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Community treatment orders are not a good thing

  • Simon Lawton-Smith (a1), John Dawson (a2) and Tom Burns (a3)

Does politicians' enthusiasm for community treatment orders lie primarily in the area of public protection? If so, can such orders reduce homicide rates? Is there adequate evidence of their value, given their adverse effects on individual liberty? This well-researched and provocative debate will enlighten readers on these and many more of the complicated questions surrounding this issue.

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1 Atkinson, JM, Garner, HC. Least restrictive alternative - advance statements and the new mental health legislation. Psychiatr Bull 2002; 26: 246–7.
2 Lawton-Smith, S. A Question of Numbers: The Potential Impact of Community-based Treatment Orders in England and Wales. King's Fund, 2005 (
3 Churchill, R, Owen, G, Singh, S, Hotopf, M. International Experiences of Using Community Treatment Orders. Department of Health, 2007 (
4 Kisely, S, Campbell, L A, Preston, N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2005; (3): CD004408.
5 Royal College of Psychiatrists. Second Reading Briefing on the Mental Health Bill 2006, House of Commons: 16th April 2007. Royal College of Psychiatrists, 2007.
6 Romans, S, Dawson, J, Mullen, R, Gibbs, A. How mental health clinicians view community treatment orders: a national New Zealand survey. Aust N Z J Psychiatry 2004; 38: 836–41.
7 Dreezer & Dreezer Inc. Report on the Legislated Review of Community Treatment Orders, Required Under Section 33.9 of the Mental Health Act. Ontario Ministry of Health and Long-Term Care, 2005 (
8 Gibbs, A, Dawson, J, Ansley, C, Mullen, R. How patients in New Zealand view community treatment orders. J Mental Health 2005; 14: 357–68.
9 Appelbaum, P. Assessing Kendra's Law: five years of outpatient commitment in New York. Psychiatr Serv 2005; 56: 791–2.
10 National Confidential Inquiry. Avoidable Deaths: Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness. University of Manchester, 2006 (
11 Department of Health. Mental Health Bill: Regulatory Impact Assessment. Department of Health, 2006 (
12 Department of Health. Mental Health Bill. Briefing Sheets on Key Policy Areas: Supervised Community Treatment. Department of Health, 2006 (
13 Okai, D, Owen, G, McGuire, H, Singh, S, Churchill, R, Hotopf, M. Mental capacity in psychiatric patients. Systematic review. Br J Psychiatry 2007; 191: 291–7.
14 Dawson, J, Szmukler, G. Fusion of mental health and incapacity legislation. Br J Psychiatry 2006; 188: 504–9.
15 Szmukler, G, Holloway, F. Maudsley Discussion Paper No.10. Mental Health Law: Discrimination or Protection? Institute of Psychiatry, 2001 (
16 Care Services Improvement Partnership. Our Choices in Mental Health. Care Services Improvement Partnership, 2006 (
17 Mintz, A, Dobson, K, Romney, D. Insight in schizophrenia: a meta-analysis. Schizophr Res 2003; 61: 7588.
18 David, A, Buchanan, A, Reed, A, Almeida, O. The assessment of insight in psychosis. Br J Psychiatry 1992; 161: 599602.
19 Priebe, S, Fakhoury, W, White, I, Watts, J, Bebbington, P, Billings, J, Burns, T, Johnson, S, Muijen, M, Ryrie, I, Wright, C. Characteristics of teams, staff and patients: associations with outcomes of patients in assertive outreach. Br J Psychiatry 2004; 185: 306–11.
20 Dawson, J. Fault-lines in community treatment order legislation. Int J Law Psychiatry 2006; 29: 482–94.
21 Chief Psychiatrist. Community Treatment Order Guidelines. Mental Health Branch, Victorian Government Department of Human Services, 2005 (
22 Kisely, SR, Xiao, J, Preston, NJ. Impact of compulsory community treatment on admission rates. Survival analysis using linked mental health and offender databases. Br J Psychiatry 2004; 184: 432–8.
23 Kisely, S, Smith, J, Preston, N, Xiao, J. A comparison of health service use in two jurisdictions with and without compulsory community treatment. Psychol Med 2005; 35: 1357–67.
24 Slade, M, Priebe, S. Are randomised controlled trials the only gold that glitters? Br J Psychiatry 2001; 179: 286–7.
25 Wright, C, Catty, J, Watt, H, Burns, T. A systematic review of home treatment services. Classification and sustainability. Soc Psychiatry Psychiatr Epidemiol 2004; 39: 789–96.
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30 Rolfe, T. Community Treatment Orders: A Review. Department of Health, Western Australia, 2001 (
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Community treatment orders are not a good thing

  • Simon Lawton-Smith (a1), John Dawson (a2) and Tom Burns (a3)
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More debate is necessary

David H Yates, retd: carer
24 September 2008

.The debate is necessary .

CTO's may help in putting pressure on Commissioning Trusts and provider Trust to fund after-care

needs so that those within this compulsion can be led into outside activities..I meet with other carers. They all know that medications is not enough - although they reduce the chance of relapse. They know that nothing moves forward from that, unless sufferers reach some kind of life, meaningful and directional, for themselves.

CTO's would help in passing authority,from professional expertise and experience in the long-term condition, into the carer situation, to help family carer escape the argument, recrimination and retaliation, when the family carer 'pushes' , on their own, for sufferer to 'exercise their lost neurons' outside themselves , outside the care base in safe areas for them.

Professional service has the authority to come to conclusions from expertise, and advise from that authority – if they exert that authority –no more so than the advice from the lead consultant psychiatrist . If the consultant psychiatrist does not specify a need at the Need Assessment stage then it will neither be commissioned by the Primary Care Trust , nor funded, nor delivered .in the Care Plan for after-care, where there is long term illness.

Home treatment is now the forefront area of care and treatment of schizophrenia,.. At present family carers feel let down. They are not given protection by being able to say – 'this is what the doctor's expertadvice says is necessary, which I have to follow .. – ' you must exercise your neurons on something as you would exercise your leg after injury to get fit again' ....CTO,s will come into consideration here. Present consultant psychiatrist lead is failing to put their authority behind 'breaks in the week' as a Home Treatment after-care need at the Needs Assessment stage of the Care programme Approach. The separation of parties reduces the chance of high EE. When 'breaks in the week' are not there as a request from authoritative psychiatric statement, there is no pressure on funders and deliverers to fund and find after-care outlets. If the outlets are not there to meet the need , the consultant lead should have the absence registered as an UNMET NEED in the Care Plan , which will stay there in the Review stage of the CPA , or under CTO. mental health teams should register it as a SERVICE Deficiency at the needs assessment stage..

Professional service has authority but little front-line presence to exercise it. Family carers have presence in abundance but neither authority to push long-term patients into engagement, nor clout to influence commissioners, on their own. They need an authoritative prescription of after-care to sustain their claims.

D H Yates FRC
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Conflict of interest: None Declared

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The conditional discharge model: just common sense?

Philip A Sugarman, CEO and Medical Director
08 August 2008

Lawton-Smith, Dawson and Burns set out their fears and hopes around the new community treatment orders, and appear to agree that usage should be selective. Compulsory community treatment in the UK has been contentious for many years (Mental Health Act Commission 1988), such that the Government's concrete proposals for de novo compulsion of "non-resident" patients brought great anxiety (Department of Health 2002).

The legislation that eventually emerged is less radical, being only applicable to detained in-patients. Arguably, it is just a new variant of the tried and tested formula of leave from hospital; and the key powers ofrequirements and of recall are very close to the equally road-tested conditional discharge for restricted forensic patients (Sugarman 1999).

So the new law builds on current clinical experience and extends the powers of psychiatrists. I believe we should respond to this trust with professionalism and common sense.

DEPARTMENT OF HEALTH (2002). Draft Mental Health Bill. Cm 5538-1. London, The Stationery Office.

MENTAL HEALTH ACT COMMISSION (1988) Compulsory Treatment of the Mentally Disordered in the Community: the Field of Choice. London: Mental Health Act Commission.

SUGARMAN (1999) New Community Mental Health Law: theConditional Discharge Model. Psychiatric Bulletin. 23, 195-198.
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Conflict of interest: None Declared

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