This comment is not so much to do with the legality of the conditions attached to a CTO, but more relating to the benefit and proportionality of attaching conditions which should then possibly lead to grounds for recall under s.17E.
Over time many doctors will suggest different conditions to attach to a CTO. We know from case law that it is no longer possible to attach a condition of residence which would amount to a deprivation of liberty. This is fine.
It is generally my belief and feeling (ethically) that the CTO should specifically relate to treatment, so apart from the mandatory conditions I will generally only agree to treatment related conditions.
The general opinion on adding conditions relating to abstaining from alcohol and drugs is the topic I wanted to gather some information about. Again, I know that these can be added but wanted some discussion about the principle of adding these conditions and opinions on whether they are valid enough to warrant as a condition. Am looking for opinions really both legally and ethically…
When asked to consider non-mandatory conditions, I took the view that what I was looking at was a contract, an agreement between the person and his/her care team. This contract was as much about what the Care Team would do, so I would on most, if not all occasions, include an engagement condition. I would also make sure that the conditions were included in the person’s Care and Treatment Plan.
When considering the person, I would ask myself were the conditions necessary and proportionate. Would the conditions ‘nudge’ or persuade the person to remain engaged in the change-based behaviour, that would promote the person remaining in the community.
Though the person does not have to agree to the conditions, I believed their usefulness was increased when you obtained an agreement.
From memory, I have considered and agreed abstinence from illicit substances and or alcohol, as well as harm reduction. Engagement with the team, visits, appointments etc as a way to review and monitor the effectiveness or not of the CTO as well as the persons mental health. When it came to medication, it would be worded ‘agrees to take’, not must take. Looking back, I would say about 75% of the CTO’s I was involved in included a condition concerning the use/misuse of alcohol and/or illicit substances.
I had some requests that I did not agree to, such as the person should not have contact with a specific named person, I thought that this was an Article 8 infringement, and in the absence of a Restriction Order, I was not about to sign something akin to this.
My question with any condition is always, what is the consequence of a breach? Most conditions are completely unenforceable, so I wonder what’s the point of them?
I understand what Nick is saying about a condition giving a ‘nudge’ to someone’s behaviour, but much more common in my experience is the patient believing (and being allowed to believe) that a condition is enforceable and therefore complying with it, when they really don’t have to. For example I had a client whose CTO had a condition that he should let his Mum keep his passport from him. He complied with it because he believed he had no choice.
I took the view that any condition could be breached, but what I kept in mind, did the breach undermine treatment in the community. I equated the trigger for recall akin to the person reaching that ‘deteriorating patient’ status you might consider for a Section 3. This made sense in my mind as recall and revocation resulted in a treatment admission.
When discussing the merits or not of a CTO with a person I would include recall and what that would look like for the individual, what thresholds we would work to. I found that setting out the nature of the person’s mental disorder and having clear examples of relapse and admission helped in this discussion. Recall in effect was never a surprise, it was always linked to the person’s Crisis and Contingency Plan.
CTOs are imposed on patients. They are not agreements nor contracts which are entered into freely and voluntarily. This view is supported by the requirement for conditions to be necessary and proportionate. In a free agreement there is no law against conditions being unnecessary and disproportionate, as decided by the parties. If patients are coerced into “agreeing” to conditions, it would be no surprise if they later repudiated them.
Hello Barry, I am well aware of the legal status of CTO’s. In my experience forming agreements, where the person is involved in the discussion and decision making promotes engagement and gives additional value to treatment in the community. This approach is very much supported by the MHA Code of Practice.