Factors Affecting Community Treatment Orders Research Study

The publication provides an overview of the use of compulsory community treatment (CCT) across Queensland, South Australia, New South Wales and Victoria. Aggregated administrative data from the Australian Institute of Health and Welfare for 402,060 individuals was analysed to determine how many people accessing specialist mental health services were receiving CCT. Our results showed that of these 402,060 individuals, 51,351 people (12.8%) were receiving CCT. Across the jurisdictions, those results looked like:

• 2-13% of people accessing specialist mental health services were receiving CCT in New South Wales; and
• 6-24% in Victoria; and
• 11-25% in Queensland; and
• 6-36% in South Australia.

People receiving services who were male, single and aged between 25 and 44 years were significantly more likely to be subject to CCT, as were people living in metropolitan areas or those born outside Oceania.

Further research is needed to understand these variations in CCT use both between and within jurisdictions.

You can access the publication using this link.

FACTORS team member Prof. Penny (Penelope) Weller attended the New Zealand Parliament Health Committee to present about compulsory community treatment (CCT) in the context of New Zealand mental health legislative reform. Penny commented on the state of contemporary ideas in mental health law, acknowledging that New Zealand’s legislative reforms offer “muted” engagement with supported decision-making, which requires legislative backing. She noted that a more robust implementation of legislative change is needed to give effect to changing the culture of mental health services and use of compulsory treatment. Penny also noted the “global question mark” about the efficacy of CCT and that CCT does not necessarily connect with improvements in mental health care. Penny criticised the features of New Zealand legislation that assume that compulsory care in a hospital setting will segway into CCT as an appropriate clinical pathway, especially considering the evidence about the efficacy of CCT, which has been glossed over in the proposed changes. Penny also brought attention to increasing global concern about the human rights implications of CCT and the World Health Organisation calling for a revision of the way that mental health legislation is attended to. Penny emphasised that voluntary care that considers cultural needs and socioeconomic contributors needs to be explicit in legislation.

Congratulations Penny on your good work.

Watch the full video here (Penny starts around the 11.25 mark).

Earlier this month, Professor Lisa Brophy presented alongside Professors Marina Morrow (York University) and Nev Jones (University of Pittsburgh) on coercive practices in mental health at the first event for the Mad Studies hub at York University in Toronto where Lisa has been a visiting academic. Marina and Nev are both members of the FACTORs international advisory panel and this event was attended by over a 100 people from all over the world.

Our international advisory panel is comprised of international experts on CTO use. Many are lawyers, social researchers, and lived experience experts. We have met four times over the life of the project to discuss findings from the FACTORS project.

Nev is a community mental health services researcher based at the University of Pittsburgh School of Social Work in Pennsylvania, United States. Nev has expertise in the areas of early intervention, public sector health services, intersectionality in community services, and centring lived experience. She brings strong disability justice and lived experience to her work and research and is currently engaged in advocacy around the rising use of CCT in the US.

Read more about Nev here.

FACTORS investigator Chris Maylea et al. published in January in Psychiatry, Psychology and Law their article titled ‘Ensuring compulsory treatment is used as a last resort: a narrative review of the knowledge about Community Treatment Orders.’

The article offers a review of literature available about Community Treatment Orders (CTOs) that showed “mixed and contested” evidence about their impact and effectiveness. It also brings attention to the lack of available literature on projects or programs aiming to reduce the use of CTOs despite their use rising, and what would be required at a systems level to do so.

Access the full publication using this link

Jesse Lenagh-Glue et al., including FACTORS team member Giles Newton-Howes, published in February in the International Journal of Mental Health and Capacity Law their article ‘How will you hear my voice? The development of Indigenous-centred supported decision-making for mental health service users in Aotearoa New Zealand’.

The article calls for a “human-rights oriented approach” to promote supported decision-making in mental health services in Aotearoa New Zealand, instead of the current Mental Health Act’s emphasis on substituted decision-making. The paper explores a co-designed and co-produced, Maori-centred approach to create Mental Health Advance Statement-type tools that can be used to effect “culturally appropriate and locally relevant” supported decision-making in mental health services.

Access the full publication using this link.

Arahia Kirikiri et al., including FACTORS team member Giles Newton-Howes, published in the Australian & New Zealand Journal of Psychiatry in September last yeartheir paper ‘The perspectives of Maori on community treatment orders: A thematic analysis’.

The aim of the research was to understand the themes for Maori subjected to CCT using thematic analysis of a purposive sample of Maori in Hawke’s Bay, New Zealand.

Five clear themes about conceptualisations of CCT for Maori emerged from analysis, including CCT being restrictive and stigmatising, CCT being used to circumvent consent and information-giving, and lack of service support for people subjected to CCT.

Read the abstract and/or sign in to access using this link.

FACTORS investigator Giles Newton-Howes has published an editorial in ANZJP with colleague Ben Beaglehole. This short article reflects on the controversy surrounding CTOs. While RCTs show little benefit overall, large New Zealand studies suggest CTOs help people with psychotic disorders by reducing hospital admissions, but may harm those with depression or personality disorders. CTOs don’t reduce mortality and show signs of inequitable use, especially for Māori. The findings support more targeted, diagnosis-specific use of CTOs and better-informed legislation.

You can read more here.

FACTORS team members Steve Kisely and Claudia Bull have been very research-active, with a new, published editorial on the boundaries between compassion and coercion in mental health services. They make the case that there are proposals in Canada and Australia to expand the reach of compulsory treatment either in terms of including substance use disorders or in terms of who can initiate compulsory treatment such as nurse practitioners. Such changes expand the use of coercive interventions, whether by diagnosis or initiating clinician, without clear evidence of clinical benefit.  This unjustifiably limits human rights and runs counter to the recovery model, which advocates for autonomy and self-determination. Rather than implementing alternatives to coercion, it seems practice is moving backwards, not forwards.

You can read the full article here.

Our surveys for consumers, carers and staff have now closed – thanks to everyone who participated or shared with their networks. These surveys asked participants about their experiences related to the use of CTOs. Our staff survey had a special focus on the factors that surround the decision to place someone on a CTO.

We’ve started our analysis and we look forward to sharing our findings in due course.

The new WHO Guidance on Mental Health Policy and Strategic Action Plans was published in March this year and includes 5 modules for addressing “rights-based, person-centred and recovery-oriented mental health polices and action plans”.

Access the new WHO Guidance on Mental Health Policy and Strategic Action Plans using this link, or watch the livestream of the launch event here with the passcode: xm=1dZ@L

FACTORS investigator Steve Kisely et al. published in the Australian and New Zealand Journal of Psychiatry with a paper titled ‘The benefits and harms of community treatment orders for people diagnosed with psychiatric illnesses: A rapid umbrella review of systematic reviews and meta-analyses’.

The researchers conduct a systematic search of several databases to identify systematic reviews and/or meta-analyses about the impacts of CTOs across jurisdictions. The results showed mixed findings on the effects of CTOs on health service uses and clinical, psychosocial and forensic outcomes, with some evidence suggesting benefits and others showing no effect. The results indicated that the effectiveness of CTOs remains inconclusive.

Access the full publication using this link.

FACTORS investigator Steve Kisely et al. also published in BJPsych Open in July with their paper titled ‘Latest findings highlight the continuing uncertainty over the utility of compulsory psychiatric treatment’.

The article again highlighted the lack of evidence to support the effectiveness of CTOs despite their increasing use across jurisdictions, and demonstrated that administrative data-sets give conflicting results about the desirability to reduce CTO rates.

Access the full publication using this link.

Our research has been recognised on an international stage with the acceptance of two symposiums at the planned 2024 International Academy of Law and Mental Health in Barcelona. This opportunity will allow us to share our findings and exchange ideas with a global audience, contributing to the ongoing conversation around the implications that CTOs have for human rights.

Last month, we made significant progress by acquiring data on CTO rates in Victoria, New South Wales, Queensland, and South Australia. States vary in the use of CTOs and,  even within the same states, some services exhibit more than a 20% difference in CTO rates, even after accounting for forensic and child and adolescent services.

Access to the data will enable us to select 10 services with high CTO usage and 10 services with low usage to gain deeper insights into how CTO are being implemented and what accounts for the amount of variation across and within Australian states. We are currently developing a survey for service users, supporters, and staff, which we plan to launch next month, in collaboration with our lived experience advisory group. Following this, we will conduct a qualitative study focusing on two high-use and two low-use services.

Meanwhile, our law and policy team has been investigating the differences in legislation and policy across Australia and the relationship between the availability of policy and the rates of CTO usage. So far, we have discovered that there is a wide variation in the amount of policy across the four states than we initially anticipated. This finding has been resulted in the need for considerable analysis and the formulation of understanding about the role of policy in the use of CTOs.

We were able to present and discuss our preliminary findings at an event at La Trobe city campus on the 6^th May attended by consumers, carers, service providers and others interested in our research. This helped us develop further ideas about FACTORS driving CTO use in Australia and the implications of our research.

We are excited about the upcoming phases of our study and look forward to sharing more insights and findings with you soon.

This panel have been instrumental in broadening our approach to understanding the complexities surrounding CTOs in Australia. These experts have shaped our research methodologies, and provided insights into relevant mental health policies, legal contexts and the application of CTOs globally.