The prescriptive nature of Community Treatment Orders (CTOs) has led to debate about the coercive nature of this legislative development. This debate helps to show the interface between ethics and the law in mental health practice: on what basis is it just to lawfully deprive a person of freedom(s)?
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Nature of Community Treatment Orders (CTOs)
A CTO or Community Treatment Order authorizes mandatory care for individuals living in the society or community. In order words, CTO has been legal order by Magistrate or Mental Health Review Tribunal outlining the terms within which an individual needs to accept therapy, management, medication, rehabilitation, counselling and another service. It offers lawful right to the physicians to take care of psychologically damaged patients who fulfil a particular criterion to offer treatment rather than the patient's consent. Conversely, the preamble of CTO as mandatory treatment has led it controversial aspects in the mental health area. In reference to such aspects, this essay will produce arguments about what fundamental it is reasonable to deprive any psychologically damaged patients of his basic right to freedom and consent. The essay will discuss legal, ethical, policy and theoretical aspects of CTO as an attempt to justify questions related to coercive nature as well as the perspective of the particular legal order. The case of Josh will be considered to answer certain question related to coercive nature of CTO. The critical evaluation utilizing EBP will be undertaken to understand the effect of illness and mental health on Josh, his family and significant others. The psychosocial facet of illness familiarities will also be produced in a detailed manner in related to the provided case of Josh. Later, the conclusion will be outlined after discussing the involuntary nature of CTO as legal instruction.
The legal structure for mental health practices
The legislation offering legal obligation for coercive treatment has been a controversial issue in mental health regulation in the past few decades. The purpose of offering an involuntary cure to patients of mental health has been to confirm public safety and facilitate access to psychological treatment without restricting patient’s public relations and environment. The two of the rational that facilitate the foundation for justifying mentally ill patients deprived of basic freedom and consent involves policy power as well as the power of parens patriae (Bradbury, Ireland & Stasa, 2014). In law, parens patriae termed as communal policy authority of the state to interfere opposing negligent or abusive parent, informal caretaker, legal guardian and acting parent of any individual or child that require protection (Bradbury, Ireland & Stasa, 2014). The police power noted to empower the individual to limit the freedom of certain potentially intimidating people that may be a threat for the citizen. Given the case of Josh, his mother mentioned various instances of finding his son yelling and screaming on the fellow residence as well as encounters him physically attacking their property by punching on the house walls. Rugkåsa (2016) supported that the individual who lost their ability to make rational decisions and may threaten other citizen living in their surrounding is must be limited from their fundamental right of freedom. Under the regulation of the police power and parens patriae, state has been forced to obstruct Josh’s freedom to safeguard their neighbours prior they does certain harm to his fellow community people within psychologically damaged situation. In addition, Josh’s mother herself felt little intimidated by him and Alice felt safe whenever Josh remained away or absent from home. It is often evident that both the law of police power and parens patriae limits individual freedom due to their assaulting behaviours to protect wellbeing of other members associated with them. In accordance to Alice, Josh remained non-compliant with medication treatment for his depressive series prearranged by his GP. Glasby & Tew, (2015) argued that psychologically damaged people are a consistent risk to the community people and exhibiting abnormal or unusual behaviour need not be lawfully questioned until they harm or commit the crime. The friends, family, mental health expertise and relatives in the case remained unable to act in a timely manner to safeguard instances of serious results like robbery, murder or theft poses a legislative obstruction to the individual’s freedom. The practices of community treatment order as regulatory order within mental health legislation can be strong approach to eliminate such consequences in the future. On the contrary, CTOs implied within mental health law likely to be a strong approach to safeguard psychologically damaged people and citizen around them. In case of Josh, individual breaches a CTO by not following with circumstance of the order. Such people can be taken to the mental health institutions and provided correct treatment involving medication. The assaulting behaviour of the Josh has depicted his incapability to take rational decision and let family members to obstruct his fundamental right of freedom under legal order. The respective lawful order thus safeguards citizen from threats and support mentally ill people without limiting their social relation or environment.
The CTO or Community Treatment Order is often coercive in nature for patients like Josh who are abusive in behaviour and stop them from leveraging from compliance to the cure or care. Rugkåsa (2016) added that the coercive perspective of respective legislation is crucial to receive patient conformity with treatment and protect the society people from harm. The avoidance of patient compliance might be because patient’s disinclination, though literature report recommended that several external factors often contribute to non-compliance in the individual that is mentally unstable. The external elements mainly involve reasons that are far away from individual control like insufficient funds for childcare, illness or transportation (Glasby & Tew, 2015) These exterior factors are the reason behind non-compliance of the mentally ill people irrespective of their reluctance to get treatment as the only element. In context to respective coercive legislation, the government needs to assist patients related to transportation facilities, childcare help that is favourable to improve their treatment conformity. The lawful activities become mandatory to safeguard patient and people within the community from harm as well as help such individual with required medical attention.
Theoretical aspects of mental health practices
Mental health referred to as the level of psychological welfare and non-existence of mental illness. It is related to the condition of an individual who is capable of functioning at a satisfactory level of behavioural and emotional adjustment (Golightley & Goemans, 2017). Given the case of Josh, his mother noticed symptoms common to schizophrenia in him and she stated listening strange voices. Moreover, sometimes Josh also found punching holes in the neighbour’s property walls. In the existence of such mental illness, CTO has been essential for patient losing their rational decision-making capabilities in case of an illness like schizophrenia. As Josh found related to drug misuse history, where his mother encounter an instance of him using needle in bedroom, the two elements are sufficient to validate CTO as crucial aspect for him. In reference to the given case study, Josh does not have any idea about his mental impairment and his mother added that he consider himself completely fit without any drug problem. The mentally unstable individual like Josh who thinks they do not have any health issue, community treatment order becomes crucial for them. In context to John who fails to consider that they are in immediate need of medical attention as well as treatment, CTO would be crucial to coercively and involuntarily limit his freedom. Such actions are taken for the well being of the mentally ill individual like John and significant others surrounding or related to him. The respective legal order let the patient leave the hospital and cured safely within the community environment than a hospital. The mentally unstable individuals often find themselves completely fit without any health issues, but CTO has played a crucial role for people that lack insight about their mental health (Rugkåsa, 2016). It supports significant efforts towards safeguarding the safety and wellbeing of the individuals living in the community. A mentally unsteady individual needs continuous emotional support from their friends and families in their recovery phase; however, isolating patient by keeping them in hospital can lead to additional emotional pressure for their mental instability. Similarly, CTO offers mentally ill patients a chance to get treatment without isolated from their own friends and family members. The realization of the aspect that legislation had inconsistency that was avoiding the psychologically disturbed individual from medical attention from related health institutions has led to the formation of CTO legal order.
Policy and Ethical structure for mental health practices
The utilization of CTO and other kinds of compulsory outpatient treatment has been divisive. The debate on the effectiveness of the mandatory treatment in the society addresses the volatile mixture of clinical, social policy, human right and ethical issues. It has led differences in the perception of people about CTO to be violating human rights and obstructing civil liberties as well as rights. The debate contribute to be conflicting because of the coercive nature of respective legal order that promote the power of doctors over patient even it needs violating the autonomy of patient power. Conversely, there is a perception that CTO further enables health authority and a mentally ill patient with more liberty (Golightley & Goemans, 2017). This has been because of the legal order that psychologically damaged people are provided with the opportunity to get away with hospital treatment and receive treatment in the social atmosphere. In certain cases, physicians are likely to discharge the admitted patient in the hospital for mental illness under CTO than waiting for the patient to exhibit total recovery. In accordance with the literature report, Victoria has a minimum count of psychiatric hospitalization, and it was not because of certain state policy, however, due to the utilization of CTO. Their perception is that legislation of community treatment, in the case, it is coercive, are entrance with suspicion and doubts as ethical clarification. It relatively depends on identification of libertarian consistency of nominal mediation and general beliefs that CTOs are corrective, less defamatory and corrective (Rugkåsa, 2016). The legal order ultimately safeguard individual with psychological incapability to be flexible with obstructions and strengthen healthy beginning of freedom.
The psychosocial facet of the illness familiarities
The psychosocial facet in mental illness can be related to traumatic stress that influences individual mental development and course of common decision-making. The impact of psychological damage has not been only on the patient; however, on an individual's dependent as well. The freedom of choice for people with mental instability has been rational for disputes, and it ended with the confirmation of inpatient civil commitment; however, its utilization restricted by the large decrease in accessibility of psychiatric inpatient beds. The recent concern in psychiatry has polarized the several stakeholders in the mental health classification similarly as the propriety of practising community treatment orders. A CTO has been a regulatory provision by which any physician might need an individual with mental illness meeting specific facet to follow the path of treatment while residing in the society. It can be beneficial to differentiate between preventive and diversionary CTOs. For a person to be positioned on diversionary CTO, they need to fulfil jurisdiction's inpatient committal specification, where within preventive CTO individual does not require to fulfil inpatient committal specification (Szmukler, 2015). The community treatment order has been introduced to confirm care for mentally ill people like Josh without eliminating them from their community. Maughan et al., (2014) argued that patient with mental instability largely faces the stress of social deprivation and isolation, wherein case they forced to accept treatment often lead to the adverse occurrence of hostility. Such people may feel forced treatment as another approach of punishing them for remaining secluded from social customs. The healthy therapeutic relationship between patient and physician is building on confidence and trust in each other (Newton-Howes & Ryan, 2017). On the contrary, in CTO related physician presume a position of control and monitoring, as well as trust, cannot be accomplished because of which the psychosocial facet of the respective legal order remains unmet.
It is beneficial for the mentally ill patient to get medical support and willingness to engage with treatment even though to be unaware of their mental health condition. Given the case of Josh, his willingness to receive medical treatment is likely to favour him getting his mental stability back. The physicians may use such a situation to build a certain therapeutic relation of understanding and trust initially with Josh. The physician, rather than trying to attain have controlling position, needs to understand the suffering of patients with mental illness (Newton-Howes & Ryan, 2017). All this, in return, would help physicians to establish a healthy therapeutic relationship with psychologically damaged people.
The Impact on the family and considerably others
The process for authorizing treatment at the time of patient has found to be unstable varies largely among jurisdiction. Slade, (2014) discussed that in the certain stipulation, the treating physician takes the decision for the patient and on the other hand second responsible individual also engages in deciding the significance of treatment for mentally ill people. This often offers certain assurance to families or significant others for the clinical alternative, involving possibilities of foregoing treatment are completely undertaken in the instance of a patient encountering substantial side effects. Rugkåsa (2016) stated that there is two distinctive perspective of impact on family members and significant others. On one side, the community treatment order provides authority to the family to stay with the mentally unstable patient throughout the treatment procedure. On another side, it is observed that family member often feel relieved by the condition of CTO depicting responsibility of handling mentally ill person shifting to the professionals in healthcare (Szmukler, 2015). In case of
Josh, his mother would be relieved by legal order of CTO as she sometimes felt threaten by his own son and realized that at some point he might even harm other people. After the introduction of CTO and receiving health professional support, Alice would likely to sense relief that her son would be receiving required medical attention and she does not have to tense about his medical compliance. The initial episodes of mental disturbance due to bipolar disorder, depression, anxiety or schizophrenia occurs when individual still living their friends or families. The psychological impairment has ripples impact on families building tension, troubled emotions, uncertainty and large alteration in the way people progress their lives. In certain cases, families not heard by healthcare professionals, yet they are often main support for individuals impacted by mental disturbance or illness. In case any patient's family member is threatened by their abusive behaviour and afraid of them, the regulation of CTO would enable them to receive additional support from healthcare professionals. The family and significant other members of the patient will experience the relief that the mentally ill individual is going to receive required medical attention as well as they do not need to stress about the treatment compliance (Maughan et al., 2014). The family of Josh would be able to support in his recovery process, where friends and family are allowed to stay with the patient. Alice found to be worried about Josh health and trying hard to help him regain his mental stability by supporting him through every hardship. Such assistance is going to stop further damage, inevitable crises and deterioration of Josh encountering mental illness. The emotional support and encouragement from family or friends have the potential to enhance a healthier relationship with the patient (Maughan et al., 2014). The more amount of time spent with family is likely to be more significant than attending crisis management courses. They require information about the treatment offered and illness as well as about training or support to benefit themselves along with the individual that is ill or mentally disturbed. In addition, Community Treatment Order or COT might be successful and effective only it encourages a therapeutic relationship of trust between physicians, patients and family.
A critical assessment of the Impact of illness and mental health
The majority of the issues in mental health arise because of incapability of people to realize the requirement for medical need and non-compliance with treatment. The proponent opposes that community treatment order stops involuntary hospitalization and thus involved with the principle of offering treatment in the minimum restrictive atmosphere (Rugkåsa, 2016). The mental illness impacts the mental status of families and friends related to the patient. The influence of mental illness seen on neighbours, whom mentally disturbed patient often screams and verbally abuse under their mental state.
Given the case of Josh, he depicted several instances of mental instability in context his past actions. Josh’s mother assured that she sometimes hear abnormal noises and Josh has record of intravenous medicine mistreatment in addition to the drinking alcohol and smoking weeds. Additionally, John noted to remain away from his home for various days without any notice or information provided to his mother. Such consequences highlights that influence of mental illness not only reflected on individual patient, however largely disturb patient’s dependents. The adverse influence of mental instability is so serious that individual impacted by psychological disturbance fails to recognize the harm they are causing themselves and people surrounding them. Such an individual losing capability to take decisions often noted to execute dangerous crime and theft. In case of Josh, his mental illness affected mental health level of his mother and she has been in constant fear from his own son whenever he visited the home. Additionally, the influence might be observed on Josh’s neighbours to whom he used to verbally annoy and often screamed within psychologically damaged state. Hence, before the mentally ill patient loses all their control, it is important that concerned family members should get medical treatment for them, even it needs obstructing the patient's basic right to freedom. Rugkåsa, (2016) explained that because of influence of legal order, patients likely to be highly inclined by the physicians as a supervisor, where they have authority to utilize their control over the mentally ill patient to confirm treatment. It is noted by several of RCT that community treatment order has led a significant impact on decreasing count of hospitalization from 0.7 to 3.7 per thousand days as well as decreasing financial stress on the economy of state (Charlesworth & Josh son, 2018). In such a context, it is deduced that compulsory treatment regulation is beneficial to confirm the patient's safety and their dependent's wellbeing.
In a declaration to the above study, it is concluded that CTOs are often not essential in case the government offer community services. The respective belief has not been applicable in the situation of a mentally ill patient. The psychologically damaged individual remains uninformed about personal mental state and continuously decline treatment because of stigmas attached to the mental health institution and their support lack of information about mental wellness. The coercive nature of CTOs has been justified on the respective term that the mentally ill individual is unable to undertake rational decisions for themselves. Moreover, community treatment order places the physician in controlling and authority position. The physicians often noted to take the decision for wellbeing of the patient without the individual’s autonomy and family authority. Some of the clinicians argued that physician achieves an autocratic place in CTO law and prevent the establishment of the therapeutic relationship between physician as well as the patient. There have been several contradictions to criticize the legal order, but during risk-benefit analysis, the count of benefits outnumbered the threat related to CTO. The only adjustment needed to be included in the legal order relate to supporting the improvement in patient compliance like children facilities and stipulation of transportation. It residues to be observed that these additions have the potential to ensure that services are really provided to improve the mental health of community people.