MENTAL HEALTH // Compulsory Treatment Orders - My Experience

In my previous post, I briefly introduced Compulsory Treatment Orders and outlined what they are, when and why they might come into use. Today I wanted to address the question: what does it feel like when they do?

The truth is, every person is unique and the experience, thoughts and feelings they have surrounding a CTO will be entirely unique too. I can only speak for myself. Bearing in mind my story tells only mine alone, here it goes...

In theory, Compulsory Treatment Orders have always seemed to me to make good sense. They are a useful element of the Mental Health Act, intended as a safeguarding tool when a person's mental disorder is at its most acute. 

In practice, I guess I never imagined I could be deemed "unwell" enough for it to be used!

The Application 

I was pretty devastated when I heard they were making the application to place me under a CTO. Having been in hospital under a short-term detention certificate, I had been given the impression that I would be allowed to go home when the 28 days came to an end, so to hear otherwise was something of a blow. My psychiatrist and MHO (Mental Health Officer) sat down with me to deliver the news and I felt completely thrown. I couldn't wrap my head around the idea that things were that serious or that other people could see reason to be that concerned about me. In my mind, it was an unnecessary waste of everyone's valuable time.

And the thing is - it does take up valuable time! Gathering the evidence, writing the reports, submitting the application and turning up to the Tribunal all make for a lengthy and time-consuming process for the professionals involved. They wouldn't give themselves such a mammoth task if they didn't believe it was necessary, though I struggled to recognise this at the time. 

A large part of me was confused that it should be required, given I've been consistently good at taking medication and turning up for appointments throughout all my time under mental health services. An even larger part of me was sad and desperately disappointed that my life had come to this - that I had reached a point where the professionals felt they needed to take my last remaining semblance of independence away from me.

I saw a CTO as some sort of symbol of failure (which it absolutely isn't!) and was determined to fight against it from the beginning. I read a statistic somewhere (I'm not sure how accurate!) that 98% of all CTO applications are granted, but I didn't let that deter me! I was determined to be in the 2% and in the weeks leading up to my Tribunal, I worked incredibly hard to maintain a strong front and convey the message that everything was somehow magically better than in previous weeks. Internally, I was crumbling - more than aware that I was walking a tightrope with the Tribunal date the point at which I would fall, catastrophically - but I fixed my eyes firmly on that point, just about held it together for that short period, and managed not to stumble. They'd have been hard-pressed to find fuel for any CTO fire in those few weeks alone.

The Tribunal

When the Tribunal finally rolled around, I had both an independent advocate and a solicitor on board. Not everyone feels able to attend in person - and that's okay - but I couldn't handle the thought of everyone talking about me, without me, and so felt I needed to be present in the room. Fearful that I wouldn't be able to articulate myself in such an unfamiliar and stressful environment, I also submitted a written piece (which every patient is entitled to do) to be copied and distributed to each of the panel and those presenting to them, which allowed me to feel more confident that I had represented my own point of view. (Apparently people usually submit a paragraph or two. I, of course, wrote a five page tome!) 

My experience of the Tribunal was far less terrifying than I had anticipated. The panel seemed genuinely interested in getting to know something of me as a person, as well as gaining a clear understanding of the circumstances which had led to this meeting. It was a lengthy meeting, but they were consistently kind and patient throughout and took time to hear from my doctor, MHO and solicitor, before asking me questions which I felt able to answer quite clearly by myself. Once they had heard - and read - the whole case, we were dismissed to the waiting room while they took time to discuss and make their decision.

From the get-go, everyone (including the doctor and MHO making the application) had said mine was not a clear-cut case; that there would always be a significant question mark over my decision-making ability; and that no one could really predict which way the decision would go. This certainly seemed to be reflected in the amount of time they took to deliberate!

Eventually, we were called back to the meeting and told that they were granting an interim (temporary) hospital-based CTO - which lasts for 28 days - in order to allow my solicitor (who had come on board at very short notice) the opportunity to better prepare and re-present my case before a second meeting of the Tribunal.

I was distraught. Logically, I knew that the decision was made out of genuine concern for my well-being, but emotionally it felt like something else entirely. I felt like I had screwed up; like my hard work (to appear "well"; to write my piece; to attend and speak in person) had not been good enough (as usual); and that I had somehow made such a mess of things that my life had reached this ultimate low. I was gutted. The mask quickly began to fall.

The Interim

Ironically, in practice, the interim CTO changed very little in regards to my treatment. The professionals involved in my care had no real intention of keeping me in hospital, seeing the CTO as a "safeguard," more than anything, providing a bit of back-up when I was allowed to go home. I was discharged just a few days later (in light of how much "better" things had been) and retured home with a firm medication and appointment regime to follow. 

Unfortunately, as predicted, I struggled to maintain the facade or walk the tight-rope for long after Tribunal day. I went home and crumbled completely.

Shortly after the first follow-up appointment with my doctor, I had my first experience of the CTO coming more notably into play.

When the results of some tests came back amiss, it was clear that I needed to get to the hospital for treatment. Alas, they made this discovery late in the evening, by which point my miserable, isolating self was already "medded and bedded" and oblivious to the fact the hospital were trying to get in touch. As a result of this, they decided to use the CTO to "recall" me to the hospital and sent the police to get me. The officers were very kind, but it was a humiliating experience to have them appear at my home (and meet me in my PJs!) and to climb into the back of a police car in the middle of a quiet residential street.

It was late by the time we got to the hospital and I felt treated like a criminal by the unfamiliar night staff - as though I had deliberately been avoiding treatment or doing something awful - and I was left fearful and disorientated by the lack of explanation about what had just happened or what I should now expect. I was taken to my old ward, but no one there had been given any information and could only tell me to go to bed and try to sleep while they attempted to find out what was happening.

Eventually it transpired that I needed physical treatment and had to be transferred to the local medical hospital to receive it. That night and much of the following day were spent in treatment, before I was passed back to the psychiatric ward, like some kind of human yo-yo.

I don't want to paint this incident as some sort of horror story, because parts of it had to happen in order that I got the treatment that was necessary (and it was very much necessary!), but I felt dehumanised by the experience and like it could have been handled with a little more compassion and a lot more clarity!

Back at the psych ward the following day, my psychiatrist and I decided to try discharge again. Things hadn't gone smoothly, but we both knew that home was a much better environment in which to be.

Alas, I really struggled to make the transition a second time round and things deteriorated rapidly. I reached out to the Out of Hours service for help, but was told there was nothing they could offer me. The irony of being transferred to hospital by police one day, but sent away when I was actively seeking help a few days later was not lost on me!

In the end, my doctor made the decision to readmit me and it was decided I would stay in hospital until we got the second tribunal out of the way.

The feelings of hopelessness, helplessness and the profound sense of inadequacy that came about as a result of my "failed" discharge had a significant knock-on effect on me. Things felt about as low as they had ever been.

The Second Tribunal 

By the time the second tribunal rolled around, I had given up. My solicitor and advocate still thought there was a chance the six month CTO might not be granted, but I had tried so hard the first time round I had nothing left to fight with. I submitted another written piece, alongside my original one, but it was more bullet-point-list than essay this time round. I showed up to the Tribunal in person once again, but felt like there was little left to say.

The Tribunal panel was made up of entirely different members and, while they were still interested and kind, their manner was more business-like and I had a very different experience on this second occasion. The meeting seemed shorter, though more people had been invited to speak, and so much had happened since the granting of the interim order that I felt in a poor position to argue my case.

Once dismissed, the panel took far less time than the first (though not unreasonably so!) to deliberate and we were called back into the room for delivery of the final blow: I had landed myself a six month CTO.

The Six Month CTO 

I spent the first four of those six months almost permanently in hospital. The professionals suddenly more responsible for my safety and well-being than ever before, it felt, for a while, that we became entirely adverse to risk. Home seemingly no longer an option and no one coming up with any alternatives, I felt stuck - trapped in a place that I hated and increasingly hopeless. Those feelings came to be the driving force behind unhealthy behaviours which in turn came to drive the need to micro-manage risk, and so a vicious cycle was created.

Besides being kept in hospital, the CTO continued to have little impact regarding the treatment of my mental health. I continued to be fully compliant with medication and my doctor and I actually began to reduce it slowly - eventually cutting it out entirely - in a bid to see what impact it was really having. (None.) As for engaging with other professionals or attending groups and activities, I was more than happy to do this of my own accord, thankful for anything to break up the ward-life monotony!

Where the CTO most came into play in those six months was, ironically, the area for which its use is least intended: enforcing treatment for physical conditions. Time and time again I was transferred to the medical hospital for treatment of a certain condition and, every single time, my experience was entirely different. I struggled with the inconsistency (ah, consistency!)  and I struggled with the experience of being forced to undergo a somewhat invasive procedure without having to give my permission. It was dehumanising.

Nine times out of ten, a medical professional would simply appear and tell me I was about to receive treatment, with no room for conversation or discussion. It was like the CTO gave them permission to skip the usual process of explaining the pros and cons to a patient. I was deemed to have impaired decision-making, so why even bother asking my opinion?

Occasionally, I would get lucky and find myself in the hands of a professional who took a different approach. I remember thanking one young doctor for taking the time to explain things clearly and for really asking my opinion first.

"But it's your treatment..." he said, a little bemused.
"Yes, but I'm on a CTO. That's not how most people approach things, so thank you."
"A CTO should only ever be a tool to allow us to have a better discussion," came his response.

And it's true. This is precisely the kind of approach a CTO should help to facilitate, but it was sadly the one I encountered less often than not.

I learned the hard way what would happen if I actively refused and so I stopped putting up a fight and accepted that my opinion didn't really count - a thought confirmed repeatedly by the fact it was so rarely sought out. It's a hard thing to feel like you no longer have sole power and control over what happens to your own body.

Don't get me wrong, there were a number of occasions when the treatment was absolutely necessary - where, without it, I probably wouldn't be fit to type this, if I were even alive - but there were also occasions when I would have preferred not to receive it; where I feel like it was used for a "quick fix" or a bit of an "easy life". I trust that the professionals did what they thought best at the time, but the lack of dialogue often made it difficult to understand exactly why. (And, my word, it's important to me to understand exactly why!)

Those were a difficult few months for everyone involved. The feelings of shame and inhumanity contributed more to that old vicious cycle for me, while the professionals were left with fewer and fewer ways to respond. We were all stuck and it seemed, for a while, that I would be in hospital for the full six months and beyond!

And then something surprising came along. My Social Worker presented my case to a panel for Supported Accommodation and, though it was rejected the first time around, a service provider later decided to take a risk on me and a plan was quickly drawn.

It gave me a clearer outline of what was expected or asked of me and set out a far more consistent, validating response. I benefited greatly from a more solid framework to work with and things gradually began to improve. Eventually, we were in a place where the professionals felt more able to take positive risks and my life became less and less restricted. In my final month in hospital, I spent far less time being "ob'd" and was able to build up my time off-ward until we reached the point where I was able to come and go as I pleased and was deemed ready for discharge!

My hospital-based CTO was suspended (meaning it was still possible for them to recall me to hospital if things went wrong) and I was allowed to go home. Discharge went far more smoothly this time - supported accommodation turning out to be the ideal stepping-stone between the 'all' of hospital and the 'nothing' of going home alone.

If anything, it is for this I most appreciate having had a CTO in place. I'm not sure how easy it would have been to secure supported accommodation - and stop that hospital-to-home yo-yo - had this not been the case.

Nothing is perfect and there were a few blips along the way, but the transition from hospital went better than anyone could anticipate and the next two months were a considerable improvement on the four following the CTO's granting!

The Ending 

Things went so well, in fact, that when my CTO neared its end sometime in June, we made the decision that it should be allowed to lapse. My Psychiatrist (who acts as my Responsible Medical Officer) and MHO sat down with me in the preceding week to chat through the five criteria and came to the conclusion, together, that my "ability to make decisions about medical treatment" was no longer impaired and that, along with my willingness to comply with treatment, this deemed "the use of compulsory powers" no longer necessary.

Considering the limited practical impact, given I was no longer in hospital at this point and would continue to engage in the exact same treatment, it is perhaps surprising how much of an emotional impact was made by the revocation of my CTO. I felt like a free woman once again - like something intrinsic to my identity (my sense of independence and autonomy) had been handed back to me - and it felt brilliant!

Since its termination, I continue to meet with the same team and my care and treatment is still ongoing. I have gladly engaged with each of these people (I'm kind of a fan of my current team!) throughout, but the dynamic feels different now that the CTO is gone: I know with absolute certainty that I am present and participating because I want to be, not because I have to be, and it is empowering to know that I can make that choice for myself once again!

In Summary

I didn't have the best of experiences as a person under a Compulsory Treatment Order, but I think it would be fair to say that many of the negative impacts were emotional rather than practical.

There are certain elements of the process that I wish had never occurred - encountering the police; spending so long in hospital; and (sometimes) receiving physical treatments against my will - but on the other hand it enabled me to secure a Supported Accommodation tenancy and I am very thankful for that.

I regret that I reached a point in my life where such an order was allowed to be granted and a large part of me would still debate its necessity today, arguing that I maintained decision-making capacity throughout. It very much came about out of concern for my safety and while, even now, I might argue that my safety is mine alone to maintain and that nobody else should interfere with my choices, I do truly know that the professionals chose to use the limited tools available to them out of a genuinely good, concerned and well-intentioned place.

It definitely wasn't the best period of my life - and certainly not one I'd like to repeat! - but here I am on the other side, alive and CTO-free!

As I said at the beginning, this is my story and mine alone - there are thousands of other perspectives and experiences on the use of a CTO, some more negative and others more positive by far. Everyone's story is unique: if yours has, does or is about to feature a CTO, please recognise that you might have a very different experience to the one I had!

And please also know there is help and advice to be had if the CTO chapter of your story isn't going so smoothly:

• 'A Guide to Compulsory Treatment Orders'
• 'A Guide to Emergency and Short-Term Powers' 
• 'Know Your Mental Health Rights'
• 'The Mental Health Act (Scotland) 2015'
• The Mental Health Tribunal for Scotland 
• The Mental Welfare Commission for Scotland
• Scottish Independent Advocacy Alliance 

xo