Community Treatment Orders

I have been under a Community Treatment Order (CTO) since my most recent discharge in 2011. Without going into the in’s and out’s, legal terminology and fine details of what a CTO actually is…in simple terms…it is like being sectioned but allowed to live out of hospital, in the ‘community’. There are conditions in the CTO to which you must follow; a set of rules. If you don’t, you can be immediately recalled to hospital for as long as the doctor deems necessary. It could be days, months or years.

Now to many, a CTO with all its rules and threat of hospital may seem like a prison, a restriction of freedom and liberty. And this is something that has to be considered when a Doctor applies for a patient to be put under a CTO and when it is renewed annually. The least restrictive option has to be chosen. And in some cases, this may lead to a patients discharge from a CTO-it is not deemed necessary to impose such a restriction on a patient who could cope without it and appears to manage their mental illness.
This was my life before I had a CTO

 Not every patient that has been in hospital is eligible for a CTO. To be put under a CTO you have to be in hospital under a Section 3. Then on discharge, a Doctor can impose a CTO. To be put under a Section 3 you have to be considered to lack ‘capacity’-the ability to make an appropriate decision regarding your health and treatment when provided with the relevant information, facts and logic. To be ‘Sectioned’ means you are seriously ill and unwilling to accept treatment and therefore, the section is imposed to force treatment upon you involuntarily.

In all my three hospital admissions I was placed under a Section 3. However, it was only from my last admission that I was put under a CTO. And it is this that has saved my life. Before, I was a revolving door, going in and out of hospital and with each discharge, losing large amounts of weight to deadly levels. I was allowed to lose a lot of weight before being admitted to hospital. But my CTO stopped this. And this is a good thing about CTO’s. The CTO ensures that you have immediate access to treatment at the first sign of relapse. The conditions outlined in my CTO state that if I go below a certain weight, I am immediately sent back to hospital. And this weight is far higher than my previous admission weights. This threat of hospital at, to me, not a particularly low weight is my worst case scenario. Being in hospital and made to gain weight is a living hell, and the thought of having to do this at a higher starting weight is just unthinkable. So this provided me with the motivation to maintain my weight and I am now entering my sixth year on the CTO and I would not be where I am today without it.

At first, the CTO helped me because I knew the weight boundary I had to stay within and I did not want to go below this because I didn’t want to be sent straight back to hospital. When I was eating, I was eating because the CTO was making me…it wasn’t my choice-I HAD to eat otherwise I would lose that 1kg that would send me below my weight boundary and back to hospital. And yes, this did seem very strict…I felt like I had very little leeway. But now I can see this was a good thing. Anorexia pushes boundaries…it likes you to eat as little as possible and be as low a weight as possible. But the CTO completely stopped this. It was there in black and white, outlined in my conditions…this was the weight I had to stay above and there was no negotiation on that.
The CTO has allowed me to graduate
Because I have stayed within my weight boundary it has meant I have had 5 years free of hospital. It has come close on several occasions but the threat of hospital from the CTO has got me back on track. And the longer the CTO has kept me out of hospital, the more time it has given me to start experiencing life again, breaking that hospital cycle and letting me start to live. The more time I have had out of hospital (thanks to the CTO) the more I have started to realise that I do want more from life and my thought processes have started to change, which is key to initiating recovery. Previously, recovery had never been an option because I was in and out of hospital and  anorexia dominated my life. But over these 5 years out of hospital, starting to get back to some sort of normality, I know anorexia is not what I thought it was, it isn’t going to give me the life I want, it isn’t going to make me happy. And recovery will be possible. Whereas I started on the CTO five years ago, 1 kg above the bottom of my band, now I am several kilos above. Yes the progression is slow but without the CTO, I don’t think the progression would be there at all…I would have reversed back to hospital. Recovery from anorexia is a lengthy process and having a CTO in place during this is very helpful.

So, initially the CTO helped me because it enforced the weight boundary, but overtime, it has started to break anorexic habits and has allowed me to realise that I do actually want a life. And I believe the CTO could help many other sufferers. With anorexia, patients have to get to very low, life threatening weights before they are forced to hospital and therefore, CTOs are critical to enable hospitalisation at higher weights, before the patient becomes acutely unwell which would reduce health deterioration and entrenched anorexic thinking, and ultimately; be life-saving.

Entrenched and severe anorexic thinking occurs with increasing weight loss; the more weight you lose, the stronger anorexia becomes and the more difficult it is to recover. CTO’s help to prevent this by allowing more immediate and higher weight admissions which is key to stopping patients becoming as ill in the first place, and helping recovery. And because of the time it gives patients out of hospital, it allows their anorexic habits and thoughts to start to change.
I can now spend Christmas at home with my family
 If it is predicted that there may be rapid relapse, prolonged illness or severe consequences to the self (all of which are extremely relevant to anorexia) then CTOs have the advantage of allowing rapid recall. Also, because CTO use would result in hospital admissions at higher weights, it would mean that admissions would actually be shorter which is beneficial to both patient and government (shorter admissions mean less government spending). The threat of hospital is very real with a CTO and this can be motivating to maintain weight, reducing damage to health and the need for long hospital admissions (again, which is cost-saving).
Also, my experience from being in hospital is that many anorexics do not want help and do not want to engage with treatment and then, on discharge, they want to lose as much weight as possible. But CTO’s enforce compliance, especially initially, which can then translate, over time, in the patient actually wanting help (as was the case for myself). CTO’s have received a lot of criticism by researchers, however, most of this research has been conducted on schizophrenics and therefore it is questionable as to whether the findings and conclusions can be applied to anorexics as they are very different patient types and require very different types of treatment.

One of the main lines of criticisms about CTOs is that they are restrictive. However, in my experience, I have not found the CTO restrictive at all. Yes, it imposes ‘rules’ that I must follow and I have to regular meetings with my nurse. But quite the opposite form restricting my life…it has opened the door to life. It hasn’t taken away my autonomy, but has actually started to give it back as anorexia had taken it away. A CTO is far less restrictive than living with anorexia.
The CTO has allowed me to start to make friends and socialise
And that is why I want to campaign for greater use of CTOs. I believe they should be used as a fundamental tool in anorexia treatment. They can be cost-saving and most importantly, life-saving. Their potential for success in preventing the development of severe and enduring anorexia, and in helping anorexia recovery, I truly believe is could be huge.

Also, in Scotland, CTO’s can be administered without the need for prior hospital admission and this could reap benefits it became the law England. This allows the weight boundaries to be outlined whilst remaining in the community setting and therefore patients are less likely to reach such severe low weights where anorexic thought patterns become entrenched and difficult to change. Also, by not necessitating hospital admission, the competitive nature of anorexia is reduced and there is less likelihood of learning anorexic ‘tricks’, both of which inhibit recovery and are very prominent in a hospital setting.

I am currently conducting some research and looking into starting a campaign for greater CTO use and I would welcome any support and advice. Mental illness is as important as physical illness. If there was a possibility to use a measure that would prevent cancer becoming terminal, it would be used without a second thought. CTO’s have this potential with anorexia. CTO’s can offer, for anorexics, the key to life.

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