Community Treatment Orders (CTOs) involve individuals receiving supervised treatment in the community rather than in hospital. CTOs appear to be on the way out next year but Ian Cruise argues they should not be dismissed altogether.

I fundamentally support the ongoing review of the outdated Mental Health Act. Over the past 30 years a great deal has changed in the way Mental Health problems are viewed and treated and the law is no longer fit for purpose. However, to say CTOs should be fully repealed, as the charity Mind and others have campaigned for, is in my opinion short sighted.

It will leave a number of vulnerable people in danger of being readmitted under section, or a much worse fate, if they are not receiving necessary treatment in time. This is exacerbated by the fact that some on a CTO have very little insight into their mental illness.

"I am not saying CTOs are a panacea, but they require reform rather than repeal."

It is sometimes described that CTOs ‘impose’ medication compliance. No person on a CTO has their medication, whether depot or oral, imposed on them. It is disingenuous to paint a picture of community mental health teams forcibly administering medication to a person on a CTO.

However, if a person is on a CTO, a Responsible Clinician has the power of recall if there is an issue with medication compliance negatively impacting on the mental stability of the individual, causing their condition to deteriorate markedly, thus potentially putting themselves and the public in danger.    

I am not saying CTOs are a panacea, but they require reform not repeal. CTOs in their current form are too ambiguous and unstructured to ensure the least restrictive option is always available. Whilst the patient will always have a plan on being moved on to a CTO, the generic nature of CTOs mean the person could be discharged from their CTO before they are ready as there is no real structure to the step-down process.

There is a fundamental need for some form of conditions for people when they are discharged from hospital, especially when the person has very little insight into their illness and where detaining them in hospital is too restrictive a measure for managing their mental state.

Personally, I would advocate a more structured step-down process on discharge from hospital, as happens while a patient is detained under the Act.

Staggered system

There are differing levels of mental illness so there needs to be a step-down structure to reflect this. This would allow clinicians to place the patient on discharge on the correct ‘step’ that their illness requires.

For example: an individual with very little insight into their illness on discharge who could relapse quickly should be able to move into supported accommodation. They can live independently but have the security of trained staff on site, should their condition deteriorate. This can also ensure the person is medication-compliant and minimises the chances of relapse. During this process, the psychological therapy and engagement in education and work-related activities should be continuing, to encourage independence.

As the person’s mental wellbeing gradually improves, they step-down to the next stage – moving into the community, where their medication can be monitored as now. There should be engagement with initiatives such as the work and health programme. 

As their mental wellbeing improves, there should be regular contact between the mental health teams in the community and the responsible clinician to explore whether a reduction in medication can be trialled and whether talking therapies or counselling can be introduced to substitute medication.

Introducing a more structured process would in my opinion ensure clarity of purpose, provide patients with the correct pathway back into community and ensure less people were recalled to hospital.

Ian Cruise is an Independent Mental Health Lay Manager at Birmingham and Solihull Mental Health Foundation Trust, a former Councillor and Mental Health Champion at Birmingham City Council, and lives with chronic depression.