By Ken McLaughlin
The history of psychiatry is full of examples of political, social and economic influences on both diagnosis and treatment. There are the blatant examples, such as drapetomania, a 'mental disorder' said to affect black slaves who wanted freedom, the classification of homosexuality as a mental disorder and the use of psychiatry to detain and treat political dissidents in the former USSR.
Psychiatry has changed immensely since those dark days and there have been many improvements in the care and treatment of the mentally ill. Most psychiatrists and other mental health professionals are deeply committed to alleviating the pain and distress of those they work with, often within a service that is grossly under-resourced.
Even those psychiatrists who still cling rigidly to the biomedical model acknowledge the influence of political, socioeconomic and psychological factors on the mental well-being of their patients.
Nevertheless, psychiatric practice is still all too often directed not by advances in mental health care but by the political and cultural concerns of the day. The use and abuse of Community Treatment Orders (CTOs) is but one of the more recent manifestations of this process. They are reflective of a wider culture of fear and risk aversion, of a political establishment increasingly concerned with the micromanagement of community life, a process which also affects professionals who increasingly work in a risk-averse manner.
Dubbed the 'psychiatric asbo', CTOs arose out of a concern that community care had failed and that the public had been placed at risk by a worthy but misconceived policy to close down the long-stay mental hospitals. High profile tragedies where ex-patients had killed were used to argue that community care had failed and that it had put the public at risk from psychiatric patients, and the patients at risk from themselves due to violence, self-harm and/or neglect.
Mental health legislation enacted prior to the widespread move to care in the community was held by some to be inadequate for a time when most mental health care was located within the community rather than in the old long stay psychiatric institutions. Whilst not without controversy and much opposition such concerns were highly influential in the drawing up of the Mental Health Act (MHA) 2007 which amended the 1983 Act.
The MHA 2007 provided powers by which patients detained in hospital for treatment, could, upon discharge, be made subject to Supervised Community Treatment, more commonly known as a Community Treatment Order (CTO). The CTO can compel the patient to abide by certain specified conditions, most notably, though not exclusively, that they continue to take any prescribed psychiatric medication. Failure to comply could lead to the patient being recalled to hospital, where the drug could be forcibly administered.
The introduction of CTOs was controversial in a number of ways, but mainly because it changed the status of psychiatric patients post-discharge from hospital. Whereas previously, under the MHA 1983, patients lost the right to refuse medical treatment whilst subject to hospital detention, once discharged from their section and returned to the community they regained the same rights of citizenship as the rest of us, such as the right to refuse medical treatment, even if this goes against professional medical opinion and is likely to be detrimental to our health.
Cases of ex-patients discontinuing their prescribed medication are not uncommon. Psychiatric medication can lead to some severe and unpleasant side-effects such as tardive dyskinesia (symptoms similar to Parkinson’s disease), drowsiness, tremors, sexual problems and weight gain. Unsurprisingly, some patients exercised their then right to stop taking their medication as soon as it was possible.
In addition, some patients would dispute that they had a mental illness, instead see themselves as victims of psychiatric oppression and again stop co-operating with mental health professionals as soon as it was possible.
Such non-compliance was implicated in several cases were psychiatric patients had committed homicide. Despite the dangers posed by ex-patients being greatly exaggerated such tragedies were hugely influential in the framing of the debate that subsequently led to the introduction of CTOs. It was initially thought that CTOs would mainly be used on patients with several psychiatric admissions, the so called ‘revolving door’ patient phenomenon, whereby someone was admitted to hospital, got better with medication, was discharged, stopped taking the medication, relapsed, was readmitted to hospital and so on.
Irrespective of this, a history of non-compliance is not necessary for a CTO to be imposed; it can be applied to a patient after a first compulsory admission for treatment provided the necessary criteria are met.
Once professionals had the power to put people on CTOs they made full use of them. For example, the government envisaged that between 350-450 CTOs would be issued in England and Wales in the first year that the powers came in to force. However, the number far exceeded the government’s and its advisers’ expectations. In the first five months in which professionals were able to issue them, November 2008 to March 2009, there were 2,134 issued in England alone. And the numbers have continued to rise. According to NHS figures cited in The Independent, the number of people placed on CTOs has risen steadily since they were first brought in. In 2012 there were 4,764 people subject to such orders – 473 more than in 2011, an 11 per cent rise. In addition, many patients placed on a CTO were not 'revolving door' patients but were subject to the order following their first admission.
Given the political and media pressure that can follow a public tragedy such as a homicide by an ex-psychiatric patient, it may be the case that in many instances people are being discharged on CTOs not for their own benefit but for that of the professionals – to cover their backs in the case of something going wrong. Recently, Tom Burns, a prominent psychiatrist and proponent for the introduction of CTOs concluded that they were ineffective.
Many people see little difference between the mentally ill being subject to involuntary care and treatment in hospital and in the community. For them, there is no ethical contradiction, the hospital wall being only an arbitrary line between in-patient and out-patient. This may be the case but it is problematic for two main reasons. First, for a free society such barriers between the public and private spheres are essential, but increasingly we are witnessing the steady encroachment of public bodies into the private lives of citizens. CTOs are but one example of a wider cultural trend.
Second, as I argue elsewhere, whereas psychiatric intervention can be justified at the point of hospital admission, it is not necessarily justified at the time of discharge. On admission, the patient may be in an acutely psychotic state, having lost touch with reality. However, at the time of discharge, this is rarely the case. At discharge the patient can be well, have full mental capacity, with greatly reduced psychotic symptoms, or even none at all.
Prior to the introduction of CTOs it was acknowledged that at the point of discharge, the now ex-patient regained the status of an autonomous subject. In the process, he or she regained the rights of citizenship, including the right to refuse medical treatment even if doctors deem it to be in his or her best interest. Today, subject to a CTO, the patient does not return to full citizenship status but to a reduced social standing, neither full citizen nor patient but a diminished hybrid of the two - the 'community patient'.
Dr Ken McLaughlin is a lecturer in social work at Manchester Metropolitan University. He is speaking at the session Community Treatment Orders: the psychiatric ASBO? at the Battle of Ideas festival, taking place at London’s Barbican on 18-19 October.
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