The Community Treatment Order (CTO) – An Altruistic Overreach in Patient Care in Psychiatry

I read with interest and appreciation the article “Coercion in Outpatients under Community Treatment Orders: A Matched Comparison Study” by Nakhost et al. ¹ in the November edition of your journal.

In my opinion, the key to solving the problem of perception of coercion is the voluntary agreement of the patient to comply with the CTO. For instance, a patient who no longer qualifies for involuntary treatment and who is no longer acutely ill is most likely capable of consenting to treatment and, in the event that his/her consent is not considered and he/she is put on a CTO, the patient is justified in seeing the CTO as coercive and will not be enthusiastic in complying with the order. The result will be having to resort to an apprehension order, which further undermines the treatment team and patient therapeutic alliance and increases the risk of burn out on the part of the community team supervising the CTO.

Mental health teams want to do the best by their patients. However, they must never forget the principle of “procedural justice.” In striving to meet the standards of procedural justice one must not forget the patient’s right to autonomy. The golden road to arrive at this standard is to appreciate that the CTO is not a treatment order per se, but an order to present oneself for treatment.

I strongly believe that at the crossroads of the perception of coercion is the undermining of the consent clause by enthusiastic and altruistic treatment teams thus rendering the CTO a “utilitarian” instrument. ² There are enough provisions to get patients treated and the general public protected, including the existing Mental Health Acts, the Common law provisions, the Charter of Human Rights, The Criminal Codes of Countries, amongst others. The UN declaration of Human Rights (UN 1948) states that patients have a right to life, liberty, and security of person (Article 3) without undue interference (Article 12).

As I make my submission in this letter, I wonder what Thomas Szasz will be thinking, as he maintained he was not anti-psychiatry but anti-coercion psychiatry. ³

Daniel Chinedu Okoro, MD, DPM, LMCC, FRCP(C), DABPN, FAPA Department of Psychiatry, University of Calgary Calgary, Alberta, Canada [e-mail]