How shortcomings in the mental health system affect the use of involuntary community treatment ordersEdwina M. Light A J , Michael D. Robertson A , Philip Boyce B , Terry Carney C , Alan Rosen D E , Michelle Cleary F , Glenn E. Hunt G , Nick O’Connor H I , Christopher J. Ryan A B and Ian H. Kerridge A
A Centre for Values, Ethics and the Law in Medicine, Level 1, Medical Foundation Building (K25), University of Sydney, NSW 2006, Australia. Email: email@example.com; firstname.lastname@example.org
C Sydney Law School (F10), University of Sydney, NSW 2006, Australia. Email: email@example.com
D Illawarra Institute of Mental Health (Bldg 22), University of Wollongong, NSW 2522, Australia.
E Brain & Mind Research Centre, University of Sydney, NSW 2006, Australia. Email: firstname.lastname@example.org
F School of Health Sciences, Faculty of Health, University of Tasmania (Rozelle Campus, Sydney), Locked Bag 5052, Alexandria NSW 2015, Australia. Email: email@example.com
G Discipline of Psychiatry, Concord Hospital (C22), University of Sydney, NSW 2139, Australia. Email: firstname.lastname@example.org
H North Shore Ryde Mental Health Service, 2C Herbert St, St Leonards, NSW 2065, Australia. Email: email@example.com
I Discipline of Psychiatry, University of Sydney, NSW 2006, Australia.
J Corresponding author. Email: firstname.lastname@example.org
Australian Health Review 41(3) 351-356 https://doi.org/10.1071/AH16074
Submitted: 3 April 2016 Accepted: 3 June 2016 Published: 15 July 2016
Objective The aim of the present study was to examine stakeholder perspectives on how the operation of the mental health system affects the use of involuntary community treatment orders (CTOs).
Methods A qualitative study was performed, consisting of semi-structured interviews about CTO experiences with 38 purposively selected participants in New South Wales (NSW), Australia. Participants included mental health consumers (n = 5), carers (n = 6), clinicians (n = 15) and members of the Mental Health Review Tribunal of NSW (n = 12). Data were analysed using established qualitative methodologies.
Results Analysis of participant accounts about CTOs and their role within the mental health system identified two key themes, namely that: (1) CTOs are used to increase access to services; and (2) CTOs cannot remedy non-existent or inadequate services.
Conclusion The findings of the present study indicate that deficiencies in health service structures and resourcing are a significant factor in CTO use. This raises questions about policy accountability for mental health services (both voluntary and involuntary), as well as about the usefulness of CTOs, justifications for CTO use and the legal criteria regulating CTO implementation.
What is known about this topic? Following the deinstitutionalisation of psychiatric services over recent decades, community settings are increasingly the focus for the delivery of mental health services to people living with severe and persistent mental illnesses. The rates of use of involuntary treatment in Australian community settings (under CTOs) vary between state and territory jurisdictions and are high by world standards; however, the reasons for variation in rates of CTO use are not well understood.
What does this paper add? This paper provides an empirical basis for a link between the politics of mental health and the uptake and usefulness of CTOs.
What are the implications for practitioners? This paper makes explicit the real-world demands on the mental health system and how service deficiencies are a significant determinant in the use of CTOs. Practitioners and policy makers need to be candid about system limitations and how they factor in clinical and legal justifications for using involuntary treatment. The results of the present study provide data to support advocacy to improve policy accountability and resourcing of community mental health services.
References National Mental Health Commission. Report of the national review of mental health programmes and services: summary. Canberra: National Mental Health Commission; 2014.
 Light E, Kerridge I, Ryan C, Robertson M. Out of sight, out of mind: making involuntary community treatment visible in the mental health system. Med J Aust 2012; 196 591–3.
| Out of sight, out of mind: making involuntary community treatment visible in the mental health system.CrossRef | 22621153PubMed |
 Light E, Kerridge I, Ryan C, Robertson M. Community treatment orders: rates of use in Australia. Australas Psychiatry 2012; 20 478–82.
| Community treatment orders: rates of use in Australia.CrossRef | 23136187PubMed |
 Australian Institute of Health and Welfare. Mental health services in Australia. Canberra: Australian Government; 2015.
 Rosen A, Gurr R, Fanning P. The future of community-centred health services in Australia: lessons from the mental health sector. Aust Health Rev 2010; 34 106–15.
| The future of community-centred health services in Australia: lessons from the mental health sector.CrossRef | 20334766PubMed |
 Rosen A, Gurr R, Fanning P, Owen A. The future of community-centred health services in Australia: ‘when too many beds are not enough’. Aust Health Rev 2012; 36 239–43.
| The future of community-centred health services in Australia: ‘when too many beds are not enough’.CrossRef | 22935108PubMed |
 Senate Select Committee on Mental Health. A national approach to mental health – from crisis to community: first report. Canberra: Commonwealth of Australia; 2006.
 Singh BS, Castle DJ. Why are community psychiatry services in Australia doing it so hard? Med J Aust 2007; 187 410–12.
| 17908007PubMed |
 O’Halloran P, O’Connor N. Time to invest in developing community mental health services. Australas Psychiatry 2015; 24 268–71.
| Time to invest in developing community mental health services.CrossRef | 26442518PubMed |
 Maughan D, Molodynski A, Rugkasa J, Burns T. A systematic review of the effect of community treatment orders on service use. Soc Psychiatry Psychiatr Epidemiol 2014; 49 651–63.
| A systematic review of the effect of community treatment orders on service use.CrossRef | 24136002PubMed |
 Lawton-Smith S. A question of numbers: the potential impact of community-based treatment orders in England and Wales. London: King’s Fund; 2005.
 Rugkasa J, Dawson J. Community treatment orders: current evidence and the implications. Br J Psychiatry 2013; 203 406–8.
| Community treatment orders: current evidence and the implications.CrossRef | 24297787PubMed |
 Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. London: Sage Publications; 2006.
 Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage; 2008.
 Strauss A, Corbin J. Basics of qualitative research – techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage; 1998.
 Light E, Robertson M, Boyce P, Carney T, Rosen A, Cleary M, Hunt G, O’Connor N, Ryan C, Kerridge I. The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers. Australas Psychiatry 2014; 22 345–51.
| The lived experience of involuntary community treatment: a qualitative study of mental health consumers and carers.CrossRef | 24963099PubMed |
 Light E, Robertson M, Boyce P, Carney T, Rosen A, Cleary M, Hunt G, O’Connor N, Ryan C, Kerridge I. The many faces of risk: a qualitative study of risk in outpatient involuntary treatment. Psychiatr Serv 2015; 66 649–52.
| The many faces of risk: a qualitative study of risk in outpatient involuntary treatment.CrossRef | 25828877PubMed |
 Light E, Robertson M, Kerridge I, Boyce P, Carney T, Rosen A, Cleary M, Hunt G, O’Connor N, Ryan C. Re-conceptualizing involuntary outpatient psychiatric treatment: from ‘capacity’ to ‘capability’. Philos Psychiatry Psychol 2016; in press.
 Miles M, Huberman A. Qualitative data analysis: a sourcebook of new methods. Newbury Park, CA: Sage Publications; 1984.
 Rosen A, Gorrell J, Cornish A, Miller V, Tennant C, Nash L, McKay D. Promoting constructive change in the service system: a qualitative study of change in staff attitudes with the implementation of early intervention in psychosis. In: Boydell KM, Ferguson HB, editors. Hearing voices: qualitative inquiry in early psychosis. Waterloo: Wilfrid Laurier University Press; 2012. pp. 98–118.
 Szmukler G. Ethics in community psychiatry. In Bloch S, Green SA, editors. Psychiatric ethics. Oxford: Oxford University Press; 2009. pp. 453–71.
 Brophy L. Achieving reciprocity for people on community treatment orders. In: David N. Weisstub, editor. Abstracts of the XXXIIIrd International Congress on Law and Mental Health 2013, 14–19 July 2013, Amsterdam. Amsterdam: International Academy of Law and Mental Health; 2013. pp. 358–59. Available at: http://ialmh.org/congress/past-congresses/amsterdam-2013/ [verified 17 June 2016].
 O’Brien AJ, McKenna BG, Kydd RR. Compulsory community mental health treatment: literature review. Int J Nurs Stud 2009; 46 1245–55.
| Compulsory community mental health treatment: literature review.CrossRef | 19296950PubMed |
 Molodynski A, Rugkasa J, Burns T. Coercion and compulsion in community mental health care. Br Med Bull 2010; 95 105–19.
| Coercion and compulsion in community mental health care.CrossRef | 20501486PubMed |
 Brophy L, Healy B. Mental health law and its implications for social work practice. In: Rice S, Day A, editors. Social work in the shadow of the law. Sydney: The Federation Press; 2014. pp. 406–26.
 World Health Organization (WHO). Mental health legislation and human rights. Geneva: WHO; 2003.
 Dawson J. Community treatment orders and human rights. Law Context 2008; 26 148–59.
 Mental Health Commission of NSW. Living well: a strategic plan for mental health in NSW. Gladesville: NSW Mental Health Commission; 2014.
 Mental Health Commission of NSW. One year on: progress report on the implementation of living well: a strategic plan for mental health in NSW 2014–2022. Sydney: NSW Mental Health Commission; 2016.
 Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E, et al An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use. J Psychiatr Res 2013; 47 650–6.
| An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use.CrossRef | 23415453PubMed |
 Segal SP, Preston N, Kisely S, Xiao J. Conditional release in Western Australia: effect on hospital length of stay. Psychiatr Serv 2009; 60 94–9.
| Conditional release in Western Australia: effect on hospital length of stay.CrossRef | 19114577PubMed |
 Hiday VA. Putting community risk in perspective: a look at correlations, causes and controls. Int J Law Psychiatry 2006; 29 316–31.
| Putting community risk in perspective: a look at correlations, causes and controls.CrossRef | 16533532PubMed |
 Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E. Reducing all-cause mortality among patients with psychiatric disorders: a population-based study. CMAJ 2013; 185 E50–6.
| Reducing all-cause mortality among patients with psychiatric disorders: a population-based study.CrossRef | 23148054PubMed |
 Kisely SR, Campbell LA. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Systematic Rev 2014; 2 CD004408
 World Health Organization (WHO). Improving health systems and services for mental health. Geneva: WHO; 2009.
 Australian Government. Australian Government response to contributing lives, thriving communities – review of mental health programmes and services. Canberra: Commonwealth of Australia; 2015.