OutlineIntroduction to mental healthMental Health ActMental Health Amendment Act – Bill 31Benefits of Community Treatment Orders

(CTO’s)Criticisms of CTO’sImplications

http://www.youtube.com/watch?v=dFdYqRuqKDM

Alberta Mental Health Act• Provincial Statute/Law• 1 of 3 Acts that take away people’s liberty to

make their own decisions (Criminal Act is another)

• Very powerful! • Allows for involuntary detention & treatment of

persons w/mental illness under certain conditions:– Mental disorder– Danger to self or others– No alternative

MHA cont’dActs contain regulations (HOW the Act will

be carried out). In the MHA the following regulations are included:Apprehension S 10 (how someone gets to facility)Examination S 5 (what Doc & facility can do)Admission Certificates S 2 (that allow ppl to be detained

in facility)Renewal Certificates S 8Treatment Decisions Ss 26-29Review Panels Ss 34-41Judicial Review S 43

MHA – Patient Rights• The following patient rights are listed within

the Act:– Information– Confidentiality– Communications– Visitors– Legal representation– Refusal of treatment– Appeal– Have an advocate

MHA Amendment Act - 2007Not law yet. First passed April 17, May 10, and

again on December 7, 2007. Not yet proclaimed.Significant Changes

- New Act will lower the threshold for certification, and for CTO’s

- Detainment not only in facilities but in community as well (CTO)

- CTO can be revoked and you can be ordered back as an inpatient

- Role of other health care professionals expanded- May have large impact on ER’s- Good middle step which is following legislation of other

provinces

Community Treatment Orders• Patient must still suffer from a mental disorder• Must still meet list of criteria as outlined in MHA S

9.1(1)(b)• Treatment must exist in community AND will be

provided• Physicians must believe there will be compliance by

pt• Expiration:

– Expires 6 mths after issued– No restriction on amt of renewals– If person breaches order, physician signs an instant

order for police to apprehend the person to a facility and be assessed for certification

“While opponents of community committal make the case that it denies people the basic right to choose or refuse treatment, those who favour this strategy counter that we are not enhancing people's rights by allowing them to live without dignity or decent quality of life. Without regular treatment, people are more apt to be admitted and readmitted to hospital, a place where involuntary patients have few rights indeed. In fact, by helping to see that they receive treatment outside the hospital, we are actually helping to safeguard people's right to a fulfilling life in the community. ” (CMHA, 1998).

“For both consumers and others, it often comes down to a question of human rights and civil liberties,” (CMHA, 1998).

Consistent treatment It does not enhance rights to allow people to live without

dignity or decent quality of life Clients have very few rights if involuntarily hospitalized;

community committal is less restrictive is a preferred last resort alternative to involuntary hospitalization

There is less intrusion on civil liberties than in hospital and savings on costs can be transferred to community services

Some mental illnesses affect ability to reason New medications are effective if used consistently Professional role is more effective if patients comply with

treatment

Community Treatment Orders

Benefits

A Community Treatment Order (CTO), “...means an order requiring treatment for mental illness of a person who is at large in the community but does not apply to a person in prison or a patient in an approved mental health service,” (Brophy & Ring, 2004, pp. 159).

- Depending on the individual, different measures will be taken- The intended purpose of CTO’s is...

Community Treatment OrdersCriticisms

‘Police Like’ Role vs. The Therapeutic RoleCTO’s effectiveness is questionableFurther Oppressive (State power over human

rights)Response to and filling the gap for lack of

community resourcesInvoluntary and enforced on non-compliant patientsInformed Choices and Human RightsNegative impacts of coercionFurther disempowering

Implications to Practice and Mental Healthcare

• Intended Consequence: Economic Savings

- Proponents of CTO’s cite many positive consequences including freeing up hospital beds and economic savings to an overtaxed healthcare system

- It has been noted in the literature, however, that consumers struggle to obtain adequate community services voluntarily, let alone if individuals are mandated.

- How can we achieve adequate service provision in the community to support CTO’s in the current economic and political climate?

- Will hospital services remain an adequate alternative should patients need that level of care?

Intended Consequence: Consumer Stabilisation & Consistency of Care

- As opposed to revolving door hospitalizations and lack of cohesive and consistent care after discharge

Challenges- Structure of services not currently existing in

diversity or number- Inequity of service provision geographically in

province

Possible Unintended Consequences Social Implications

Consumer loss of personal autonomy and control over treatment

Coercion a) Causes anxiety for practitioners who over-see CTO’s

b) Strongly opposed by many consumer groups as in direct conflict with human rights

c) Also opposed by family and allies for the same reasons

Legalities CTO’s could criminalize mental health by bringing consumers into contact with

police and making treatment a legal issue

Substantial Deterioration or Serious Impairment

Intended Consequence: to allow health professionals to treat a person who is seriously mentally ill that are not a danger to themselves or others

Possible Unintended Consequences:Medical : Assessment tools need to be created or

implemented in health setting as applies to Bill 31Legal: term ‘serious’, ‘substantial’ and

‘deterioration’ are ambiguous and may become a constitutional issue because they are open to interpretation

Community Treatment OrdersIntended Consequence: to improve quality of

life for individuals through treatmentPossible Unintended Consequences:

Not a recovery model thus individuals are in a continuous cycle of being ‘the disabled’

Treatment not defined Social: flexibility also can create opportunities for

abuses of power Legal: ambiguity may lead to constitutional issues

Cultural Implications Case of Ifufunyane vs. PsychosisPossible Unintended Consequences:

Social: may close down conversations about the underlying assumptions of health/mental health

Proposed changes to Mental Health Act are substantial and merit planned review for effectiveness

- Changes will be implemented this September, with CTO being implemented in January

- While most Mental Health Acts set out a timeline for evaluation, Bill 31 has no such plan for evaluation

- The last two phases of the stages of policy making could hindered as implementation of Bill 31 could be hindered by lack of service structure and evaluation of the bill has not been specified.

ConclusionsQuestions & Comments

ReferencesAlberta Mental Health Patient Advocate. (2008). Amendments to the Mental Health Act. Retrieved from http://www.mhpa.ab.ca

Al-Issa, I. (Ed.) (1996). Handbook of culture and mental illness: An international perspective. Madison: International Universities Press, Inc.

Brophy, L. & Ring, D. (2004). The efficacy of involuntary treatment in the community: Consumer and service provider perspectives. Social Work in Mental Health, 2

(2-3), 157-174.

Canadian Mental Health Association. Alberta Division: Advocacy. Retrieved from http://www.cmha.ab.ca/bins/site_page2.asp?cid=284-285-1247&lang=1

Canadian Mental Health Association. Alberta Division: Community Committal. Retrieved from http://www.cmha.ab.ca/bins/content_page.asp?cid=5-33-179&lang=1

Dawson, J., Romans, S., Gibbs, A. & Ratter, N. (2003). Ambivalence about community treatment orders. International Journal of Law and Psychiatry, 26 (3), 243-255.

Dreezer & Dreezer Inc. (2005). Report on the legislated review of community treatment of community treatment orders, required under section 33.9 of the mental

health act for Ontario ministry of health and long term care. Retreived on September 1st, 2009, from

http://www.ssaedmonton.com/PDF%20files/Bay_CTO_Review.pdf.

Mental Health Act. c. M-13 R.S.A. (2000).

Mental Health Admendement Act. M-13. (2007).

Niehaus, D. J. H., & Stein, D, J, & Koen, L, &, Lochner, C, & Muller, J. E., Mbanga, N. I., et al (2006).Clinical case discussion: a case of ifufunyane: a Xhosa culture-

bound syndrome. Journal or Psychiatric Practice, 11(6), 411-413.

Premier’s Council on the Status of Person’s with Disabilities (2008, August). Changes on the way for the mental health act. Disability in Focus. Retrieved on September,

2nd, 2009, from http://www.seniors.alberta.ca/PremiersCouncil/DIFnewsletter.pdf

Provincial Health Ethics Network. (2007). Review of bill 31: Mental health amendment act 2007 submitted to the standing committee on community services. Retrieved

September 1, 2009, from http://www.phen.ab.ca/pcons/docs/MHActSummaryFinal.pdf

Psychiatric Patient Advocate Office, Government of Ontario. Retrieved from http://www.ppao.gov.on.ca/inf-com.html

Schizophrenia Society of Alberta. (2007). Alberta Bill 31 Mental Health Amendment Act 2007 Comparative Analysis. Retrieved September 1 from

http://www.ssa-edmonton.com/PDF%20files/BILL31-comments.pdf

Yip, S. (2003). Social workers’ and physicians’ experiences with review panels in British Columbia. Social Work in Mental Health, 2 (1), 71-89.