise myself with his conditions and national policy on CTO. After introduction, the AMHP asked the doctor to lead the assessment. The doctor asked the Michael that what CTO means to him. Michael lacked the capacity to answer the questions; he instead began to speak about off-topic subjects, such as the diet he follows and the hardships he has had to endure due to COVID-19 and then asked to be prescribed anti-depressants. The doctor was satisfied that, Michael met the criteria in order to remain in CTO and he has received treatment for his condition to have own safety and the safety of others.

Due to non-engagement with the treatment, Michael’s doctors’ and his social worker agreed that, his CTO should be extended under S20; Mental Health Act to be treated in the community, rather than in Hospital and it will be reviewed in every 6 months. The doctor and AMHP agreed that Michael suffering from a mental disorder and it is a nature (an episode of paranoid Schizophrenia) and degree (refuses to engage with services, remaining guarded and also presenting with self-neglect), which makes it appropriate for him to remain under CTO condition for another 6 months. I felt, both the professionals didn’t give a choice to decide what he wants, but CTO has been in place for 5 years, and it seemed to me that, the improvement was likely to be due to the changes in social circumstances and a process of maturation, rather than the CTO. I was confident that, he can be effectively managed without the need for a CTO. Many patients, with similar diagnosis and without support, are managing in the community without one and being forced to take medication that did not make any difference in their symptoms and behaviour. When I mention the doctor, he agreed with me and stated that, he also doesn’t like keeping people on CTO but he was new to his job, therefore he cannot revoke the CTO.

Professionals like CTO, make life easier in overstretched with local services and bed crisis in hospitals. Since administration of medication can simply be legally enforced, staff members don’t have to spend as much time forging an alliance with the patients. If patients relapse, the mechanism to bring them back into hospital is quicker and easier than if they were not on a CTO and this is dependents if there is bed in the local hospital. Moreover, CTOs now seem to be utilised sometimes to discharge people from hospital before they have fully recovered from the acute episode that led to admission. Underpinning all these practical reasons, it is a difficulty in recognising that sometimes our interventions might not be as useful as we think.

The CTO further discriminates against the individual with a mental disorder by allowing a form of preventive detention on the basis of 'risk', without any previous crime or violence against anyone been committed ( https://www.mentalhealthforum.net/forum). Burns et al. (2013) stated that, the process CTO is time consuming therefore clinician must ensure that, intentionally it is used for clinical convenience.

The responsible clinician and the AMHP did not add additional condition in to his existing one. They felt existing one is appropriate for his social situation. The Code of Practice encourages AMHP’s considering the patients background, support network, accommodation issue during the assessment, but in this case AMHP did not consider his background, race and religion.

The CTO gives power to the responsible clinician to recall the patient to hospital under section 17 E (1) The Mental Health Act 1983: The code of practice). CTO was the favoured option than the compulsory hospital admissions in Michael’s case.

The CTOs are intended to prevent repeated relapse leading to frequent readmission, thus breaking the revolving door cycle that makes the patient to adjust living in community independently and reduce deinstitutionalisation (Rugkåsa, 2016). The idea is that, the patients achieve stability and engage in treatment, participate in community activities but also keep him in the boundary of the mental health Act and also rather than long hospital admissions, CTO actually allows people to keep their liberty and sense of community (Dye et al., 2012). He was at least able to stay in his own home and comfort, socialise, visit and invite relatives and friends and was able to choose how to go about his daily life. Earlier raised ethical and practical objections and also suggested that, the introduction of CTOs was likely to lead to undermining of constructive working relationships with the patients and further alienation and stigmatisation (Weich et al., 2018).

Burns et al. (2013) opined that, putting restrictions on the patient liberties would be unethical unless accompanied by a rigorous assessment of their potential health benefits and implications to their full potential.

Responsible clinicians discussed the pros and cons before extending CTO. The doctor and the Approved Mental Health Professional (AMHP) considered the likelihood of deterioration of his mental state, if he does not follow the condition that attached to the CTO. In this occasion the AMPH and doctor made their mind before seeing the patient. It’s appears that his nearest relative and independent advocacy worker were not invited to meeting.

Although the doctor was reluctant and did not want him on CTO but concluded that it was for Michael’s own benefit to extend the CTO for another six months. The reasoning of the extension of the CTO and conditions of the CTO was explained several times to Michael but he was uninterested and quick to leave the assessment. He repeatedly asked if he could go. Heun et al. (2016) documented that, placing patient on CTO could jeopardise patient–psychiatrist and AMHP relationship. Michael was encouraged to participate in the community activities to keep health and not socially isolated.

Michael’s was not married, he received regular support from his mother, he also didn’t have children therefore his mother come top of the list Nearest relative Section 26 Mental health Act. We were informed that she was his nearest relative and she was updated about the outcome of the CTO and her consultation.

From the literature view and observation and talking to AMHP, It’s seem that, there is no resolution or agreement in sight among the patients, carers and health care professionals. Some argues that health care professionals needs to decide for some patent who are unwilling take their medication and accept treatment in their own best interest or in the interest of others around them. CTO might infringe human right of the individual but also enable patients to live in community, get married, engage in community services and rely on less medications. In Michael's case, it might be seen that, CTO deter him not complaining with his medication and implication to his freedom, but this doesn’t mean that, CTO will be effective for another patient. In Michael's case, he had very supportive social network and had very robust care plan for keeping him out of hospital. Involving family members in the care plan might provide alternative options to CTO.

References

https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/policy/policy-rcpsych-mha-review-submission-2018.pdf?sfvrsn

Burns, T., Rugkåsa, J., Molodynski, A., Dawson, J., Yeeles, K., & Vazquez-Montes, M. et al. (2013). Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. The Lancet, 381(9878), 1627-1633. https://doi.org/10.1016/s0140-6736(13)60107-5

Dye, S., Dannaram, S., Loynes, B., & Dickenson, R. (2012). Supervised community treatment: 2-year follow-up study in Suffolk. The Psychiatrist, 36(8), 298-302. https://doi.org/10.1192/pb.bp.111.036657

Heun, R., Dave, S., & Rowlands, P. (2016). Little evidence for community treatment orders – a battle fought with heavy weapons. Bjpsych Bulletin, 40(3), 115-118. https://doi.org/10.1192/pb.bp.115.052373

Lepping, P. (2007). Ethical analysis of the new proposed mental health legislation in England and Wales. Philosophy, Ethics, And Humanities In Medicine, 2(1), 5. https://doi.org/10.1186/1747-5341-2-5

Rugkåsa, J. (2016). Effectiveness of Community Treatment Orders: The International Evidence. The Canadian Journal Of Psychiatry, 61(1), 15-24. https://doi.org/10.1177/0706743715620415

Weich, S., Duncan, C., Bhui, K., Canaway, A., Crepaz-Keay, D., & Keown, P. et al. (2018). Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study. BMJ Open, 8(10), e024193. https://doi.org/10.1136/bmjopen-2018-024193

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