Community Treatment Orders – MHA

Definition of a community treatment order

A community treatment order (CTO) under the Mental Health Act is a tool intended to assist you in complying with treatment while in the community. Your community treatment order is a treatment and care plan that outlines care specific to your needs, and may include (but is not limited to) medications you must take and appointments you must attend with care providers.

Criteria

A CTO is not court ordered. Two physicians (one of whom must be a psychiatrist) determine whether a person is suitable to be on a CTO using the criteria in the Mental Health Act. To be placed on a CTO, a person must:

1. Be suffering from a mental disorder;
2. AND one or more of the following must apply:
   1. Over the past three year period, on two or more occasions, or for a total of at least 30 days have:
      1. Been a formal patient in a facility, or
      2. Been in an approved hospital or been lawfully detained in a custodial institution where there is evidence that, while there, the person would have met the criteria of being a formal patient, or
      3. Been both above;
   2. And/or within the past three years, have been subject to a community treatment order;
   3. And/or in the opinion of the two physicians, have, while in the community, exhibited a period of recurrent or repetitive behaviour that indicates the person is likely to cause harm to the person or others or to suffer substantial mental or physical deterioration or serious physical impairment if the person does not receive continuing treatment or care while living in the community;
3. AND in the opinion of the two physicians, be likely to cause harm to the person or others or to suffer substantial mental or physical deterioration or serious physical impairment if the person does not receive continuing treatment or care while living in the community;
4. AND be able to comply with the treatment or care set out in the community treatment order.

For a CTO to be initiated:

• The treatment and care identified on the CTO must be available in the community,
• AND consent must be obtained or, if certain conditions apply, the physician may issue the CTO without consent.

The following words are often used:

• Facility – a place or part of a place (usually a hospital) designated in the regulations as a mental health facility.
• Formal Patient – a patient detained in a facility on the authority of two admission certificates or two renewal certificates.
• Designated Physician – a physician designated by a board or regional health authority to issue, renew, amend or cancel a community treatment order when there is no psychiatrist available.
• Mental Disorder – a substantial disorder of thought, mood, perception, orientation or memory that grossly impairs:
  1. Judgement;
  2. Behaviour;
  3. Capacity to recognize reality; or
  4. Ability to meet the ordinary demands of life.

Common questions

Who issues a CTO?

Two physicians, one of whom must be a psychiatrist, may issue a CTO. If there is no psychiatrist available to issue the CTO, the health authority can designate a physician to act in this capacity, only after the physician consults with a psychiatrist. It is important to note that the psychiatrist or designated physician who issues a CTO may not be the physician who supervises the care of the person under a CTO.

Am I considered a “formal patient” if I am under a CTO?

No. The CTO may have been issued when you were a formal patient under two admission certificates or two renewal certificates. Your certificates are automatically cancelled once you are on a CTO.

Is consent required for a CTO to be issued?

As a general rule, a person or his/her substitute decision maker must give consent for a CTO to be issued. A person’s consent is not required if the physicians are of the opinion that a) the person has a history of not obtaining or continuing with treatment or care in the community that is necessary to prevent the likelihood of harm to others; and b) the CTO would be reasonable and less restrictive than retaining the person as a formal patient.

How long does a CTO stay in effect?

A CTO is in effect for six months and may be renewed any time before its expiry. A CTO can be renewed for a period of six months. There is no limit to the number of times a CTO can be renewed.

If I am on a CTO, what are my responsibilities and what will happen if I do not comply?

Being on a CTO means that you must follow the treatment and care requirements listed in the CTO. The care provider must report if you do not follow the treatment and care requirements. At that time, a psychiatrist or designated physician will make reasonable efforts to inform you (or your substitute decision-maker, if any) that you are not complying with the CTO and provide you with reasonable assistance to comply. The psychiatrist also will advise you that an apprehension order may be issued if non-compliance continues.

If you still do not follow the treatment and care requirements listed on your CTO, the psychiatrist may issue an order that authorizes a peace officer to apprehend you and convey you to a facility for an examination.

Can treatment be forced through a CTO?

No. Regardless of whether the CTO is issued with a person’s consent or without a person’s consent, the person must agree to any treatment before it is provided.

What will happen if I am taken to a facility because I have not followed through with the treatment and care requirements in my CTO?

Once you arrive at a facility, an examination must be completed by two physicians (one of whom must be a psychiatrist or designated physician) within 72 hours. Once the examinations have been completed:

1. The CTO may be cancelled and you may be released or offered a bed as a voluntary patient; or
2. The CTO may be amended (changed) and you may be released to resume your treatment and care plan in the community under the amended CTO; or
3. If you meet the criteria for certification, the CTO may be cancelled and you may be admitted to a designated facility as a formal patient.

Who do I talk to if I have questions about my CTO?

You may speak to the psychiatrist who issued the CTO. If another physician has assumed supervision of your CTO, you may also speak with that physician or any other provider closely involved with your care.

What can I do if I want my CTO changed?

A CTO can be changed by a psychiatrist or a designated physician. If you feel your CTO needs to be updated, you should discuss this with your case manager or someone closely involved with your care. You may also talk with the psychiatrist or physician who is supervising your CTO.

Who can cancel a CTO?

A psychiatrist or designated physician can cancel a CTO, as well as a review panel or the Court of Queen’s Bench.

What can I do if I want my CTO cancelled?

You can speak with your psychiatrist or supervising physician. You can also ask for a review of your CTO by the review panel. To start this process, you must submit an application form to a review panel chair. You can obtain an application form for the review panel from the psychiatrist (or physician) who supervises your CTO, other care providers working with you, hospital staff, or the mental health clinic in your community. The form is called "Form 12. Application for Review Panel Hearing: Mental Health Act."

You should have received a brochure entitled “Review Panels: Community Treatment Orders” that provides more information about this process. You can also obtain this brochure by asking your care providers.

Do persons under a CTO have rights protected under the Mental Health Act?

Yes. The Mental Health Act provides persons under a CTO with many rights. For example, when a CTO is issued, a form called a “written statement” must be given to the person under the CTO, as well as his/her substitute decision-maker (if any) and any other person that is designated to receive notices on the person’s behalf.

Where can I find more information about my rights and how to access legal services?

If you are receiving treatment or care under a CTO you may request assistance from your case manager or other (mental health) staff involved in your care. They will provide you with information, such as brochures regarding Review Panels, Legal Aid Alberta and the Mental Health Patient Advocate Office.

You may also contact the Mental Health Patient Advocate Office directly. The Advocate Office provides rights information, follows up on concerns, and assists persons under a CTO upon request.

Review Panel hearings

Applications for a Review Panel hearing can be sent to the appropriate Chair for your zone at the address below. It is important to include your address on the application form so the review panel in your area will hear the application.

Edmonton and North Mental Health Review Panel
R. Allan Harris, Chair
Suite 302, Energy Square, 10109 – 106 Street N.W.
Edmonton, Alberta  T5J 3L7

Calgary and South Mental Health Review Panel 
Marilyn Smith, Chair
323 – 11 Avenue N.E.
Calgary, Alberta  T2E 0Z2

Central Alberta Mental Health Review Panel
Alan Fielding, Chair
4708 – 49 Street
Camrose, Alberta  T4V 1M7

If you are not sure which health zone you live in to determine which Chair to contact, check the Alberta Health Services Zone map.