A Community Treatment Order (CTO) is a legal order made by the Mental Health Review Tribunal.
This section outlines: A Community Treatment Order is a legal order made by a Local Court Magistrate or the Mental Health Review Tribunal. It authorises the compulsory care and treatment, usually including the regular administration of medication, of a person with mental illness living in the community.
A Magistrate of a Local Court also has the power under Mental Health and Cognitive The loss or limitation of physical, mental or sensory function on a long-term or permanent basis. For people with mental health conditions this would also include a loss of function on an episodic basis, which in many cases leads to long term or permanent impairment and subsequent disablement. Forensic Provisions Act 2020 (NSW) to make a CTO under the Mental Health Act 2007 (NSW). For more information follow this link to Orders.
The Mental Health Review Tribunal make a CTO when you are on an An Involuntary patient is someone who is admitted and detained in a hospital or psychiatric unit for care and treatment under the Mental Health Act 2007. In most cases it refers to a person who is detained under an Involuntary Patient Order made by the Mental Health Review Tribunal. In some circumstances the term includes an ‘assessable person’ detained in a mental health facility prior to a Mental Health Inquiry. To read more see Chap 4C.5. Order; when you are appealing against the Authorised Medical Officer’s refusal to discharge; when you are on a CTO that is about to expire or when there is an application from the community by an authorised person.
Applications can be made by:
An application for a CTO can be made in relation to a person who is:
The Mental Health Review Tribunal can put you on a CTO at a hearing if:
If you have never been on a CTO before, or have not been on a CTO in the twelve (12) months before the Inquiry, the Tribunal will also consider whether you have been previously assessed as having a mental illness and have a previous history of refusing to accept appropriate treatment.
This means that:
If you have been subject to a CTO in the twelve (12) months immediately before the Inquiry, The Tribunal will also consider whether you will continue in or relapse into an active phase of mental illness if the CTO is not made.
When making a CTO, the Tribunal may consider the efficacy of previous CTOs you have been on (if relevant), medical reports and information about your psychiatric and psychosocial history.
A Community Treatment Plan (Treatment Plan) must set out in general terms an outline of the proposed medication, management, rehabilitation, counselling and other services that are to be provided to you. It must also set out in specific terms the method by which, the frequency with which, and the place at which these services are to be provided.
A Treatment Plan is prepared by a psychiatric case manager (who may call themselves a care coordinator) under delegation from the Director or Deputy Director of a community mental health facility that will be responsible for implementing the CTO, if made, and must be presented to the Mental Health Review Tribunal for approval.
The Mental Health Act 2007 (NSW) requires that, if it is proposed that you be put on a CTO, every effort that is reasonably practicable must be made to involve you in the development of the Treatment Plan. However, if you refuse to cooperate in the development of the Treatment Plan, it can be developed without your involvement. The ultimate decision about what the Treatment Plan includes will be made by the community mental health facility, even if you disagree with what is proposed.
After discussing the Treatment Plan with you, the case manager/ care coordinator) or a staff member from the community mental health facility (appointed as your case manager/ care coordinator), along with the doctor and/or social worker in hospital (if you are currently a patient of a mental health facility), will finalise the Treatment Plan. Case managers come from several different educational backgrounds including social worker, psychology, occupational therapist and mental health nursing.
The Treatment Plan usually involves a regular meeting between you and the case manager to review your mental state and to support you with any day to day issues (for example in relation to housing, employment, social activities and rehabilitation, physical health, as well as family/ carer support). They must make every effort to understand your personal goals for recovery and support you with referrals to other services in the community that you would like to be connected to. This might be for example: connecting you to the NDIS for an assessment, or working with the NDIS care coordinator to see where you can get the services you need and want; connecting with a general practitioner or community managed organisation program or service or helping you with a legal matter. The frequency of these appointments will depend on your situation, but usually you will be required to see your case manager at least once every month. These meetings will usually occur at the community mental health facility. They may occur at your home, only if you and your case manager agree to this.
Sometimes Treatment Plans will also require you to attend the community mental health facility, hospital clinic, or your General Practitioner to be administered medication, particularly if this is by way of intramuscular injection or ‘depot’. This may also occur at your home if you agree to this, and your case manager also agrees.
The Treatment Plan will also require you to meet regularly with your psychiatrist or his or her delegate for psychiatric reviews. The frequency of these appointments will depend on your situation, but usually you will be required to see your psychiatrist at least once every three (3) months. These meetings will usually occur at the community mental health facility but may be at your home if you agree to this, and your psychiatrist also agrees.
The Treatment Plan can specify what medication you must take and how often you must take them and at what times of day.
Depending upon the type of medication, Treatment Plans may also impose other obligations on you, including:
The Treatment Plan should also include obligations on the part of the treating team as well as things the team might encourage you to do because they believe they will assist your wellbeing and recovery, such as psychoeducation, rehabilitation and information, alcohol and drug counselling and engagement with physical health programs and work related initiatives.
Note that a treatment plan can’t impose an obligation on you to do something that is unrelated to your The term mental health condition is a broad term that refers to symptoms that may be caused by life events, genetic factors or birth defects. They can be temporary or lifelong and include mood, anxiety, personality, psychotic and compulsive disorders. It includes, but is not limited to those conditions and symptoms recognised as constituting mental illness under the Mental Health Act 2007 (NSW).. For example, a treatment plan could not require you to attend a dentist, visit the general practitioner or take medication for a physical health condition.
If an application for a CTO is made for you, you must be told in advance when the Mental Health Review Tribunal will hear the application and you must be given a copy of the proposed Treatment Plan. The person who made the application is responsible for giving you this notice.
Notice can be given in person, by post or by fax.
You must be given fourteen (14) days’ notice, unless:
Where the requirement for a fourteen (14) day notice period does not apply, you should still be given enough time to prepare for the hearing, discuss the treatment plan with your case manager and to seek legal advice if you wish. If you don’t think you have been given enough notice of the hearing you should seek legal advice from a solicitor at the Mental Health Advocacy Service who will be able to advise you as to the requirements for notice in your case and what to do if there has been insufficient notice.
The participants in the hearing before the Mental Health Review Tribunal will depend on the circumstances in which the application for a CTO has been made.
If you are a patient in a public mental health facility, the Applicant for the Order will usually be represented by an Authorised Medical Officer. This will usually be a registrar, but in some cases a consultant psychiatrist or career medical officer will attend the hearing. There will usually also be a nurse, and sometimes also, a hospital based social worker, psychologist, occupational therapist, rehabilitation professional or peer worker. The Mental Health Review Tribunal will usually expect a representative of the community mental health facility that will be responsible for implementing the CTO to attend the hearing, at the very least by phone.
If you are not an inpatient, the Applicant for the Order will usually be represented by the intended case manager of the community mental health facility that will be responsible for implementing the CTO, if it is made. Sometimes a consultant psychiatrist, other medical practitioner, psychologist, occupational therapist or social worker, peer worker or mental health worker representing a community managed service from which you received a service will also participate.
You also have a right to attend and participate in the hearing and the Mental Health Review Tribunal will expect you to be present. It is very important that you do participate so that the Mental Health Review Tribunal can hear your views before it makes its decision about the application. If you do not attend the hearing, the Mental Health Review Tribunal has the power to hear the application in your absence. You can also make your views known by forwarding them to the Tribunal prior to the hearing.
You cannot avoid a CTO being made by not attending the hearing. If there is a good reason why you cannot attend the hearing (for example, it clashes with another important obligation, or you would like a support person to attend, but they are unavailable that day) you should ask for the hearing to be rescheduled (‘adjourned’) to a date when you can attend. The Tribunal would prefer to meet you, but they can call you if you are unable to attend in person.
Other people also can attend the hearing unless the Mental Health Review Tribunal refuses to allow them to attend and participate. This includes members of your family, friends, patient advocates, support persons and other lay advocates. It also includes staff of non-government agencies/community managed organisations that may be involved in supporting you in the community (such as a Housing Accommodation and Support Initiative/CLS or National Disability is defined (Disability Discrimination Act 1992 (Cth)) as: total or partial loss of the person's bodily or mental functions; total or partial loss of a part of the body; the presence in the body of organisms causing disease or illness, capable of causing disease or illness; the malfunction, malformation or disfigurement of a part of the person's body; a disorder or malfunction that results in the person learning differently from a person without the disorder or malfunction; a disorder, illness or disease that affects a person's thought processes, perception of reality, emotions or judgment or that results in disturbed behaviour. Insurance Scheme worker).
You have a right to be legally represented at a hearing of an application for a CTO. If this application is made at a Mental Health Inquiry you will be provided with legal representation by the Mental Health Advocacy Service. However, legal aid is not automatically available for hearing in relation to any other application for a CTO. It is only available if you specifically apply for legal aid and that application is granted following consideration of your financial means and the merit of your application for assistance.
The maximum length of time for which a CTO may be made is twelve (12) months. However, most orders are made for period of six (6) months. In deciding how long a CTO should be, the Mental Health Review Tribunal must take into account the length of time it will take to stabilise your The term mental health condition is a broad term that refers to symptoms that may be caused by life events, genetic factors or birth defects. They can be temporary or lifelong and include mood, anxiety, personality, psychotic and compulsive disorders. It includes, but is not limited to those conditions and symptoms recognised as constituting mental illness under the Mental Health Act 2007 (NSW)., and the length of time it will take to establish, or re-establish a therapeutic relationship between you and your case manager.
If the person applying for a CTO is asking for a longer order, they need to explain why. For example, if you have had a long history of mental illness and repeated admissions to public mental health facilities, a longer order may be seen to be more helpful. Sometimes the case manager will request a twelve (12) months order because the In this Manual, ‘consumer’ refers to someone who receives or has received in the past, mental health or psychosocial support services, such as a patient in a mental health facility or unit, or is a client of a community mental health service whether public or community managed. experiences distress about and during hearings, which is detrimental to the person’s wellbeing and their therapeutic relationship with the case manager.
However, the Tribunal may still decide a six (6) month order is more appropriate in view of a diversity of circumstances. For example, you could be strongly opposed to a longer order, you were not told that an application for a longer order had been made or your treatment is still changing.
There is no limit to the number of CTOs that may be made for you. An application to the Mental Health Review Tribunal for a further CTO will be made before a current CTO lapses. If subsequent applications are granted by the Mental Health Review Tribunal, you may continue to be subject to compulsory treatment in the community for an extended period of time.
If you are subject to an existing CTO, or were previously subject to a CTO, the Mental Health Review Tribunal will consider the effectiveness of that Order as one of the factors in determining if it should make a new order.
A person who is subject to a CTO is legally obliged to comply with the obligations imposed on them by the CTO. Failure to comply with these obligations may lead to a ‘breach’ of the CTO if the director of the community mental health facility decides to take action. This could result in the administration of medication using reasonable force at a community mental health facility, or to the person’s admission to a hospital mental health facility where treatment may be administered with reasonable force if necessary.
If you fail to comply with an obligation imposed upon you by a CTO, the director of the community mental health facility will consider:
The Director of the community mental health facility responsible for implementing the order may do the following things:
Firstly, they must inform you that any further refusal to comply with the order will result in you being taken to a community or hospital mental health facility where you will be treated. This is referred to as a ‘verbal warning’.
If you still do not comply, the Director may send you a letter stating you have breached the order. This is called a ‘breach notice’. The breach notice will require you to accompany a member of staff of the community mental health facility to receive treatment in accordance with the CTO, or to a hospital mental health facility. It will also warn you that the assistance of the NSW Police Force may be obtained to ensure your compliance with the CTO.
If you still do not comply, the Director may make a written ‘breach order’ that will require you to be taken, usually by NSW Police, to a specific mental health facility for treatment. A member of the NSW Police Force, acting on a breach order, is entitled to enter your premises, apprehend you without a warrant and use The force necessary to prevent someone causing harm to themselves or others. The degree of force used must be proportionate to the degree of threat of harm. if necessary.
If you are detained in a hospital mental health facility because you have breached a CTO, you must be assessed by an Authorised Medical Officer at that facility within twelve (12) hours, and that Officer must determine if you are a mentally ill or a In the Mental Health Act 2007 (NSW) a mentally disordered person is defined as such if: their behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care and, treatment or control of the person is necessary for the person’s own protection from serious physical harm or for the protection of others from serious physical harm.. The Authorised Medical Officer has the power to require you to receive treatment on a accordance with your CTO and may authorise reasonable force to ensure that this occurs.
If the Authorised Medical Officer determines that you are a mentally ill or In the Mental Health Act 2007 (NSW) a mentally disordered person is defined as such if: their behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care and, treatment or control of the person is necessary for the person’s own protection from serious physical harm or for the protection of others from serious physical harm. for whom no other care or a less restrictive kind, consistent with your safe and effective care is available, you must be given a Statement of Rights .You can continue to be detained in hospital for further observation and treatment until either:
If the term of your CTO has not expired at the time you are discharged from a mental health facility, your CTO comes back into force upon your discharge.
If you are detained in a mental health facility because you have breached your CTO and you remain in that facility for a period of three (3) months, the Authorised Medical Officer must arrange for you to be reviewed by the Mental Health Review Tribunal. At its review, the Tribunal must determine if you continue to be a mentally ill person within the meaning of the Mental Health Act 2007 (NSW), and if there is any less restrictive care available consistent with your safe and effective care. As a result of its Review, the Tribunal may discharge you subject to the terms of your CTO, authorise your continued detention in hospital for the unexpired term of your CTO, or it may make an Involuntary Patient Order authorising your continued detention in hospital.
You, your case manager, or any other person who could have applied for the Order can apply to the Mental Health Review Tribunal (MHRT) to have a CTO changed (‘varied’) or cancelled (‘revoked’). The MHRT is unlikely to change or cancel an order unless circumstances have changed significantly since the order was made or there is new information available that wasn’t available when the Order was originally made.
If you want to have your CTO varied or revoked by the MHRT, it is advisable for you discuss this with your case manager first, explaining the reasons why you want this.
The Mental Health Review Tribunal is required to base its decisions on the evidence before it. Consequently, unless you are able to obtain a different assessment or opinion from a psychiatrist (preferably) or another health care professional, the MHRT will only have the evidence and opinions of the community mental health team upon which to base its decision as to whether you should remain on a CTO. There will be costs associated with getting an independent opinion from a psychiatrist.
If you do get a report from another psychiatrist, that psychiatrist should state his or her opinion on the following matters:
The Director of a community mental health facility responsible for implementing a CTO can cancel a CTO at any time if they think you no longer benefit from the order. They must consult you first, and your The amendments to the Mental Health Act 2007 (NSW) were assented on the 28 November 2014 by way of the Mental Health Amendment (Statutory Review) Act 2014 (NSW). These changes are now in force. The Mental Health Act 2007 (NSW) has replaced the term 'Primary Carer' with the term Designated Carer.To read more see Chap 9 and 12D. and The amendments to the Mental Health Act 2007 (NSW) were assented to on the 28 November 2014 by way of the Mental Health Amendment (Statutory Review) Act 2014 (NSW). These changes are now in force. The Mental Health Act 2007 (NSW), now recognises a new category of persons, who are referred to as a 'principal care providers'. A principal care provider is the individual who is primarily responsible for providing support and care to a person with mental illness. The principal care provider generally has the same rights to notice, to be consulted and to make requests as the 'designated carer' (formerly the 'primary carer'). To read more see Chap 12D. where practicable.
If you wish to appeal a CTO made by the MHRT, you must go to the Supreme Court. You should seek legal advice.
CTOs can be made for people from another state or territory if they are to be put into effect by a health care facility in NSW.
CTOs made in NSW can be put into effect in another state or territory, depending on the laws of that state or territory. However, NSW Health retains ultimate responsibility for this order and for monitoring you. If you breach a CTO in this situation, then the breach will be dealt with according to that state or territory’s law.
CTOs from Victoria, Queensland, South Australia and the ACT are recognised in NSW and if you are on a CTO from one of these states and territories, your CTO can be implemented in NSW, with you being treated by Community Mental Health in NSW.
Updated February 4, 2021