Alberta's community treatment order legislation and implementation: the first 18 months in review.

• Author: Orr, Fay
• Position: Giving Voice 2: Advocacy & Mental Health

Introduction

Providing the appropriate level of treatment and care to individuals with serious and persistent mental disorders can be a significant clinical challenge. Some individuals become caught in a "revolving door" cycle of formal hospitalization when they meet the criteria for involuntary admission, respond to psychiatric treatment, and are discharged once stable, only to deteriorate in the community and require re-admission. Other individuals require long term hospitalization in psychiatric facilities as the nature of their symptoms and/or disabilities cannot be adequately and safely managed by resources available in the community on a completely voluntary basis. On January 1, 2010, Community Treatment Order (CTO) legislation was proclaimed for the first time in Alberta. (1) This provided an option for the community management of these patients.

This article provides information about the first 18 months of implementation of CTOs, based on the experience of Alberta clinicians and health care administrators, and the Mental Health Patient Advocate (Advocate). Brief background information will be reviewed and demographics of patients cared for under CTO legislation to date will be provided, as will a discussion of lessons learned and challenges to be resolved.

Background

Prior to the enactment of CTO legislation by way of Bill 31, the Mental Health Amendment Act, a substantial consultation process occurred. A legislative committee held public meetings, and submissions were heard from concerned individuals, as well as representatives from professional organizations, advocacy and consumer groups.

During consultations on Bill 31, the Advocate was supportive of the introduction of CTOs, viewing them as a way to support recovery from mental illness. The Advocate's 2007 written submission on the Bill stated: "There is an evolving recognition of the role that empowerment plays in mental illness and recovery. Experience from other jurisdictions shows that CTOs work best when clients and substitute decision-makers are consulted and involved in the formulation of a CTO." (2)

The Advocate submission also advised that appropriate checks and balances should be included in legislation to reduce the impact of CTOs on patients' rights under the Canadian Charter of Rights and Freedoms. Protections should include the right to independent review of the need for a CTO, the right to appeal unfavourable decisions to the courts, and to access legal counsel. Additionally, "when they cannot afford legal counsel, legal aid should be provided. A standard practice for all patients placed on CTOS is a formal explanation of their rights." (3)

The Advocate's support was also contingent on the appropriate supports being available to patients in the community. "Recovery is limited unless the social determinants of health (e.g. treatment, housing, income, meaningiul activities) are addressed. Indeed the successful implementation of legislation that focxises on CTOs is predicated upon collaborative approaches to address these fundamental supports for patients." (4)

Most of the Advocate's recommendations were accepted. Persons under CTO were accorded the same rights and protections as formal patients, including the right to access the Advocate. Legal Aid was provided at no cost regardless of income to those appealing their CTO to a Review Panel.

Amendments to the Mental Health Act

The amended Alberta Mental Health Act (the "Act") sets out the criteria under which a CTO may be written. A CTO may be issued if two physicians, one of whom must be a psychiatrist, are of the opinion that the person is suffering from a mental disorder and that they meet applicable criteria to ensure that their psychiatric condition has proved to be chronic. Thus, the person must, in the preceding 3-year period, on 2 or more occasions for a total of at least 30 days, have been a formal patient in a facility, or have been lawfully detained in a custodial institution while meeting the criteria required to be a formal patient, or some combination of the two. Alternatively, the person might have been previously subject to a CTO within the immediately preceding 3-years, or while living in the community exhibited a pattern of recurrent or repetitive behavior that indicates the likelihood of harm to self or others or to suffer substantial physical or mental deterioration or serious physical or mental impairment if the person does not receive continuing treatment or care while living in the community. Note that almost all CTOs written to date in Alberta have been initialed while the person was a formal patient.

An assumption is made that living in the community is a less restrictive alternative than formal hospitalization. Prior to issuing a CTO, however, it must be evident that the treatment or care that the person requires exists in the community, is available to the person and will be provided to the person. The person must also be determined to be able to comply with the treatment or care requirements set out in the CTO.

The person must provide informed consent to the CTO if competent. The Act sets out the mechanism for appointing a substitute decision maker if the person is not competent. Consent for the CTO is not required in a circumstance where the person has exhibited a history of not obtaining or continuing with treatment or care that is necessary to prevent the likelihood of harm to others, and the CTO is reasonable in the circumstances and would be less restrictive than retaining the person as a formal patient. Note that the consent to a CTO in Alberta is not a consent to specific treatment and does not permit treatment (i.e. medication) to be administered without the person's...