Position Statement: Community Treatment Orders

While community treatment orders may have utility with a small number of severe and persistently ill people, the potential for abuse, the lack of clear outcome evidence and the availability of less coercive options would indicate that there should be a far greater priority in improving community resources than putting in place community treatment orders.

Community treatment orders may be effective in some very specific circumstances but they must be introduced at the end of a continuum of other, demonstrably effective protocols and community supports that have already been put in place. This is not yet the case currently in Alberta or, to our knowledge, elsewhere in Canada.

Canadian Mental Health Association strongly advocates that most treatment of mental illness is best offered in the community and that assertive community treatment and other community supports are a priority. Only in very specific conditions and circumstances are community treatment orders the best option.

Background information:

• Community Committal
• Informed Consent to Treatment

A Summary of the CMHA’s Top Priorities

1. Promoting a community based system of care built around contemporary “best practices” in mental health reform

Specifically the CMHA would like to see:

• An explicit vision shared by stakeholders
• Protection of a single mental health funding envelope
• A plan of concrete measurable outcomes
• Regular monitoring for accountability
• A common, confidential information system
• One local (regional) level organization responsible for ensuring services
• Community based services near people’s homes
• A labour strategy to redeploy institutional staff over time

The Association’s policies would see a balanced system of care including mental health institutions, regional psychiatric units and a system of community support services. Over time, modern science including pharmacology, along with a comprehensive community support system, should reduce our reliance on institutions. This in turn will provide opportunities to transfer additional resources to community based programs. These community programs should include:

• assertive community outreach services
• a continuum of crisis programs
• a variety of supported housing alternatives
• an array of in and outpatient care in regional hospitals
• consumer initiatives like skill training, mutual aid and economic development
• support for family groups
• employment, education and recreational opportunities

Many of the Association’s strategies in this area have evolved in partnership with the member organizations of the Alberta Alliance on Mental Illness and Mental Health.

2. Promoting children’s mental health services

Alberta citizens, with the support of government have made considerable progress in this area over the past two years. The Children’s Mental Health Initiative (CMHI) and more than ten million dollars in new funds have resulted in a range of new services including therapists and consultants, residential programs for children and youth, in-home support, day treatment, early intervention parental support, living skills training, integrated intake and suicide prevention. Notwithstanding these improvements, much more needs to be done. Priorities include:

• Adequate funding for community based agencies like Edmonton’s Children and Adolescent Services Association (CASA)
• Establishing coordinated intake systems
• Maintaining existing and unfunded inpatient beds until community capacity is developed
• Expanding the availability of Day Treatment
• Providing long term “case management” for high risk children
• Increasing the availability of program and educational consultants
• Providing outreach services to rural communities
• Funding program evaluations to ensure accountability and results
• Providing parents with respite opportunities
• Ensuring transitional services for children reaching adulthood
• Providing psychiatric crisis services

One of the major difficulties in implementing expanded services is the availability of qualified staff, and recruitment and retention issues must also be addressed.

3. Promoting the “diversion” of mentally ill people from the criminal justice system

Over the past thirty years, mental health hospitals have been downsized as part of a philosophy of “de-institutionalization.” Unfortunately the promise of alternative services in the community was neverreality for many of these people. As a consequence, some committed minor crimes or suffered a relapse of their illness, resulting in the police and the courts being left to pick up the problems by default. This situation is now referred to as the “criminalization” of people with mental illnesses. Portions of our jails are now the “new asylums” but without many of the psychiatric resources available to mental health hospitals. A 1999 Alberta study found that a full 34% of male inmates in provincial jails suffer a serious form of mental disorder like schizophrenia or bipolar disorder and 22% have attempted suicide. Suicide is now the number one cause of death for Canadians in Correctional facilities. In an attempt to counter these problems Ontario, twelve American states and several European countries have developed approaches to carefully screen mentally ill people as they go in to the Criminal Justice System, with referral to more appropriate programs. These initiatives do not excuse criminal behaviour or allow the mentally ill to “get off.” Rather, they attempt to find appropriate and helpful responses which in turn may eliminate future occurrences. Specifically CMHA is calling for:

• A community based system of care based on “best practices” (See item #1) that minimize police involvement in minor incidents.
• Police receive training and access to mental health professionals when responding to incidents.
• Crown Attorneys divert minor offenders and court workers ensure there are options.
• Specialty “Mental Health Courts” link to community services to ensure assessment, treatment and release through diversion, bail, probation or Review Board supervision.
• Linkages to Forensic in and outpatient services refer unfit or not criminally responsible (NCR) clients on a timely basis.
• Incarcerated offenders receive appropriate treatment.

The Association is currently a member of a multi-department/community committee charged with developing a “Diversion Framework” for consideration by the departments of Health and Justice.

4. Promoting the development of a province wide, coordinated approach to suicide prevention

Every year more than 400 Albertans die by suicide. More deaths than by traffic accidents. Suicide is the leading cause of death in Alberta among males age 10 to 65 years. Alberta’s suicide rate is the second highest in Canada, after Quebec. For every suicide there are more than a hundred attempts. An estimated 40,000 Albertan’s deliberately harm themselves each year. In addition to the personal harm and trauma the cost of suicide to the economy is staggering – estimated at $244 million for suicides and $755 million for attempts (1996.) The Alberta government spends about 1 million a year on suicide prevention.The CMHA believes that suicide can be reduced through a concentrated, coordinated effort to improve the suicide prevention activities of all social service, justice, employment, health, education and community groups. It isn’t happening.Alberta has had a Suicide Prevention Program since 1981 when a government advisory committee accepted a CMHA recommendation for a plan which would have seen a suicide prevention “framework” including a number of “essential” elements. Those elements are community coordination, education, training, research, evaluation and public policy. Community coordination was to be undertaken by a provincial “Suicidologist ” in partnership with locally based community agency “Coordinators.” The Suicidologist would also oversee public policy, research and evaluation and CMHA contracted with the Alberta government to undertake the education and training components.The CMHA components became known as the Centre for Suicide Prevention and they are now being used world wide. SIEC is a computer assisted resource library containing print and audio visual materials on a wide range of suicide related issues. The SPTP offers caregiver workshops in suicide prevention, awareness and bereavement. Both programs utilize the local funded agency Coordinators in the application of the suicide resources.While the provincial Suicidologist position no longer exists in early 2001 the Alberta Mental Health Board appointed a coordinator of the suicide programs to attempt to revive the concepts of provincial coordination, public policy and evaluation which for several years have been lost. The research agenda never materialized.Specifically CMHA is calling for:

• A Federal government supported National Action Plan on suicide prevention.
• The establishment of an Alberta Suicide Prevention Coordinating Centre with responsibilities to:
• Provide leadership, advice and coordination to existing programs
• Assist in the continued development of the Suicide Information Collection
• Assist in the development of caregiver programs through the Suicide Prevention Training Programs.
• Assist funded agencies in the cooperative development of new resources.
• Conduct research into suicidal behavior
• The expansion of existing Suicide Prevention Coordinators to all 17 Health Regions.

The Association is working with the Federal and Provincial Departments of Health and with the government’s Alberta Mental Health Board in order to achieve the programs “essential elements.”