Treatment in the community

The closure of hospital wards and the movement towards community care makes it desirable for treatment to be administered outside the hospital setting. In some countries, mental health legislation does not allow this. The powers conferred under the 1983 Act, for example, do not allow for the compulsory treatment of those who are not detained in hospital, and this led in the past to attempts to circumvent these limitations through the use of conditional leave of absence. Under such arrangements, patients were given leave of absence from hospital on the understanding that if they refused to accept treatment outside hospital their leave would be revoked. In R. v. Hallstrom, ex parte W (24) the court ruled that this practice was not authorized by the legislation and it was thus prevented. One solution to this problem is the possible introduction of community treatment orders, which would require patients to accept treatment in the home, clinic, or other suitable place. Community treatment orders are legally authorized in many jurisdictions in the United States (25) and in Australia and New Zealand.(26>

Arguments in favour of the extension of psychiatric supervision into the community have been reinforced by serious incidents involving discharged patients. Some of these, involving the death of the patient or fatal attacks on members of the public, attracted considerable attention and fuelled calls for closer monitoring of such patients. However, opposition to the community treatment order system has continued to be voiced from a civil libertarian perspective. Critics of community treatment orders see them as an unwarranted extension of psychiatric power outside the negotiated and closely controlled framework of compulsory hospital treatment. Indeed, their legality in terms of the European Convention on Human Rights is questionable. (27>

The Mental Health (Patients in the Community) Act 1993 introduced a compromise whereby supervised discharge is available to patients who, under former practice, may have been given leave while continuing with treatment. Under this legislation, a supervised discharge order may be made in respect of a patient suffering from mental disorder who requires to receive after-care in order to avoid a substantial risk of serious harm to his or her health or safety. Such supervision is also available if there is deemed to be a risk to the safety of other persons. A supervision order lasts for the same period as a patient's detention and may be renewed in the same way as detention may be renewed, provided that the patient is still liable for detention.

As is the case with guardianship orders, a supervision order may make broad requirements of a patient. The patient may be required, amongst other things, to live at a named place, to undergo training, and to present him- or herself for medical treatment. However, the 1993 Act does not give authority to compel the acceptance of medical treatment. Ultimately, the sanction for non-compliance with treatment directives might be the threat of detention in hospital. It is possible, however, that a supervisor might be able to exert considerable pressure within the framework of the supervision and that non-compliance with treatment recommendations could be countered with more restrictive supervision conditions.(28)

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