Do Community Treatment Orders in Psychiatry Stand Up to Principalism: Considerations Reflected through the Prism of the Convention on the Rights of Persons with Disabilities

Abstract

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.

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References

Thornicroft and

Tansella , “Balancing Community-Based and Hospital-Based Mental Health Care,” World Psychiatry 1, no. 2 (2002):84-90.

Dawson

, “Fault-Lines in Community Treatment Order Legislation,” International Journal of Law and Psychiatry 29, no. 6 (2006): 482-494.

Callaghan and

Newton-Howes , “Coercive Community Treatment in Mental Health: An Idea Whose Time Has Passed?” Journal of Law and Medicine 24, no. 4 (2017): 900-914.

Leff ,

Trieman , and

Gooch , “Team for the Assessment of Psychiatric Services (TAPS) Project 33: Prospective Follow-Up Study of Long-Stay Patients Discharged from Two Psychiatric Hospitals,” American Journal of Psychiatry 153, no. 10 (1996): 1318-1324.

Churchill

, International Experiences of Using Community Treatment Orders (Kings College London: Institute of Psychiatry, 2007).

Newton-Howes and

Banks , “The Subjective Experience of Community Treatment Orders: Patients' Views and Clinical Correlations,” International Journal of Social Psychiatry 60, no. 5 (2014): 474-481; D. Maughan, A. Molodynski, J. Rugkasa, and T. Burns, “A Systematic Review of the Effect of Community Treatment Orders on Service Use,” Social Psychiatry and Psychiatric Epidemiology 49, no. 4 (2014): 651-663; K. Canvin, J. Rugkåsa, J. Sinclair, and T. Burns, “Patient, Psychiatrist and Family Carer Experiences of Community Treatment Orders: Qualitative Study,” Social Psychiatry and Psychiatric Epidemiology 49, no. 12 (2014): 1873-1882; M.S. Swartz, H.R. Wagner, J.W. Swanson, V.A. Hiday, aNd B.J. Burns, “The Perceived Coerciveness of Involuntary Outpatient Commitment: Findings from an Experimental Study,” Journal of the American Academy of Psychiatry and the Law Online 30, no. 2 (2002): 207-217.

See Newton-Howes, supra note 6;

Lawton-Smith

, A Question of Numbers The Potential Impact of Community-Based Treatment Orders in England and Wales (London: King's Fund, 2005).

Lawton-Smith ,

Dawson , and

Burns , “Community Treatment Orders are Not a Good Thing,” The British Journal of Psychiatry 193, no. 2 (2008): 96-100.

Burns and

Molodynski , “Community Treatment Orders: Background and Implications of the OCTET Trial,” Psychiatric Bulletin (2014), doi: pb. bp. 113.044628; T. Burns, J. Rugkåsa, and A. Molodynski, et al., “Community Treatment Orders for Patients with Psychosis (OCTET): A Randomised Controlled Trial,” The Lancet 381, no. 9878 (2013): 1627-1633.

10.

Newton-Howes and

C.J.

Ryan , “The Use of Community Treatment Orders in Competent Patients is Not Justified,” The British Journal of Psychiatry 210 (2017): 311-312.

11.

See T. Burns, J. Rugkåsa, and A. Molodynski, et al., supra note 9;

H.J.

Steadman ,

Gounis , and

Dennis , et al., “Assessing the New York City Involuntary Outpatient Commitment Pilot Program,” Psychiatric Services 52, no. 3 (2001): 330-336; M.S. Swartz, J.W. Swanson, H.R. Wagner, B.J. Burns, V.A. Hiday, and R. Borum, “Can Involuntary Outpatient Commitment Reduce Hospital Recidivism?: Findings from a Randomized Trial with Severely Mentally Ill Individuals,” American Journal of Psychiatry 156, no. 12 (1999): 1968-1975.

12.

Lepping and

Malik , “Community Treatment Orders: Current Practice and a Framework to Aid Clinicians,” The Psychiatrist 37, no. 2 (2013): 54-57.

13.

Niveau

, “Relevance and Limits of the Principle of ‘Equivalence of Care’ in Prison Medicine,” Journal of Medical Ethics 33, no. 10 (2007): 610-613.

14.

Newton-Howes

, “A Factor Analysis of Patients' Views of Compulsory Community Treatment Orders: The Factors Associated with Detention,” Psychiatry, Psychology and Law 20, no. 4 (2013): 519-526.

15.

Newton-Howes and

Mullen , “Coercion in Psychiatric Care: Systematic Review of Correlates and Themes,” Psychiatric Services 62, no. 5 (2011): 465-470.

16.

P.S.

Appelbaum

, “Thinking Carefully about Outpatient Commitment,” Psychiatric Services 52, no. 3 (2001): 347-350.

17.

Gooding

, “Navigating the ‘Flashing Amber Lights’ of the Right to Legal Capacity in the United Nations Convention on the Rights of Persons with Disabilities: Responding to Major Concerns,” Human Rights Law Review 15, no. 1 (2015): 45-71; M. Simmons and P. Gooding, “Spot the Difference: Shared Decision-Making and Supported Decision-Making in Mental Health,” Irish Journal of Psychological Medicine 34, no. 4 (2017): 275-286.

18.

Newton-Howes and Mullen, supra note 15;

Szmukler and

P.S.

Appelbaum , “Treatment Pressures, Leverage, Coercion, and Compulsion in Mental Health Care,” Journal of Mental Health 17, no. 3 (2008): 233-244; B. Link, D.M. Castille, and J. Stuber, “Stigma and Coercion in the Context of Outpatient Treatment for People with Mental Illnesses,” Social Science & Medicine 67, no. 3 (2008): 409-419.

19.

Newton-Howes

, “Coercion in Psychiatric Care: Where are We Now, What Do We Know, Where Do We Go?” The Psychiatrist 34, no. 6 (2010): 217-220.

20.

Szmukler and Appelbaum, supra note 18.

21.

Harper ,

Davidson , and

McClelland , “No Longer ‘Anomalous, Confusing and Unjust’: The Mental Capacity Act (Northern Ireland) 2016,” International Journal of Mental Health and Capacity Law no. 22 (2016): 57-70.

22.

Lynch ,

Taggart , and

Campbell , “Mental Capacity Act (Northern Ireland) 2016,” BJPsych Bulletin 41, no. 6 (2017): 353-357.

23.

V.A.

Hiday and

R.R.

Goodman , “The Least Restrictive Alternative to Involuntary Hospitalization, Outpatient Commitment: Its Use and Effectiveness,” The Journal of Psychiatry & Law 10, no. 1 (1982): 81-96.

24.

Keilitz ,

Conn , and

Giampetro , “Least Restrictive Treatment of Involuntary Patients: Translating Concepts into Practice,” St. Louis University Law Journal 29, no. 3 (1984): 691-746.

25.

J.S.

Mill

, “On Liberty,” in A Selection of His Works, ed.

J.S.

Robson

(MacMillan, 1966): 1-147.

26.

F.J.

Parker

, “Lake v. Cameron: Involuntary civil commitment storm warnings,” Family Law Quarterly 4, no. 1 (1970): 81-89.

27.

Weiden and

Glazer , “Assessment and Treatment Selection for ‘Revolving Door’ Inpatients with Schizophrenia,” Psychiatric Quarterly 68, no. 4 (1997): 377-392.

28.

Burns, Rugkåsa, and Molodynski, et al., supra note 9.

29.

Szmukler

, “Risk Assessment: ‘Numbers’ and ‘Values,’” Psychiatric Bulletin 27, no. 6 (2003): 205-207; S.R. Kisely and L.A. Campbell, “Compulsory Community and Involuntary Outpatient Treatment for People with Severe Mental Disorders,” The Cochrane Library (2014).

30.

Newton-Howes

, “Risk in Mental Health: A Review on and of the Psychiatrist, The Journal of Mental Health Training, Education and Practice 13, no. 1 (2018): 14-21.

31.

Newton-Howes

, “Use of Seclusion for Managing Behavioural Disturbance in Patients, Advances in Psychiatric Treatment 19, no. 6 (2013): 422-428.

32.

List and

Pettit , Group Agency: The Possibility, Design, and Status of Corporate Agents (Oxford: Oxford University Press, 2011); P. Pettit, “Agency-Freedom and Option-Freedom,” Journal of Theoretical Politics 15, no. 4 (2003): 387-403.

33.

P.M.

Gooding

, “Change and Continuity: A Historical Overview of the Significance of the United Nations Convention on the Rights of Persons with Disabilities to Mental Health Law,” European Journal of Current Legal Issues 20, no. 3 (2014).

34.

Burns and

Firn , “Assertive Outreach in Mental Health,” A Manual for Practitioners (Oxford: Oxford University Press, 2002).

35.

Brophy and

Ring , “The Efficacy of Involuntary Treatment in the Community: Consumer and Service Provider Perspectives,” Social Work in Mental Health 2, no. 2-3 (2004):157-174.

36.

Breeze

, “Can Paternalism be Justified in Mental Health Care?” Journal of Advanced Nursing 28, no. 2 (1998): 260-265.

37.

Le Boutillier ,

Leamy ,

V.J.

Bird ,

Davidson ,

Williams , and

Slade

“What Does Recovery Mean in Practice? A Qualitative Analysis of International Recovery-Oriented Practice Guidance,”

Psychiatric Services 62, no. 12 (2011): 1470-1476.

38.

Arstein-Kerslake and

Flynn , “The General Comment on Article 12 of the Convention on the Rights of Persons with Disabilities: a Roadmap for Equality Before the Law,” The International Journal of Human Rights 20, no. 4 (2016): 471-490.

39.

Dawson

, “A Realistic Approach to Assessing Mental Health Laws' Compliance with the UNCRPD,” International Journal of Law and Psychiatry 40 (2015): 70-79; M.C. Freeman, K. Kolappa, J.M.C. de Almeida, et al., “Reversing Hard Won Victories in the Name of Human Rights: A Critique of the General Comment on Article 12 of the UN Convention on the Rights of Persons with Disabilities,” The Lancet Psychiatry 2, no. 9 (2015): 844-850.

40.

Dawson, supra note 2.

41.

Newton-Howes and Ryan, supra note 10.

42.

Ryan ,

Nielssen ,

Paton , and

Large , “Clinical Decisions in Psychiatry Should not be Based on Risk Assessment,” Australas 18, no. 5 (2010): 398-403.

43.

Swartz et al., supra note 11;

Swanson ,

Van Dorn ,

Monahan , and

Swartz , “Violence and Leveraged Community Treatment for Persons with Mental Disorders,” American Journal of Psychiatry 163, no. 8 (2006): 1404-1411.

44.

Burns and Molodynski, supra note 9.

45.

Romans ,

Dawson ,

Mullen , and

Gibbs , “How Mental Health Clinicians View Community Treatment Orders: A National New Zealand Survey,” Australian and New Zealand Journal of Psychiatry 38, no. 10 (2004): 836-841.

46.

Simmons and Gooding, supra note 17.

47.

K.B.

Fulford

, “Ten Principles of Values-Based Medicine (VBM),” Philosophy and Psychiatry (Berlin: Walter de Gruyter, 2004): 50-80.

48.

Dawson and

Szmukler , “Fusion of Mental Health and Incapacity Legislation,” The British Journal of Psychiatry 188, no. 6 (2006): 504-509.