Coerced psychiatric treatment in the community: perspective from England and Wales

Background

The UK Government has been pursuing a program to update the mental health law in England and Wales. The various proposals have met with sustained, widespread criticism. The intention now is to amend the statute in limited areas. This presentation will examine the clinical and legal context of a proposed change: introduction of supervised community treatment in the form of community treatment orders.

Methods

Past changes in mental health law relevant to community compulsion through amendments to the Act and by case law will be examined and set against the continuing reduction in in-patient beds and the increasing focus on treating patients in the community and avoiding hospital admissions. Inquiries after homicides committed by mentally disordered people have highlighted the issue of non compliance with medication and renewed calls for more compulsion of patients.

Results

The procedure of allowing detained patients leave from hospital prior to completed discharge was used as a proxy for compulsory treatment until its use was curbed by the courts. Recently case law has seen significant developments in its use again for this purpose. Supervised discharge orders introduced by amendment to the Mental Health Act in 1995 have never been popular with psychiatrists who regard them as 'toothless'. The proposals for supervised community treatment combine aspects of these two regimes. The mechanism of conditionally discharging patients subject to ongoing restrictions following criminal convictions remains the most widely respected system of monitoring psychiatric patients in the community.

Conclusion

The proposed introduction of supervised community treatment does very little to change the legal landscape. Perceived failings in community care can be better addressed through the proper application of existing laws, protocols and guidance. A more explicit debate about compulsion outside the institution needs to take place.