DO THESE THREE SIMPLE LETTERS GO TOO FAR?

Ontario Considers A Law That Forces The Mentally Ill To Take Medications

GRENFELL, Sask. - ELROY AND MARDEL Schmidt believe they owe their lives to
a few paragraphs of ink. Ink that allows them to get their son Earl
immediately to hospital when he fails to take his medication. Which is
often.

The Schmidt family has lived what Ontario is now debating: the use of
legislation known as the community treatment order - or CTO. It is one of
the most divisive, ethically complex tools imaginable.

And the Schmidts say it saved them.

In a nutshell, community treatment orders are a legal way to encourage
people with serious mental illnesses to take their medications. They're
aimed solely at those people who have a chronic pattern of failing to take
their medication and winding up back in hospital.

The orders mean that if you refuse to take your pills (or accept your
injection), you're breaking the law. The police have the right to take you
immediately to hospital for examination.

The theory is simple: people subject to the orders will prefer taking their
medication to returning to hospital.

In Saskatchewan, the only province with a community treatment order law,
the reality is far more complex.

Earl Schmidt is 40. As a young man, he was outgoing, a good student, a hard
worker. His natural ability with tools and engines led him to become a
journeyman mechanic, one with an excellent reputation for working on
tractors and other heavy machinery. His illness began when he was 22.

``He was working at the garage and one day it just seemed to get too much
for him all of a sudden,'' says his mother, Mardel.

Soon, there were other behavioural, even physical, anomalies.

Elroy Schmidt recalls entering his son's bedroom and seeing his eyes rolled
upward, so high only the whites were visible.

Earl was unable to respond, unable to shift his eyes back to a normal
position. The family took him to see the local doctor.

``He said, `Your son has . . . '' Elroy pauses and furrows his brow,
contemplating how foreign what he next heard sounded, ``schizophrenia? I'd
never heard that word in my life. I said `What's this mean?' He said:
`He'll likely never work again and there's no cure for it.' ''

Earl Schmidt did not accept that he had an illness, but agreed - at least
initially - to take anti-psychotic medication. His interest in helping with
work, even small tasks, rapidly faded. His friends no longer called. He
became withdrawn.

``He lost all of his school friends and women didn't want anything to do
with him.'' Elroy stops, reflects. ``He lost all of his friends.''

Yet, for the first few years, the family - including Earl - managed to
cope. The Schmidts built a house for their son at the farm, so he could
have the independence he desired and the family's support.

It was a good plan. But it didn't work out.

Earl, who sometimes complained of side effects from his medication, would
stop taking the drugs. And start hearing the voices. His delusions worsened
and he came to believe his parents were involved in a conspiracy against
him. ``The minute he was off his medication, we always had the problem of
how to get him to go to see the doctor, or to a hospital or whatever,'' his
mother says.

At the time, there were no community treatment orders. There was no way,
beyond gentle encouragement, to get Earl to take his drugs. He was
strong-willed and strong physically. Too much for his father to handle.

``That kind of patient won't go,'' says Elroy. ``Over the years, many
times, psychiatrists would tell me - and it would just irk me - `If he's
misbehaving bring him in.' How do we bring him in? He's bigger than I am. I
can't take him by the arm and say, `Sonny, let's take you to the doctor.' ''

The Schmidts stress they sought treatment for Earl only when it became
absolutely necessary. But those occasions were many.

There is a pointed gouge in the kitchen counter Arborite - a reminder of
when Earl demonstrated what he was capable of accomplishing with a butcher
knife.

There was the time Earl tried to run his father down with a pickup truck.

And - most vivid in Elroy's mind - there was the time Earl nearly choked
him to death.

It is difficult for Schmidt to tell the story. His breathing gets heavier
as he recalls how he tried to escape from a son who was trying to throttle
him in the street.

``I got into my truck, locked the doors. He jumped into the back of the
truck, my half-ton truck.

``I hadn't spotted that the back window was open because I was very scared
and wondering how I could get help. And after driving about three blocks,
all of a sudden I hear the back windows sliding open while I'm trying to
drive and he got me around the neck.''

Elroy brings his own hands up and mimics the choke hold.

He speaks of a frantic drive through the small town, honking the horn
incessantly for help, as he came closer to unconsciousness. ``And I really
leaned on the horn then. And just kept blowing and blowing (the horn), and
I was just about out of air. There were several people outside, but they
were too scared to know what to do.

``Luckily, he could see that this was attracting the attention of some
people. He did, on his own, give up. That was just three blocks from our
home.'' Eyes wide, Elroy slowly relaxes his hands from his throat.

The family says the only time Earl was violent is when he had stopped
taking his medication.

But there were lots of those times.

``I don't think I'm exaggerating, when I say there were 50, maybe hundreds
of incidents over the past 18 years,'' his father says. ``I know I had
personally four times when I was very close to losing my life.

On those occasions, Earl was clearly ill enough that he would have
satisfied the Mental Health Services Act criteria for involuntary admission
to hospital because he was posing a danger to himself or others. But that
admission requires an examination by a physician - a virtual impossibility
in a rural area without Earl's co-operation.

(Once, when the local physician did write a certificate for examination and
the police arrived to accompany Earl to hospital, he charged toward the
doctor's house, screaming he would ``fix him.'' The officers caught him at
the doctor's front door.)

Before community treatment orders were introduced, police were powerless to
take Earl to hospital unless he was causing a disturbance in a public
place. They could have charged him with a criminal offence - but the family
simply wanted treatment.

Which meant the only option was for the Schmidts was to lay sworn
information before a judge, who would issue a warrant for Earl to be picked
up and examined. The judge sits just once a week in a neighbouring town
down the Trans-Canada Highway.

``In other words, sometimes a week would go by before this court took
place,'' Elroy says.

``And how did we feel, going in front of a judge and talking against our
son? We love our son, and he's our son, but he needs help.''

Earl's pattern is typical of the most difficult cases.

The individual goes into crisis, is admitted to hospital, stabilized,
discharged. Once back in the community, however, some people continually
slide into a pattern of non-compliance - forgetting, or refusing, to take
their medication. They again become ill, triggering a perpetual cycle of
readmissions to hospital - the revolving door.

The community treatment order is aimed at breaking that cycle by imposing a
powerful incentive for patients to take their medication. Likewise, it
offers care-givers an instant remedy if they don't. The goal is to keep
people like Earl as stable as possible - in their own community.

* THE CASE FOR:

Saskatchewan is the only province to implement and enforce treatment
orders. (British Columbia, this fall, introduced a similar mechanism.)

Saskatchewan began considering the controversial legislation in the early
'90s, after the provincial Schizophrenia Society and some mental health
agencies complained that the existing Mental Health Services Act was flawed
because people could be quite ill but still not qualify for an involuntary
admission.

``It was found that individuals were being left in the community far too
long,'' says Aurelia Beach, program consultant with the mental health
services branch of Saskatchewan Health. ``They were becoming far too ill,
they were too much at risk for their own deteriorating health, for losses
of function, for becoming a risk to their own safety and the safety of
others.''

The problem involved only a small group of patients - the so-called
``chronic non-compliers.'' Community treatment orders, it was argued, could
break their pattern by: Reducing readmissions to hospital, freeing
resources for other patients. Preventing frequent relapses. This would not
only ease the strain on the health system, it would also help prevent the
long-term deterioration that can occur with repeated psychotic episodes.
Promoting the person's liberty and independence by allowing life in the
community rather than in an institution. Providing some leverage to ensure
the person takes medication. Ensuring faster, easier access to hospital,
should the person fail to comply with its provisions.

Saskatchewan Health believed such orders would apply to less than 1 per
cent of the estimated 20,000 people in the province who have serious mental
health problems.

People like Earl Schmidt, who has never - in 18 years - recognized that he
has a mental health problem.

* THE CASE AGAINST:

In Ontario, there is significant opposition to community treatment orders.
Critics argue that the province's Mental Health Act is strong enough and
cite the right to equal protection and benefits under the Charter of Rights
and Freedoms.

Under Ontario's Health Care Consent Act, any capable person - someone who
can make a rational choice - has the legal right to choose treatment. That
choice can include rejecting treatment. Opponents of the community
treatment order scheme argue it could coerce capable people into accepting
medication they don't want.

Critics of the orders also point out that Ontario's Mental Health Act's
``leave of absence'' provision that can achieve the same result.

Involuntary hospital patient can be released into the community on a
``leave of absence,'' providing they comply with any requirements the
hospital sets - such as taking their medicine. It the requirements aren't
met, the hospital can notify the police and have the patient returned to
the facility.

But leaves of absence are rarely used - partly owing to a lack of hospital
beds. Which begs the question: where precisely would we put people who
refuse to comply with their orders?

And what about people who go into psychiatric crisis because of shoddy
housing or income supports?

What about people who choose not to take their medication because they
can't stand the side-effects? Some consumers of mental health services find
that - while the drugs may indeed calm the most overt symptoms of the
illness - the over-all effect leaves the person feeling deadened, detached.

``People should always have the right to get the treatment they want,''
says David Reville, who is a former MPP. He is also a so-called psychiatric
``survivor'' - someone who has ``survived'' the mental health system - and
spokesperson for the Care Not Cuffs Coalition, which opposes community
treatment orders.

``I think you can be profoundly ill and still know that you like some
things and you hate some things.

``I don't want to trivialize this by saying that you hate carrots and like
peas. But you might know that you hate the way you feel after
electro-convulsive therapy. And you might say, `Can't you try something
else?' I think that's pretty legit.''

So critics, too, have compelling reasons why treatment orders are not
needed, including:

* Individuals have the fundamental right to choose treatment.

* Medication can have profoundly negative side effects.

* Trading compliance for freedom is coercive.

* There aren't enough beds.

* Scarce beds would be occupied by non-compliers at the expense of other,
more urgent, cases.

* Existing laws (Mental Health Act, Health Care Consent Act) are adequate.

* People's mental health can deteriorate for reasons other than
non-compliance (such as housing, poverty, isolation.)

The case against treatment orders, like the case for them, is complex. Yet
both arguments involve different interpretations of the same concept:
liberty.

``We tend to think of negative liberty - the freedom from being apprehended
and detained,'' says Dr. John Elias, consultant and former associate
executive director for mental health services in Saskatchewan.

``The other concept is of positive liberty - the freedom to be able to
function properly.''

Elias says psychosis robs people of their freedom. By making medication
mandatory, he says, that freedom is restored.

Selina Volpatti, president of the Schizophrenia Society of Ontario, puts it
another way: The illness often blinds the affected individual to its
presence.

It's known in the field as ``lack of insight.''

``Between 85 per cent and 90 per cent of persons with schizophrenia have
absolutely no insight into the fact that they are ill,'' says
Volpatti.``But they deserve to be well. They have the right to be well.''

The Mental Health Legal Committee - which represents nearly 70 lawyers and
community legal workers who advocate on behalf of the legal rights of the
mentally ill - finds this argument unsettling.

``If the proposal is to forcibly medicate individuals with mental illness
against their current or prior capable wishes, or otherwise use the
coercive threat of incarceration to effectively compel the recipient to
accept treatment, the committee opposes any such recommendation,'' the
organization told the health ministry this year.

One could argue that crack addicts or chronic alcoholics also have the
``the right to be well'' - that their minds have been adversely affected by
their addictions. Yet we put their ability to choose above society's right
to intervene.

So, do we have any greater right, any greater obligation, when the malady
is a mental illness?

* THE SASKATCHEWAN COMPROMISE:

The Schizophrenia Society put community treatment orders on the public
agenda in Saskatchewan, just as it has done in Ontario.

It speaks for care-givers - families living with a member who has been
diagnosed with the most serious of mental illnesses - who simply want the
best treatment to help the individual best cope with a terrible illness.

But that position clashed with those who opposed any tightening of the
province's laws. And, says mental health consultant Beach, there were
legitimate reasons for concern.

Under Saskachewan's old Mental Health Services Act, she says, ``people in
the 1940s and 1950s had the authority to just have police go out, pick
somebody up in their farmyard because they were behaving strangely, haul
them off miles to this big institution, and just drop them off at the door.
And they were admitted.

``People remembered that, and they didn't want it again.''

And so the negotiations began.

The province projected that between 60 and 70 people would be subject to
treatment orders at any given time. But who would be affected? Under what
criteria could an order be issued? How long would it last? How could civil
libertarians ensure that human rights were being respected? How could
groups like the Schizophrenia Society feel comfortable it was strong enough
to be effective?

In the end, the proposed legislation was less coercive than consumers
initially feared. As well, anyone subject to an order would have the
automatic right to appeal the decision to a review panel.

``It wasn't like you were going to be incarcerated and given compulsory
electric shock treatments,'' says Eric Braun, president of the Canadian
Mental Health Association's Saskatchewan division.

``It seemed more like a little bit of extra control for certain appropriate
clients to still allow them to live in the community and take their
medication so they don't go off the deep end.''

* THE FINE PRINT:

Under the Saskatchewan Mental Health Services Act, individuals considered
for a community treatment order must have been an inpatient for at least 60
days, or had three or more separate hospital stays, during the previous two
years.A psychiatrist must have probable cause to believe they are suffering
from a mental disorder for which they need treatment and supervision in the
community, and must believe they or society will suffer harm if they don't
get that care.

The intent is to target only those people who repeatedly stop taking their
medication on discharge from hospital. A treatment order lasts for three
months and requires that the person take their medicine and keep medical
appointments. Failure to comply gives the physician the power to contact
police and have the person immediately brought in for examination.

The law does not provide for automatic committal, nor for forced treatment
on site. But the psychological leverage, the threat of a forced return to
hospital, is always there.

* HOW IT HAS WORKED:

To know precisely how well this legislation has worked since it became law
in July, 1995, one requires analysis. But there is none.

Saskatchewan Health knows only the total number of orders that have been
issued since their implementation - numbers that have been lower than
initial predictions.

There were 11 orders in the last six months of 1995, 26 in 1996, 56 in
1997. What the province doesn't know is how many of its orders went to
different people and how many were renewals. The province also doesn't know
whether treatment orders have helped lower readmission rates.

There is, however, anecdotal evidence of how treatment orders have worked
in the field.

Glenn Rutherford, general manager of the Mental Health Services Care Group
of Saskatoon District Health, says the orders don't always provide the
leverage that was intended.

``We have a couple of clients who love to be admitted. So when you say:
`We're going issue a CTO on you,' they say, `Warm, three square meals a
day. Go ahead. Do me.' ''

But Colleen Molnar, program manager for rehabilitation at a Regina
community mental health centre, tells of three cases where treatment orders
turned a situation around.

``In all three cases, after the first three-month time period, they
(treatment orders) were not renewed because the clients had stabilized on
medication.''

Eric Reschke, a community mental health nurse in Regina, some people in
psychosis are grateful for treatment orders. ``You can have somebody who's
acutely ill and is non-compliant, denies his illness, and get him into a
hospital using a CTO. And when he's well he appreciates the fact that you
did it for him.''

But Reschke says a treatment order poisoned the ties he'd built with a client.

``I was always the one that reminded him of the CTO and that I would have
to enforce it and he would have to come in and get his injections. He
always came and took his injections. But he was always miserable about it.

``And as time went on and he kept getting his injection against his will,
he just got more resentful of me and would yell at me.''

Colleague Paul Hodson, who also works long term with clients with serious
mental illness, has had similar experiences.

``You're the bad guy. You have the order and it's your job to ensure that
it's carried out and if there's a refusal, to act on it.''

There is yet another side to the rights issue - the rights of the public.

``Some of these individuals can be worrisome in terms of putting the
community at risk,'' Molnar says. ``Some of those situations do exist and
with medication they can be settled down a fair amount.''

It's a point Ontario's Schizophrenia Society feels is worth emphasizing,
says the society's president, Volpatti.

``If we do not do something to protect people with schizophrenia, to
protect their families from the violence that occurs when they are
psychotic, and to protect the general public - who have no idea who is
standing next to them on the subway platform - then the pendulum, which is
swinging so far to the right to refuse treatment, will swing very rapidly
the other way.

``And then you will have results that none of us want: lock them up, throw
away the key.''

Those who work with the mentally ill, whether they are nurses, case
managers or psychiatrists, stress that treatment orders are used with
caution.

Used properly, these people agreed, they can be an effective tool. But not
always. Some people will obey them, some won't. And some won't even
understand them.

For Ontario, there is perhaps an even greater concern - that treatment
orders could be viewed as a potential substitute for other, desperately
needed supports.

Cleeve Briere, a community support worker with the Saskatoon Crisis
Intervention Centre, says the danger is that community treatment orders
could become tools for social control while the main culprit poverty - is
ignored.

``Is this going to be the substitute for all claims of other care that
might help rally this person back into a stream that's health-giving,
life-giving, so they're taking responsibility for their lives and their
illness?'' he asks.

``I couldn't say this is the best we can do, because I think there are
other things we can do. I think that in this province if we looked at the
great majority of the mentally ill - they are living in dire poverty.

``If you live on social services in this province you get $195 to buy your
groceries, and if you get declared disabled you get another $40. So you
come up with $235 to buy your clothes, your household supplies, your
groceries, your cigarettes, all those things.''

Not only can living in those circumstances, for some, exacerbate mental
illness. It can also make community treatment orders look like a pretty
appealing alternative.

``Let's be honest,'' says Briere, ``if you live on $235 a month and your
illness will give you a ticket into a $300 or $500 or $700 a-day
establishment with personal care, well-balanced food brought to you hey!
The mentally ill are ill. They're not stupid.''

* ONTARIO'S CHOICE:

It's being recommended that five of the province's 10 psychiatric hospitals
be closed.

More people with serious mental illness will be living in the community.

Would treatment orders help some of them? Yes.

Would treatment orders harm some of them? Yes.

Those are the only questions that are easy to answer.

Would we have enough beds to accommodate those who violate their orders?
Would violators wind up blocking beds from other, perhaps more acute cases?

Would some people deliberately violate their treatment orders just for a
short stay in hospital? Would others run long and hard in the opposite
direction?

Before answering those, there's a far more fundamental question Ontario
must address: Does it have the political will to supply other, desperately
needed supports beforerelying on a measure like community treatment orders?

Will there be enough quality housing?

Will there be improvements in income supports?

Would nearly as many individuals be candidates for community treatment
orders if the province allowed the newer, more expensive neuroleptics (with
fewer side effects) to be used as first-line treatment?

Should the province explore other, more holistic alternatives before
bringing down yet another hammer on the mentally ill?

In short, do we equate sound mental health solely with the injection or
ingestion of drugs?

These are questions Ontario must answer.

Quickly.

* THE SCHMIDTS:

Earl Schmidt, 40, spends his time these days at Saskatchewan Hospital North
Battleford.

He has good days - when he can talk to his folks and they get a sense of
the son that illness hijacked. And he has bad days - when nothing seems to
keep the voices at bay.

Elroy and Mardel Schmidt miss their son. He's a five-hour drive away.

Yes. Treatment orders helped the Schmidts.

Not only did they protect the family when Earl was at his worst - on a
couple of occasions, they even allowed Earl a fast admission where he was
stabilized. That is quite a change from the old days.

``A few years ago, without the community treatment order, we'd phone the
police and they wouldn't even come to help,'' says Elroy Schmidt.

``They had to have a doctor's certificate first. The police, when we call
them (now), will act immediately.''

But on his last trip to the hospital, nothing seemed to help. Says his
father: ``It was just as though he had antennae and he was picking up them
voices. He couldn't hear us three feet away or five feet away, these other
voices come in so strong.

``It's terrible for him. The voices were even coming through his shaver
cord. So he smashed his shaver.''

Mother and father, like many parents, pray for a cure, make donations to
schizophrenia research. In their case, treatment orders did not bring the
stability they hoped for.

``I would say that it helps our safety more so than it helps the patient,''
says Elroy. ``I don't think it helps our son Earl much, really.''

Earl Schmidt recently took off, briefly, from Saskatchewan Hospital North
Battleford. He saw someone key in an electronic door code on his secure
ward, entered the numbers himself, then headed downtown.

He went straight to an auto dealership and tried to buy a vehicle.

He wanted to drive back home.

Sidebar: _OUT OF MIND_

Scott Simmie was this year's recipient of the Atkinson Fellowship in Public
Policy, which allows a year of research into important social, economic and
political issues. His exploration of mental health reform took him across
Ontario, as well as to New Brunswick, Saskatchewan and the United Kingdom,
going from hospitals to hostels, and an aboriginal sweat lodge. Simmie, a
CBC employee, is the first broadcast journalist to win an Atkinson
Fellowship.

Sidebar: _Voices from the Internet_

My first contact with the psychiatric profession opened my eyes to the
whole mental health problem. For example, my parents were visiting from out
of the province. I was sitting next to my mother when she was informed that
I was now receiving psychiatric treatment. I watched with astonished
fascination as my mother slowly began moving along the sofa away from her
youngest son. That meant to me that the stigma associated with mental
illness exists because of a total lack of understanding. - Bernard

Hey group, How's it going? I think I'm ``crashing.'' Needed to go look for
jobs today. I got as far as scanning the paper and writing the places down.
I kept putting it off. I don't understand though. I want a job! Why can't I
just do it?

I decided to go study. Promising myself that I would look for jobs at 2:00
p.m. Guess what? It's 2:27 p.m. And I haven't even taken a shower. For the
past hour I have been lying on my bed like a blanket. Not moving my body.
But my mind was racing! I was thinking about running away. Taking all the
money I have - $65 - and leaving town. Then I was thinking about doing
something illegal and going to jail. And not caring. And I was thinking
about setting fires and getting in trouble so I could go to jail. I suck.
Any ideas how I can get un-stuck? I'm desperate to get un-stuck! Sarah -
From the Internet chat groups on mental health problems