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Memorandum submitted by Professor Swaran Singh[1] (MH 51)
A clinical case for Supervised Community Treatment Orders
I am a Professor of Social and Community Psychiatry at the University of Warwick and a consultant psychiatrist running an Early Intervention in Psychosis in Birmingham. I trained as a psychiatrist in India and came to Britain in 1991. I have been a consultant psychiatrist since 1997. For the past 7 years I have been developing and providing early intervention services which offer community-based assertive treatment and recovery packages to young people experiencing their first episode of psychosis. My research interests have been in the area of psychosis, ethnic influences in mental health and evaluating community-based treatments. I have conducted research into community care for psychosis since 1994, including both in the UK and abroad. I am co-author on the recently submitted report on Supervised Community Treatment Orders [2]
As things stand psychiatrists are able to forcibly treat people to get them well enough so that they can refuse further treatment. In the large majority of cases, when patients get well, they will accept voluntary treatment; but some will not. There is a widespread belief that this small group of patients who persistently refuse to take medication on a voluntary basis need some other form of care: if only mental health services did something differently and were not so keen to medicate people when talking therapies do equally well, these patients would accept care. There are two flaws in this assumption. The first is the belief that all patients with psychosis should and can make the same kind of psychological recovery with insight and, if they do not, it is a service inadequacy rather than something inbuilt in the heterogeneous outcomes of mental illnesses. The second flaw can be gleaned from the response of the Royal College of Nursing to the Welsh Assembly in January 2007, where they stated 'compulsory medication should not be used as a substitute for adequate mental health care'. The explicit assumption here is that compulsory medication and adequate health care are on opposite sides when, in fact, the former is an essential ingredient of the latter. The idea that there is a substitute for medication that does the job equally well but is not offered, because services are under-resourced, unwilling or unhelpful has become the political orthodoxy and the received wisdom. Yet there is no published study showing that any form of therapy, including cognitive behavioural therapy (CBT), ever works in the absence of adequate medication. Medication is the necessary, if not the sufficient, therapeutic ingredient in adequate mental health care.
Some patients will refuse to comply with medication despite whatever we do, because of the nature of their illness. It is the failure to accept this fact that leads to confusion about what CTOs are for and what they can achieve. Getting non-compliant patients back on medication is an end in itself. This may lead to other benefits (reduced hospitalisation, better engagement, better recovery, less adverse events, etc) or it may not. The primary purpose of a CTO is to make sure that patients stay on medication. If a CTO achieves that aim, then it achieves the purpose for which it is, or should be, designed. Any additional benefits are optional extras, but the lack of other benefits is not an argument against CTOs. As things stand we have to wait for patients to worsen in the community before we can act. I am not sure whose benefit that serves. No amount of service innovation, whether early intervention, assertive community care, 24 hour home care, etc, will change the fundamental fact: some patients who need medication will not accept it voluntarily. If patient compliance could be improved simply by throwing money at services, we would not have a major problem to begin with. And if outcomes of illnesses could be 'equalised' by the flourish of a ministerial pen, life would be easy indeed for both patients and clinicians.
There is a widespread belief, perhaps justified, that the drive to introduce CTOs is an attempt to reduce homicides and other high profile tragedies in community care. CTOs are not the answer to all the ills that can befall a patient receiving care in the community. Homicides by the mentally ill are so rare that to get enough numbers to show efficacy of CTOs would be well nigh impossible. We might never get conclusive evidence one way or the other. When such tragedies occur, and were the patient on medication under a CTO, at least we could rule out the possibility that the homicide was the result of poor compliance. This in itself would be an important finding and may help us learn more about prevention than happens now, where the standard finding of every inquiry showing 'failure of service' concludes that non-compliance was an important factor. An ex-patient of mine committed homicide last year. All our attempts to have him treated under the existing law failed. I am certain that, had I been able to put him on a CTO, the homicide would not have occurred. This is a personal view and not a research finding and, even if the homicide was not due to poor compliance, we would at least have known what else we could have done. I have patients currently under my care who are either detained in hospital for long periods when they could be discharged on a CTO or who have a revolving door pattern of admissions that the current law does not help to change.
The search for the holy grail of randomised controlled trial (RCT) evidence in this area is misguided. The ultimate aim of the RCT is to control for everything except for the one intervention under study and evaluate its impact on the outcome under question. All other variables are supposedly controlled for. Applying a CTO in any particular case is a complex decision made in an individualised manner. Here we cannot 'make all other things equal'. It is not possible to control for all the other variables which influence outcomes. A CTO, like I said earlier, is and should be an end in itself. It is also tempting in research interpretation to explain the lack of improvement in outcomes as evidence of lack of CTO effectiveness; and explain away any positive benefits as 'possibly due to other reasons'. CTOs have been shown in some studies to be liked by patients, help them stay with families and be eagerly accepted by clinicians. These are not outcomes to dismiss or explain away, although even the absence of these would not change my fundamental point: being on a CTO is a successful outcome of implementing CTOs.
As for the concern about the coercive nature of CTOs, existing laws are coercive as well. I do not see how or why CTOs are different. Liberties are curtailed by the effects of mental illness, as people act in a way they would not if unwell, and need protection from the effects of the illness on their judgement and behaviour. The mentally ill are first and foremost the victims of their mental illness: to portray them as victims of the service trying to help them is perverse. In fact CTOs should be welcomed by the civil liberties lobby, since CTOs totally adhere to the principle that people should receive the care they need in the least restrictive setting. The focus exclusively on patient rights ignores the fact that there is disability and impairment consequent upon the mental illness for which the mentally ill are protected by law. A mentally ill offender experiences different outcomes in a court of law than someone not mentally ill. Mentally ill are entitled to additional benefits and support in income, housing, vocation, etc in recognition of their vulnerability and disability. Those who argue for patient rights alone, ignoring the impact of illness on patient capacity and ability, would perhaps not be keen to have mental illness removed from defence in cases of mentally ill offenders.
The only issue of potential concern is that, in today's blame-finding and risk-averse culture, psychiatrists may be tempted to keep people on CTOs 'just to be on the safe side'. The tribunal mechanism, whereby an independent body scrutinises the need for continuing CTO use in individual cases, should be an adequate safeguard and perhaps could even be strengthened. The argument that CTOs will alienate people and 'scare them away' from seeking help is a non sequitur: if people seek help CTOs are not needed. So who is being scared away?
Interestingly CTOs are being introduced in several places even as the debate continues. No area which has introduced CTOs has repealed them, although modifications have been made. This surely must tell us something. A survey published in the British Journal of Psychiatry in 2000 showed that 46% of respondents (psychiatrists) were in favour of CTOs, 35% not in favour and 19% unsure. The authors concluded that 'a clear consensus on the need to extend compulsory powers into community settings does not exist' although a more accurate interpretation would be that, among those who had a view, majority were in favour. The authors did not break down the group by speciality, an error since the ones whose views matter are those who would use CTOs in practice.
I sincerely hope that the committee will consider some of these issues when deciding about this extremely important policy.
April 2007 [1] Professor of Social & Community Psychiatry and Consultant Psychiatrist, Health Sciences Research Institute, Warwick Medical School, University of Warwick [2] Churchill R, Owen G, Hotopf M, Singh S, 2007: International Experiences of Using Community Treatment Orders. London: Department of Health and Institute of Psychiatry, King's College London
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