Involuntary Psychiatric Treatment Act

An Interview by Tony Legere with
Dr. David Mulhall Concerning the
Involuntary Psychiatric Treatment Act


Q. Dr. Mulhall, at the beginning of the Act it says that in order to receive involuntary treatment you need to have a psychiatric disorder, to be a danger to yourself or others, to suffer from serious physical impairment or serious mental deterioration. What does serious physical impairment and serious mental deterioration mean?

A. An example of serious physical impairment would be if somebody with a physical illness, such as diabetes, refuses to take their diabetic medication because, as a result of their psychiatric illness, they believe that the medication is poison, the diabetes could get out of control. It means that if there’s a failure to treat now there might be deterioration of the person physically..

An example of somebody with mental deterioration is that if they are failing to follow treatment including taking their medication, their fears and false beliefs become greater and greater. They would take less care of themselves, or be more fearful, or be angry towards others, and become more lost in their illness. The Act allows for people to have treatment before their illness progresses.

For voluntary admission the Act says that the person must understand and have the capacity to make a treatment decision concerning the nature of their condition for which treatment is proposed, the nature and purpose of the treatment, the benefits involved in the specific treatment, and the risks of not going into treatment.


Q. How does a physician determine if the patient has the capacity to understand these treatment options?

A. First of all it’s important to remember that most patients, 90% or more, are voluntary patients. They recognize that they have difficulties, they are agreeable to treatment, and they are making voluntary and capable decisions regarding coming into hospital to accept whatever treatment is recommended.

Under the Involuntary Treatment Act people can be admitted for a three day period for assessment. During that time it is simply an assessment and the issue of their capacity does not have to be finally determined.

If however they are in for involuntary treatment, that would be determined by the end of the three day assessment. For them to be treated on an involuntary basis they have to lack capacity. How you determine someone’s capacity? Do they understand the nature of the illness? Do they understand the nature of the treatment, and the risks involved in having the treatment? Do they understand the risks involved of not having the treatment? That is how you determine the capacity for any medical decision.

For example, you have an illness such as severe angina. The angiograms show that you have blockage of your arteries. I’m recommending that you have by- pass surgery. The patient has to understand what it is. Particularly the patient has to say it back in their own words. What is it you’ve been told you have? What does that mean? What is the treatment you are being offered? Do you understand the risks involved in the treatment? Do you understand what the risks are if you don’t have the treatment? The patient has to show that they understand and appreciate the decision they have to make.

So far as the Community Treatment Orders are concerned, the prerequisite for involuntary treatment in the community are the same as those for involuntary treatment as an inpatient.


Q. Looking at the CTO from a practical point of view, how will the services required for a person to live in the community be set up?

A. If somebody fulfills the criteria that they have a significant illness, that they lack capacity, that without treatment that they are likely to deteriorate, then they can, in addition to having treatment enforced inside a hospital building, treatment can be organized and arranged on their behalf in the community.

A Community Treatment Order most commonly would start from somebody who has been in hospital and is now organizing plans for their return to the community. These patients in the past have done well with treatment in hospital but have never followed through with treatment in the community, so have become unwell on a number of occasions. What people used call the revolving-door patients. It’s that group of patients where a Community Treatment Order would be of value. These are patients who do well in treatment but they don’t themselves stay in treatment. Treatment works if they are willing to be in treatment.

The Community Treatment Order allows for those cases. It’s expected to be rarely used. The estimate of the Nova Scotia Department of Health is that only about twenty patients at any one time would likely be on a Community Treatment Order.

It involves planning. Everybody who is declared incapable who is either in hospital or under community treatment as an involuntary patient will have a substitute decision maker. That substitute decision maker is normally a relative and will be making decisions on their behalf. There must be agreement of the local mental health system and particularly agreement of the substitute decision maker. They are the ones that will be hearing from the treatment team.

What’s the most appropriate treatment? How is it going to happen? Who are the people involved? With a community treatment order all those things have to be in considered. There has to be a team available and willing to undertake that treatment, and would involve at the very minimum a Psychiatrist. Other members of the team could involve a community mental health nurse, a social worker, and a community support worker. It depends on the individual client. The treatment order would name the treatment being offered, such as the types of medication, the general frequency of appointments, and the support people who would be involved in the treatment. It would not be naming things such as where is the person is going to live, or where they spend their day.

This order is in place for up to six months, and can be renewed or can be set aside. If there is a situation during that time, such as the person becoming unwell, then there are grounds to have the person return to the hospital.

Sometimes a person will become unwell because their illness is worse, even though they are following treatment. There is no resistance to treatment, they are just getting unwell. It allows them
to return to the hospital directly rather than having to go through another assessment. The team can make that decision with the substitute decision maker being involved.

The second group is the group who are becoming unwell because they are not remaining involved in treatment, they are not coming for their appointments, they are not taking their medication. There is facility to say we need to see that person. We need to know that we can rescue the situation in the community.

Can we get to see the patient? Will the patient agree to co-operation with the community treatment order? Sometimes it might be as simple as arranging a meeting. and coming to a decision. If their situation is not stable in the community they would be brought back into the hospital to improve their situation with the expectation that they return to the community in a short time. All those decisions have to involve the substitution decision maker.

Again, the idea behind it is to prevent things going wrong all the way. It’s like seeing something going wrong and stepping in early. That’s the purpose and the intent of the Community Treatment Order. It allows for the treatment to be enforced in the community.