Community Orders

Community Treatment Orders (CTO) and Community Counselling Orders (CCO) were introduced in the NSW Mental Health Act 1990 to provide a community-based alternative to involuntary hospitalisation. They required the person to accept medication and other treatment for a period of 6 months (which may also have been renewed). The CTO and CCO are intended to allow those, who might otherwise be detained in a declared mental health facility, to live in the community and get the treatment, care and support they need in a least restrictive setting than a declared mental health facility.The Bowral Mental Health Service, as a designated health care agency under the 1990 Act, was responsible for a number of persons living in their local community under a Community Treatment Order (CTO). By and large, the use of the CTO was an effective means of coordinating appropriate care for the person. In the past 10 years or so, no local person was placed under the Community Counselling Order (CCO) as this form of order was seen as less effective than a CTO. Recognising the effectiveness of the CTO, the health services, primary carers and other advocate groups have convinced the NSW Government that the Community Orders should be included in the NSW Mental Health Act 2007. The main change has been the manner in which the Orders are applied for and reviewed, the requirements for requesting an extension of the Orders, and the possible duration of the Order being extended from 6 months to up to 12 months. Community Treatment Orders: What is a Community Treatment Order (CTO)? A CTO is a legal order made by the Mental Health Review Tribunal or a magistrate. It sets out the terms under which a person must accept medication, therapy, rehabilitation or other services. It is implemented by a health care agency that has developed an appropriate treatment plan. When can a CTO be made? The visiting magistrate can make a CTO where: a person is found to be "mentally ill", and the order for community treatment is seen as the "least restrictive alternative". The Mental Health Review Tribunal can make a CTO where the person is: a temporary patient, or a continued treatment patient, or on a CTO that is about to expire, or on an appeal from a medical superintendent's refusal to discharge on the request of the director of a community based health care agency while the person is in the community. A Community Treatment Order can only be made if the person: has been for the first time diagnosed as suffering from a mental illness; or has previously refused treatment, and experienced a relapse into mental illness when treatment was refused, and in the absence of treatment, involuntary admission occurred, or was likely to occur. Before an order will be granted the Tribunal or magistrate must be satisfied that:the person would benefit from the order because it provides for consistent, safe and effective care in an environment that is less restrictive than the declared mental health facility, and the health care agency supervising the person in the community, agrees with, and can provide the suggested care. Where an application is made to renew a CTO, or made soon after the person has come off a previous Community Order, the health care agency must provide the Tribunal or magistrate with a report on the outcome of the previous Community Order. The Treatment Plan: It sets out how the person is to managed while on a CTO and: is usually prepared by the clinician who is the person's care coordinator; must be presented to the Tribunal or magistrate for approval. What should be in the Treatment Plan? Treatment plans should only contain: treatments with a demonstrated therapeutic benefit for the person; conditions considered essential to maintain the person in the community; conditions the agency is prepared to enforce. A good treatment plan: is specifically tailored to the needs of the individual; sets out the agency's obligations to provide specific treatment and support along with the person's obligations; is specifically discussed and negotiated with the person. A poor treatment plan: sets out only the person's obligations; is not clear or comprehensible; is vague and ill-defined. Breaching a CTO: This may happen when a person on a CTO refuses or fails to comply with an Order. Before a breach can be said to have occurred, however, a clinical decision must be made. A person's failure to comply with the terms of the Order does not, of itself, automatically trigger breach proceedings. The director of the health care agency in the community must consider the case to: assess whether the agency has taken all reasonable steps to implement the Order, and decide whether there is a significant risk of deterioration in the mental or physical condition of the person, and make a written record of his or her opinions, and the facts upon which these are based. Breach process: The breach process commences and continues at the discretion of the director of the health care agency supervising the Community Order. The first warning - verbal - if the director decides that all reasonable steps have been taken by the health care agency, and that there is a significant risk of deterioration, the care coordinator will then give the person a warning that continued failure to comply may result in the client being taken to the health care agency or a declared mental health facility for treatment. The second warning - written - If the person still fails to comply the director may give the person a written notice; requiring the person to accompany a staff member to the agency or declared mental health facility for treatment and, notifying them that police assistance may be obtained to ensure compliance. Where the person agrees - if the person agrees to come to the health care agency they may be: given treatment in accordance with the CTO, and/or assessed for involuntary admission if appropriate. Force may not be used to administer treatment at the health care agency. Where the person refuses - issuing a written order - where the person refuses to comply with the second warning, the director or care coordinator may: put that order in writing and, order that the person be taken to the health care agency or a declared mental health facility. This Order may be implemented by a mental health worker, but not by force. Involving the police - if the mental health worker cannot implement the final Breach Order, it may be given to the police. Following a formal notice requesting assistance the police must respond as soon as possible. The police may use force to enter premises, apprehend the person, and take them to either the agency or to a declared mental health facility. Arriving at the declared mental health facility following a breach - on arrival at a declared mental health facility, the person has the right to: apply for a discharge, or apply to the Mental Health Review Tribunal for a review of the order in limited circumstances. The medical superintendent: must review the person's condition, and may give the person treatment in accordance with the CTO, without their consent if necessary. Detention in a declared mental health facility following a breach if the person is found to be a mentally ill person - if the medical superintendent decides that the person is a "mentally ill" person for whom no other care of a less restrictive kind is appropriate or reasonably available, the person can be detained as a temporary patient for the remainder of their CTO. The person must, however, be seen by the MHRT no later than 3 months after being detained. This is the case even if the CTO has another 4 or 5 months to run. The Tribunal considers whether the person still is a "mentally ill" person and then decides whether to: discharge with the same or varied CTO; continue the person's detention. The person must, of course, be discharged at any time the medical superintendent decides they are no longer a "mentally ill" person. Where discharge occurs before the original CTO has expired it continues to operate. If the person is found to be mentally disordered: If the medical superintendent decides that the person is "mentally disordered" then they may be detained for the remainder of the CTO or for a period of 3 days, whichever is the sooner. Where the person is discharged before the CTO has expired it continues to operate. Duration of a CTO: A CTO can generally be made for a period of up to 6 months, although in the NSW Mental Health Act 2007, it is now possible to apply for a CTO of 12 month duration. An additional change in applications for a CTO is that the 2007 Act allows for the director of the health care agency to apply for a CTO while the person is still living in the community. The director of the health care agency providing care coordination can revoke the CTO at any time where appropriate. If the health care agency feels that it is necessary to keep the person on a CTO for longer it must: apply to the Mental Health Review Tribunal for a new CTO before the existing CTO expires. The Mental Health Review Tribunal informs people of the hearing in writing; encourages them to attend, but can renew a CTO in the patient's absence.