In my upcoming book on Recovering from Psychosis (Williams, In Press) I have a chapter that critically reflects on the potential abuses of the widely discussed ‘recovery’ movement. Within this reflection a point I make is that an organisational requirement to developing clinical practice founded upon partnership in decision-making necessitates a shift in terms of power and authority within professional roles and practices (Slade et al., 2014). This is particularly problematic in the case of treatment under section within the Mental Health Act (1983; 2007) and it is hard to see how services can maintain a recovery approach when this legal enforcement of aspects of treatment are in place. What follows now are my reflections on CTO’s excerpted from my current book draft.
Community Treatment Orders (CTO’s) were introduced as a means of reducing the need for admission and detention in inpatient settings. The data on rates of admission and implementation of CTO’s does not support these ideas, and neither do early randomized trials evaluating the efficacy of CTO’s. According to the Health and Social Care Information Centre (2009; 2013) rates of detention to inpatient facilities in the U.K. increased from 47,600 in 2007/2008 – 2008 being the year in which CTO’s were introduced – to 50,408 in 2012/2013.
Within the limitations of designing and implementing randomized control trials those conducted to investigate the efficacy of CTO’s in reducing the need for admission to hospital each unequivocally indicate that CTO’s do not have an impact statistically on such outcomes (Burns and Molodynski, 2014). There is in counter-balance to this some evidence that the use of CTO’s can reduce the length of hospital stay for certain groups of people (Light, 2014).
As Light (2014) points out in discussing the whys and wherefores of the legitimacy of CTO’s in the face of unfolding contradictory and in places unequivocally negative evidence is that the process of study design, choice of ‘outcomes measures’ and what kinds of evidence inform evidence-based care are philosophical matters. An implication of such studies thus far on CTO’s is that inpatient treatment in some sense is the result of a failure of the CTO. That is there is an assumption that the function of community care is to prevent the need for inpatient treatment. In a clinical context this does not always make particularly good sense – sometimes the purpose of community mental health care is to facilitate access to inpatient care. It has also been argued that CTO’s, like recovery, amounts to a process – wherein what benefit is entailed within the treatment order is in the improved access and availability of clinical resources to the person (Kisely et al., 2013).
These studies also fail to speak as to the qualitative nature of experiencing a CTO – the most recent studies of which in Australia (Light, 2014) paint a consistent picture of distress and ambivalence about the use of CTO’s there. Strangely, whilst studies of lived experience or qualitative data tend to have a reduced regard in terms of health-economic decision-making where randomised trials are seen as the gold-standard for research, a rebuttal of the OCTET trial evidence by Mustafa (2013) argues against the withdrawal of CTO’s based largely on evidence from a fictitious case of anecdotal evidence of its efficacy! It’s a perversely inconsistent world where on one hand we have arguments against the narrow use of existent psychological therapies for psychosis based stoutly and solely on hard-won expensive scientific empirical evidence (via RCT’s) that has limited room for the complexity of user-experience outside of often researcher originated numerical scales of symptom intensity. Yet again we have arguments for the persistence of a typically unpopular form of legally enforceable intervention in the face of the same kind of evidence that draws on a putative case of user-experience to justify this. We are well overdue embracing mixed-methodologies in psychological health ‘science’ and finding ways to draw upon user-experiences so that we can provide interventions that are both empirically valid and experientially attentive.
Given that mental health services is under-pinned by professional mandate to be ‘evidenced-based’ (Goodman and Ley, 2012) and so far CTO’s fail to meet the much prized and costly gold-standard of evidence – how can we be justified in their persistent mandatory usage in the Mental Health Act as is?
This, amongst other arguments, is the basis for the #ChallengeCTOs campaign. We are calling for a review of the relevant legislation that governs the usage of CTO’s. If you agree that a review is warranted you can help get this heard in Parliament by signing up to our e-petition: http://epetitions.direct.gov.uk/petitions/67906.
Burns, T. and Molodynski, A.(2014), Community treatment orders: background and implications of OCTET trial. Psychiatric Bulletin, 38, pp3-5.
Goodman, B. and Ley, T.(2012), Psychology and Sociology in Nursing, London: Sage Publications.
Great Britain. Mental Health Act 2007. London: The Stationary Office. Available at: http://www.legislation.gov.uk/ukpga/2007/12/contents (accessed 30/06/14)
Health and Social Care Information Centre (2009), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment – 1998-1999 to 2008-2009, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].
Health and Social Care Information Centre (2013), Inpatients Formally Detained in Hospitals Under the Mental Health Act, 1983 and Patients Subject to Supervised Community Treatment, England – 2012-2013, http://www.hscic.gov.uk/article/2021/Website-Search?productid=13209&q=rates+of+CTO%27s+2007&sort=Relevance&size=10&page=1&area=both#top[Accessed: on 30/06/2014].
Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E, et al. (2014), An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res,47,pp 650-6.
Light, E. (2014), The epistemic challenges of CTOs: Commentary on Community treatment orders. Psychiatric Bulletin, 38, pp6-8.
Mustafa F., (2013) On the OCTET and supervised community treatment orders. Med Sci Law doi:10.1177/0025802413506898
Slade, M., Amering, M., Farkas, M., Hamilton, B., O’Hagan, M., Panther, G., Perkins, R., Shepherd, G., Tse, S. and Whitley, R. (2014), Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems, World Psychiatry, 13(1), pp12-20.
Williams, S. (In Press), Recovering from Psychosis: Empirical Evidence and Lived Experience, Routledge Press.