A cluster analysis of people on Community Treatment Orders in Victoria, Australia

Abstract

This paper explores the clinical, social and demographic characteristics of 164 people on Community Treatment Orders (CTOs) in one area mental health service in Victoria, Australia. The results of an exploratory cluster analysis are presented to address the question of whether people on Community Treatment Orders can be categorised into statistically reliable, qualitatively distinct groupings. The data are presented in the context of key stakeholder perspectives on the current use and purpose of CTOs. Three stable clusters emerged and each potentially reflects how social dimensions, as well as clinical issues, influence decision making regarding the implementation of CTOs. These findings are important in the context of policy and practice in Victoria, where the use of CTOs is common practice, and orders are generally made for a 12 month period. The potential for improved targeting of CTOs and more specific treatment planning is identified.

Introduction

The purpose of this research is to profile people on CTOs in a mental health service in one area of Melbourne (the capital city in the state of Victoria, Australia). The research is essentially exploratory in nature and is not investigating a particular hypothesis; however, it is mindful of the local and international debates regarding the implementation of CTOs, and the findings of qualitative research that has identified concerns about issues such as the length of CTOs, the potential overuse of CTOs and the emphasis on medication for people on CTOs (Dawson, 2005).

Community Treatment Orders are a strongly established method of providing involuntary treatment in Victoria. The implementation of involuntary treatment in the community in other parts of the world has been contested, often in the context of pressure to manage increased concern regarding risk (Brophy and McDermott, 2003, Dawson et al., 2003, Rolfe, 2001). By contrast, debate regarding the implementation of CTOs in Victoria, enabled by the Mental Health Act 1986, has been relatively low key. Carney (2003) describes the inclusion of CTOs in the 1986 legislation as ‘an afterthought’ (p.24). Initially, CTOs represented a substitute for the already common practice of placing people on leave from involuntary admission into the community, thereby providing a safety net that ensured that the person could be readmitted easily, if required (Dedman, 1990). In the mid 1990s the use of CTOs rose dramatically in the context of significant reforms that resulted in the closure of large psychiatric institutions along with a major shift to reliance on community based care. Thus, many clients were, and still are, discharged from inpatient care onto community treatment orders, and CTOs remain important in attempts to keep hospital admissions to a minimum and, in the main, locate treatment in the community (Carney, 2003).

Despite Victoria's familiarity and apparent comfort with the use of CTOs, after almost 20 years there is much to continue to learn about the implementation of CTOs and the implications they have for consumers, their carers and service providers. Up to 20% or more of consumers of public mental health services in the community in Victoria are involuntary patients and, although estimates vary, approximately 3000 people are currently on CTOs (Dawson, 2005, Mental Health Review Board of Victoria, 2004). Inpatient units can be described as being limited to providing intensive care with 21.8 acute beds per 100,000 adults and an average length of stay, as estimated in 2001, at around 14 days (Auditor-General, Victoria, 2002). Victoria is recognised as a model mental health system with a genuine focus on community based care as a way of meeting the needs of the seriously mentally ill. Community Treatment Orders are implemented in the community via either multidisciplinary continuing care teams, where case managers have an average case load of 40 people, or in mobile support and treatment teams, who care for fewer people with more complex presentations. Each area mental health service also has crisis assessment and treatment services. There is a network of psychiatric disability rehabilitation and support services, and increasing partnerships and shared care arrangements with private practitioners. However, despite the general acceptance of the use of CTOs, and the availability of a well developed community based service network, contested issues are evident. Dawson (2005), for example, in his international comparison of the implementation of CTOs, described the principal doubts about CTOs in Victoria as including: concerns about the overuse of CTOs, the length of the orders, and quality of treatment.

All states and territories in Australia have now legislated to enable involuntary mental health treatment in the community. As might be expected there is some variation in terminology and processes. However, fundamentally all legislation enables someone who meets certain involuntary admission criteria to be treated involuntarily in the community, usually with medication. Although examples in other states involve courts and/or tribunals making the order, in Victoria the orders are made and confirmed by doctors and psychiatrists, but the Victorian Mental Health Review Board, a multidisciplinary panel consisting of a lawyer, psychiatrist and community member, reviews the validity of the orders. Patients can appeal the order and the hearing will occur as soon as possible, otherwise a standard review date is set; in Victoria this review date must be within eight weeks after admission on the order, and then annually. Legislation in other states varies considerably on the duration of the orders and periods prior to review (Rolfe, 2001).

The establishment of more specific criteria, which determines whether involuntary treatment can take place, has been an important development in mental health legislation and is the key feature of the Victorian Mental Health Act 1986 (State Government, Victoria, 1986). It can be argued that, after developing an understanding of the objects and principles of the Act, the most important feature that needs to be understood by all mental health workers is the interpretation and application of these criteria because they determine the important decision making regarding involuntary treatment, both in hospital and in the community. The current criteria for involuntary treatment are as follows:

• the person appears to be mentally ill; and

• the person's mental illness requires immediate treatment and that treatment can be obtained by making the person subject to an involuntary treatment order; and

• because of a person's mental illness, involuntary treatment of the person is necessary for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition or otherwise) or for the protection of members of the public; and

• the person has refused treatment or is unable to consent to the necessary treatment for the mental illness; and

• the person cannot receive adequate treatment for the mental illness in a manner less restrictive of that person's freedom of decision and action. (Mental Health Act 1986 Section 8(1))

Community treatment orders can only be made if the person meets the above criteria and is assessed as being able to obtain treatment in the community. The order cannot exceed 12 months and may include a residence condition (Section 14(3)(b)), although the local policy, as described in the Community Treatment Order Chief Psychiatrist's Guideline (Mental Health Branch, Victorian Government Department of Human Services, 2005), encourages highly restricted use of residence conditions. The careful wording of the above legislation reflects its attempts to be in keeping with the objectives of the Act which are, in summary, to provide for the care, treatment and protection of mentally ill people and to also protect their rights (State Government, Victoria, 1986).

CTOs are an essential part of the landscape of psychiatric service delivery in Victoria. Most involuntary patients are on a CTO and there are approximately 3000 people, currently on CTOs at any time. Most people are placed on CTOs upon discharge from inpatient care, although the legislation does allow for community based admission on to CTOs (Mental Health Branch, Victorian Government Department of Human Services, 2005). There has been a significant increase in the use of CTOs since policy change and sweeping reforms in the mid 1990s enabled a major deinstitutionalisation process that resulted in the eventual closure of large institutions and the reliance on smaller psychiatric units attached to general hospitals in each area mental health service.

There tends to be strong support for CTOs amongst service providers. Local studies by Power (1998) and Muirhead (2000) have demonstrated support for the “clinical wisdom” attached to the use of CTOs. Brophy and Ring (2004) investigated the views of service providers and found that they generally held positive views about the operation of the orders in enabling greater opportunity for treatment and service provisions. Even so, participants also expressed concern about the disempowering and stigmatising impact on consumers.

Carney (2003) identifies people on community treatment orders as continuing to grow as an invisible, marginalised group in the community; thus, the people decanted from institutions have become the subject of social control measures in the community (Rose, 1998). Carney (2003) also questions the legal protections offered by compulsory annual reviews, in that large numbers of people are discharged just prior to their review hearings — a factor that may indicate misuse and complacency, or, at least, a lack of appreciation of the implications of the exercising of these powers.

The operation of CTOs and the legislative scheme supporting them were criticised by the coroner in the findings on the death of Mr. Nicholas McNulty (State Coroner, Victoria, 1997). Mr. McNulty was stabbed by a man who was, at the time, on a CTO. The coroner found the legal requirements for managing CTOs to be unclear, and found deficiencies in the awareness of mental health professionals in undertaking their legal obligations. The coroner also found that some staff were ill prepared to manage the demands of providing effective care and treatment. Recent law reform acknowledged some of the broader concerns about examples of inappropriate or poor implementation of CTOs. The need for improved consumer focus in treatment planning has also been identified (Department of Human Services, Victoria, 2002).

Statutory treatment plans were introduced in 2004 as a result of amendments to the Mental Health Act 1986 (Section 19A) in order to give consumers clear guidance about their obligations under a CTO and a clear statement of the treatment that they can expect (Mental Health Branch, Victorian Government Department of Human Services, 2005). Presumably this was recommended to both be in line with other jurisdictions in Australia and also in response to criticisms in feedback from consumers and carers about a lack of clarity regarding treatment planning. Overall recent reforms to the Mental Health Act 1986, were modest and do not suggest major change.

Feedback from consumers, carers and service providers in Victoria tends to reveal both similar and divergent themes (Brophy and Ring, 2004, McDonnell and Bartholomew, 1997, Skegg, 2002). There is general agreement that, at times, involuntary treatment in the community is required. Being heard and respected and receiving good quality treatment in the context of genuinely helpful relationships is commonly agreed upon as important, although all three groups in various studies were able to identify deficiencies (Brophy and Ring, 2004, McDonnell and Bartholomew, 1997, Skegg, 2002). There appears to be general frustration regarding lack of skills and resources in service provision. The results of recent surveys in Victoria suggest that carers and consumers often have a poor understanding of the legislation impacting on them, even if on a CTO (TQA Research, 2004). Brophy and Ring (2004) also found this amongst service providers. Consumers tended to be less positive about the benefits of CTOs, especially considering the emphasis on medication and the potential to be on CTOs for over one year (McDonnell & Bartholomew, 1997). Jaworoswski and Guneva (2000) also identified uncertainty about the optimal duration of CTOs amongst clinicians. Carers tended to be less optimistic about the quality of treatment and care available for involuntary patients (Skegg, 2002).

Brophy and McDermott (2003) identified some apparently unintended consequences of CTOs that potentially indicate the need for caution in their use. These include the possible deskilling effect of being able to rely on coercion to achieve compliance, rather than greater investment in treatment options that are more attractive to consumers (Freckleton & Lesser, 2003). Similarly, the focus on medication, particularly intra-muscular injections, in the treatment of people on CTOs suggests the possibility of CTOs contributing to medicalisation of psychiatric care despite efforts to broaden the focus of intervention in community-based treatment (McDonnell & Bartholomew, 1997). CTOs have also been recognised as being an administrative burden for medical staff, potentially diverting them from innovation and leadership in direct service (Jaworoswski & Guneva, 1999).

There are concerns, such as those expressed by Nagel (2003), that some groups may be subject to higher detention rates because of an elevated perception of dangerousness amongst certain groups, even without an evidence base for this practice. Social factors, such as gender, ethnicity, social status and availability of care have been found in UK studies to be important factors in determining whether or not someone is subject to involuntary treatment (Clark & Bowers, 2000). This may encourage the social control function of CTOs rather than doing what Dedman (1990) and Power (1999) have both suggested is most effective; that is, the CTO being a tool that assists in persuading otherwise reluctant, although persuadable, people into treatment. As discussed by Brophy and McDermott (2003) it is not surprising that there is considerable support for CTOs amongst service providers. Factors such as perceived benefit to the consumer are important, but it is likely that other factors, particularly the pressures to manage risk, and the limited resources available, also contribute to decision making (Carney, 2003). Risk management undoubtedly encourages conservative decision making in the climate created by both broader structural dimensions — for example, the impact of the media and availability of resources — and also more local considerations, such as recommendations from coronial enquiries. Patient autonomy and alternative or innovative treatments are potentially limited in this climate (Brophy & McDermott, 2003). Greater emphasis on risk management in decision making may contribute to an overuse of CTOs rather than targeting this intervention towards those most likely to benefit.

Victorian (Muirhead, 2000, Power, 1998) and international studies reveal common findings regarding the characteristics of people on CTOs, and these were summarised by Dawson (2005). Key features include the majority of recipients exhibiting the following characteristics: male, an average age of about 40 (although females tend to be older), a diagnosis of schizophrenia, living alone, rarely been married, and unemployed.

This broad qualitative profile of the characteristics of people on CTOs is useful but limited in that it presents an overly-simplistic representation of the ‘typical’ CTO recipient. Given that people on CTOs exhibit a wide range of individual differences across a number of key demographic and clinical variables, it may be that there are distinct groups, or clusters, of CTO recipients who share common profiles. While this can be investigated qualitatively, the multivariate data analysis technique of cluster analysis provides a mechanism for investigating this issue statistically.

There are a number of arguments in favour of such an investigation. If, for example, distinct clusters of CTO recipients are identified, several logical follow-up questions present themselves, the most obvious relating to the long- and short-term outcomes of the different clusters of CTO recipients. Is it the case that certain types of people respond better to CTOs than others? Is there any benefit in structuring CTOs around different types of clients? In order to address these important questions, reliable information is needed about the profiles of people on CTOs; this forms the central aim of the current research.

The topic of CTOs invites considerable scope for enquiry (Brophy & McDermott, 2003). Their very existence may be seen to be a response to contemporary debates about mental health service delivery and risk management. Research into their effectiveness has been important in other jurisdictions where the introduction of CTOs remains contested. This is also important in Victoria and supports the research efforts of Muirhead (2000) and others because, while CTOs are well established in their use, published research data are minimal. With such extensive use of CTOs in Victoria it seems also important to undertake research that contributes to clearer ethical and practice guidance in order to attempt to mediate the potential for inappropriate use of CTOs (Brophy et al., 2003, Brophy and McDermott, 2003).

Some of the unanswered questions about CTOs relate to the issue of how the practice wisdom about the value of CTOs in well-targeted situations can be measured and established. It is also not clear who the most likely people are to be placed on CTOs and whether this equates with who is most likely to benefit from a CTO and why? A fundamental assumption behind this research is that CTOs exist not just as a result of individual pathology, non-compliance and lack of insight; they are also the products of social factors. This research is interested in exploring questions regarding who is most likely to be placed on a CTO. A cluster analysis will be used to identify whether there are, at least in one area mental health service, particular ‘types’ of people on CTOs. Evidence for clusters might offer insights into decision-making regarding the implementation of CTOs, and highlight the importance of factors beyond the involuntary admission criteria.

The demographic, clinical and social circumstances data that have been collected enable a ‘snapshot’ of people on CTOs in one area mental health service in Melbourne. The data have been analysed using a cluster analysis to investigate patterns and groupings among these variables. It was anticipated that distinct categories or types of people on CTOs would emerge using this analysis.