Alberta's Community Treatment Orders: Canadian and International Comparisons

Introduction Community Treatment Orders (CTOs) are designed to assist people who, because of serious mental illness, do not avail themselves voluntarily of medication, follow-up opportunities and other services for their care and treatment while living in the community and who, without treatment, become psychotic and require repeated hospitalization. CTOs are generally viewed as less restrictive of liberty and individual autonomy than the alternative of involuntary inpatient hospitalization. CTOs have been developed relatively recently in response to the shift from hospital-based to community-based mental health service delivery (e.g. New Zealand) (1) although in some jurisdictions the tipping point for the legislative motivation to enact CTO legislation has been violent incidents involving people with untreated mental illness. Alberta, (2) Ontario (3) and New York (4) are examples. We discuss the Alberta incident and the relationship between mental illness and violent incidents in the last section of this article where we respond to criticisms of CTOs. Alberta is the fifth and most recent province in Canada to enact CTO legislation. In formulating its provisions, Alberta (5) had the benefit of experience in Saskatchewan, (6) Ontario, (7) Nova Scotia (8) and Newfoundland and Labrador (9) as well as in a large number of international jurisdictions. (10) It also had the benefit of extensive information gained from recent scientific studies. (11) In the next section of this article, we compare significant elements of CTOs in Alberta with those in the four other Canadian provinces that have CTOs and, internationally, in New Zealand, and some Australian, United Kingdom and United States jurisdictions. (12) We then address criticisms that have been levelled at CTOs in Alberta and give our conclusion. Significant Elements of CTOs This article focuses on the major substantive and procedural elements in Alberta's CTO scheme including the authority to issue a CTO, the criteria, pre-conditions, consent, treatment planning, duration, compliance, and rights and protections. Authority to issue a CTO CTOs are issued by physicians after examination of the person being assessed for a CTO. Alberta requires separate examination and signature by two physicians, one of whom must be a psychiatrist, within the 72 hours immediately preceding issue of the CTO. (13) In contrast Ontario requires only one physician who does not have to be a psychiatrist. (14) CTO criteria (harm and deterioration) In Alberta, as in other Canadian provinces and most foreign jurisdictions, the criteria for issuing a CTO builds on the criteria for involuntary inpatient hospitalization. In Alberta, in addition to suffering from mental disorder, the individual must be to cause to the person or others or to suffer substantial mental or physical or serious physical impairment (the harm or deterioration criterion) in the absence of intervention. The Alberta wording (which applies to both involuntary inpatient hospitalization and CTOs was previously to present a to himself of others. (15) The new language parallels the wording in the Saskatchewan legislation (16) and is similar to changes in wording that have been made in other provinces. (17) The rewording broadens the basis for intervention with the result that more people are now likely to qualify for a CTO than would have qualified under Alberta's previous danger criterion. Pre-conditions (previous psychiatric history) Even where a person meets the committal criteria for involuntary intervention, all jurisdictions in Canada and some jurisdictions elsewhere impose a pre-condition on CTOs. That is to say, a physician can only issue a CTO where the person has a previous psychiatric history. In contrast, most jurisdictions outside Canada impose no pre-conditions and do not require an inpatient history. …

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