Community treatment orders and the limits of freedom


The 2007 Reform of the Mental Health Act (MHA) saw the introduction in England and Wales of Community Treatment Orders (CTOs). If a patient (the MHA always refers to people as patients) has been subject to detention under section 3 MHA a CTO can be used when they are discharged from hospital.

There is not the space here to explore the tortured history of the reform of the MHA. However, the call for the introduction of CTOs can be traced back to the failures of community care in the 1980s and 1990s. A recommendation that there should be some form of CTO was the conclusion of several inquiries – the most famous of which is the Ritchie Inquiry into the Care and Treatment of Christopher Clunis (Ritchie et al 1994).

The current legislation allows for the imposition of conditions when a patient is discharged. As this paper notes the most common conditions that are imposed are to take prescribed medication and remain in contact with community mental health team. The CTO allows for a recall to hospital if the patient does not comply with the conditions. It should be noted that there is no need for a formal MHA assessment in such circumstances. This period of detention could last up to 72 hours.

Supporters of CTOs argue that they are required so that there is a framework to prevent relapse, maintain stability and avoid the pattern of repeated admissions (I personally think that the term ‘revolving door’ patient is a discriminatory so do not use it). In addition, the argument put forward that the CTO is the ‘least restrictive’ option so complies with the wider principles of mental health legislation.

The introduction of CTOs was the source of much opposition from service-users and professional groups. It is perhaps indicative of the wider status of people with severe mental health problems that there was little, if any, political opposition. The CTO is clearly a major shift in the balance between individual and community rights. The only other group of people who face such legal restrictions are offenders. Libertarians were curiously quiet on this issue. The initial idea that the CTOs would be used in very limited cases appears to be have been inaccurate (Williams 2010).