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For Some Mentally Ill People, Community Treatment Orders Work

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In an earlier blog entitled Involuntary Treatment of Psychiatric Patients Not Unconstitutional Says Ontario Superior Court of Justice, I pointed out that Justice Edward Belobaba ruled that while Community Treatment Orders (CTOs) do not violate the Canadian Charter, he did say that the appellants have provided a compelling case for government review of the existing legislation and of coercive psychiatry. He then cited two Ontario reports to back up this comment and I promised to address that.

Justice Belobaba referred to the 2005 study conducted by Dreezer and Dreezer and a 2012 report prepared by Malatest and Associates. Page 10 of the Dreezer study states that "it is undeniable that CTOs have benefited many individuals and their families. While our review identifies some operational problems and issues with the use of CTOs as a treatment modality for persons who would otherwise be detained in a psychiatric facility, CTOs clearly have a place in the treatment options that are available to health care providers and some of their patients."

Finding #1 of the Malatest report on page 12 states that "Mental health care providers and consumers should continue to have access to CTOs. CTOs are an effective way to provide treatment and support in the community for some consumers."

It also says on page nine that "Most consumers who responded to the survey agreed they felt better since being on a CTO. More than one-half reported an improved quality of life, were more satisfied with the treatment received under their CTO than with other treatment options, and felt CTOs were the best option for their situation. The family, friends and SDMs (substitute decision makers) we were able to engage with were almost uniformly positive about CTOs. They commented on the improvements they observed in their loved-ones' quality of life and improvements to their own well-being as they worried less about them.

That all sounds pretty positive to me even if not to the judge.

Erin Hawkes, a Huffington Post blogger and author of When Quietness Came, A Neuroscientist's Personal Journey With Schizophrenia, has written a number of times that involuntary treatment saved her life. One article was called medicate me even when I refuse and another, in the National Post, was called forced medication saved my life.

Justice Belobaba only had to look at the affidavit that the plaintiffs filed as part of their attack on CTOs to get an idea of how well they can work. Amy Ness had, prior to being put on a CTO, been involuntarily committed for showing violent behaviour in 2004. In 2007, while hospitalized, Ms. Ness kicked her mother in the back and hit her repeatedly. Then, in 2009, Ms. Ness grabbed a large kitchen knife and marched upstairs toward her mother after discovering a magazine about schizophrenia. In another incident, Ms. Ness kicked and punched the emergency department psychiatrist. By the time she was given a CTO in 2009, she had five hospitalizations.

Since then, while on a CTO, the judge pointed out, she takes her medication and sees her case worker on a regular basis. She has not been hospitalized, she maintains her housing and she works as a volunteer, has a job and takes courses. She does think, however, that the CTO is an attack on her personal dignity.

But what if she was not put on a CTO? No one can predict the future but with a history of violence, it is not unreasonable to assume that her violence might have escalated. What if the Navy Yard shooter had been hospitalized and then put on a community treatment order or the Colorado shooter? Would any of that have been considered coercive psychiatry? I'm not even sure what coercive psychiatry is other than a phrase used by those who do not like psychiatry or psychiatric medications. Has anyone ever heard of coercive cardiology?

Dr. Allen Frances, a U.S. psychiatrist in his recent Huffington Post blog, mentioned a hypothetical question he posed to Thomas Szasz, the author of The Myth of Mental Illness. Frances described Szasz as "probably the greatest defender of patient rights" and who "argued passionately for the dignity and freedom of choice of mentally ill inmates who were then often warehoused for life in hospitals that were aptly compared to snake pits." That question was what if "his son was having a transient psychotic episode, was hearing voices commanding that he kill himself, felt compelled to act on this, and refused treatment. As a father, would you stand by your libertarian principles or protect your son from himself, even if this required coercion. Tom smiled ruefully and said: 'I am a father first and protector of human rights second'."

That exact situation was faced by Vancouver civil libertarian, Herschel Hardin, who answered it in an excellent article which he called Uncivil Liberties originally published in 1992 in the Vancouver Sun. Hardin was a member of the board of directors of the B.C. Civil Liberties Association from 1965 to 1974, and was involved in the defence of liberty and free speech through work with Amnesty International. One of his children has schizophrenia. He stated that "far from respecting civil liberties, legal obstacles to treatment limit or destroy the liberty of the person."

Hardin further states that:

Such victims (of serious mental illnesses) are prisoners of their illness. Their personalities are subsumed by their distorted thoughts. They cannot think for themselves and cannot exercise any meaningful liberty. The remedy is treatment -- most essentially, medication. In most cases, this means involuntary treatment because people in the throes of their illness have little or no insight into their own condition. If you think you are Jesus Christ or an avenging angel, you are not likely to agree that you need to go to the hospital.

He then concluded with:

"How can so much degradation and death -- so much inhumanity -- be justified in the name of civil liberties? It cannot. The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness -- free them from the Bastille of their psychoses -- and restore their dignity, their free will and the meaningful exercise of their liberties."

The best one-liner on the topic (and modern society likes one-liners) was given by Cook County Sheriff Tom Dart on the 60 Minutes episode "untreated mental illness an imminent danger?". Chicago's Cook County jail is one of the largest institutions in North America housing the mentally ill. Sheriff Dart said "the irony is so deep, you have a society that finds it wrong to have people warehoused in state mental institutions but those very same people were OK if we warehouse them in jail. You've got to be kidding me!"

When grandma has Alzheimer's and doesn't know where she is, we don't allow her to live in an old appliance box in an alley somewhere. We look after her. So why do we refuse to look after those who are suffering from severe mental illness using the excuse for non treatment that they have the right to decide their own fate. They have the same lack of insight that grandma does.

It is not civilized. And, as this is mental health awareness week, maybe we should become more aware of those with serious untreated mental illness living on the streets, in our jails and elsewhere who deserve to be treated and to live a dignified life.

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