Alberta's community treatment orders: Canadian and international comparisons.
Community Treatment Orders (CTOs) are designed to assist people who, because of serious mental illness, do not avail themselves voluntarily of medication, follow-up opportunities and other services for their care and treatment while living in the community and who, without treatment, become psychotic and require repeated hospitalization. CTOs are generally viewed as less restrictive of liberty and individual autonomy than the alternative of involuntary inpatient hospitalization.
CTOs have been developed relatively recently in response to the shift from hospital-based to community-based mental health service delivery (e.g. New Zealand) (1) although in some jurisdictions the tipping point for the legislative motivation to enact CTO legislation has been violent incidents involving people with untreated mental illness. Alberta, (2) Ontario (3) and New York (4) are examples. We discuss the Alberta incident and the relationship between mental illness and violent incidents in the last section of this article where we respond to criticisms of CTOs.
Alberta is the fifth and most recent province in Canada to enact CTO legislation. In formulating its provisions, Alberta (5) had the benefit of experience in Saskatchewan, (6) Ontario, (7) Nova Scotia (8) and Newfoundland and Labrador (9) as well as in a large number of international jurisdictions. (10) It also had the benefit of extensive information gained from recent scientific studies. (11)
In the next section of this article, we compare significant elements of CTOs in Alberta with those in the four other Canadian provinces that have CTOs and, internationally, in New Zealand, and some Australian, United Kingdom and United States jurisdictions. (12) We then address criticisms that have been levelled at CTOs in Alberta and give our conclusion.
Significant Elements of CTOs
This article focuses on the major substantive and procedural elements in Alberta's CTO scheme including the authority to issue a CTO, the criteria, pre-conditions, consent, treatment planning, duration, compliance, and rights and protections.
Authority to issue a CTO
CTOs are issued by physicians after examination of the person being assessed for a CTO. Alberta requires separate examination and signature by two physicians, one of whom must be a psychiatrist, within the 72 hours immediately preceding issue of the CTO. (13) In contrast Ontario requires only one physician who does not have to be a psychiatrist. (14)
CTO criteria (harm and deterioration)
In Alberta, as in other Canadian provinces and most foreign jurisdictions, the criteria for issuing a CTO builds on the criteria for involuntary inpatient hospitalization. In Alberta, in addition to suffering from mental disorder, the individual must be "likely to cause harm to the person or others or to suffer substantial mental or physical deterioration or serious physical impairment" (the "harm or deterioration" criterion) in the absence of intervention. The Alberta wording (which applies to both involuntary inpatient hospitalization and CTOs was previously "likely to present a danger to himself of others". (15) The new language parallels the wording in the Saskatchewan legislation (16) and is similar to changes in wording that have been made in other provinces. (17)
The rewording broadens the basis for intervention with the result that more people are now likely to qualify for a CTO than would have qualified under Alberta's previous "danger" criterion.
Pre-conditions (previous psychiatric history)
Even where a person meets the committal criteria for involuntary intervention, all jurisdictions in Canada and some jurisdictions elsewhere impose a "pre-condition" on CTOs. That is to say, a physician can only issue a CTO where the person has a previous psychiatric history. In contrast, most jurisdictions outside Canada impose no pre-conditions and do not require an inpatient history. (18)
Jurisdictions with pre-conditions differ widely on the amount of psychiatric history the person must possess. Those jurisdictions that impose restrictive previous hospitalization requirements effectively limit CTOs to assisting persons whose illness has basically become chronic and who repeatedly vacillate between community and hospital (the "revolving door" syndrome). Because the ambit of assistance is broader in jurisdictions with no previous hospitalization requirements, the CTO could help people earlier in the illness progression thus improving the prognosis. (19)
Where does Alberta sit in comparison with other provinces on hospitalization pre-conditions? Alberta requires that:
... within the immediately preceding 3-year period the person has on 2 or more occasions, or for a tolal of at least 30 days,
(A) been a formal patient in a facility,
(B) been in an approved hospital or been lawfully detained in a custodial institution where there is evidence satisfactory to the 2 physicians that, while there, the person would have met the criteria set out in section 2(a) [mental disorder] and (b) [harm or deterioration) at that time or those times, or
(C) [a combination of (A) and (B)]. (20)
In Canada, Alberta and Ontario, (21) with their almost identical provisions, have the least stringent previous hospitalization requirement. In these provinces, an individual with one hospitalization of 30 days or two admissions within the previous three years would satisfy the pre-condition. Therefore, although there is a pre-condition of hospitalization, the CTO can be issued at a relatively early stage of the illness. Other provinces have more restrictions because they use a shorter time period, two years, with Saskatchewan (22) requiring 60 days or three hospitalizations and Nova Scotia (23) 60 days or two admissions while Newfoundland and Labrador (24) specify three admissions but no time period.
Unlike any other Canadian province, Alberta recognizes hospitalization equivalencies whereby a person who has been in a facility such as a jail for the same period could qualify if they likely had a mental disorder and met the harm or deterioration criterion while in the custodial institution. (25) This should be helpful For some of the many people with mental illnesses who become involved with the criminal justice system.
In addition, unlike any other province, Alberta does not require a hospital or institutional history. A physician may issue a CTO if:
"... the person has, while living in the community, exhibited a pattern of recurrent or repetitive behaviour that indicates that the person is likely to cause harm to the person or others or to suffer substanlial mental or physical deterioration or serious physical impairment if the person does not receive continuing treatment or care while living in the community (26)
Although Alberta has the most lenient CTO preconditions in Canada, the conditions are more restrictive than those in some foreign jurisdictions which ask only if the committal criteria apply. If they do, whether the person is treated in hospital or community becomes a decision based on considerations of safety, service availability, patient preference and clinical factors. (27)
Consent to CTO
Does the CTO have to be consented to? Despite being called an "order", in Alberta (with one exception), (28) Ontario (29) and Nova Scotia, (30) a CTO can be implemented only if consent to the CTO is obtained from a patient capable in law of giving consent or the substitute decision maker of an incapable patient. In these jurisdictions, consent to a CTO is handled in the same way as consent to the treatment of an involuntary patient.
In Saskatchewan, (31) Newfoundland and Labrador (32) and many foreign jurisdictions, (33) the CTO is authorized without reference to consent usually by the physician. This approach is more akin to the approach taken to involuntary inpatient hospitalization where the consent of the patient or substitute decision maker is not a consideration.
Alberta has chosen aspects of both approaches. Ordinarily a CTO must be consented to but if the person, while in the community, has a history of not accepting the treatment necessary to reduce the likelihood of harm to others the physician may issue a CTO despite the failure to obtain consent. (34)
A detailed treatment plan need not have been developed before a person is admitted to hospital as an involuntary patient. In contrast, many CTO laws require a treatment plan before a CTO is issued. Plans required by legislation differ on comprehensiveness. For example, the provision in Newfoundland and Labrador is quite comprehensive. It mandates "a plan of treatment ... that describes the necessary medical and other supports, including income and housing ..." and imposes obligations on "health care professionals, persons and organizations who have agreed to provide treatment or care and supervision." (35) Other jurisdictions require, in essence, only that the plan be designed to keep the person out of hospital. (36) The Alberta regulations (37) require a detailed plan, signed by the parties who are designated to provide services but the plan need not be as detailed as the plan required in Newfoundland and Labrador. In Alberta, as in all provinces and many foreign jurisdictions, a CTO cannot be issued unless the services required by a condition of the CTO are available. (38)
While these detailed statutory requirements lead to good planning they can be complex and divert time from clinical care to "paperwork". For that reason, some psychiatrists may avoid putting a person on a CTO. (39) Good treatment plans are needed whether or not a patient is on a CTO. Putting the plan down on paper should be a straight forward matter. The greater difficulty may be obtaining signatures of others participating in the plan. CTO coordinators have been appointed to facilitate these requirements in Alberta and in Ontario, where they have been very well received. (40)
Another concern is that a breach of any requirement in a complex care plan under a CTO could result in mandatory review and, perhaps, hospitalization. Some have argued it makes more sense to develop a comprehensive plan but to include only the critical terms in the formal document. In our view, the Alberta statute minimizes the concern by allowing a psychiatrist to issue an order authorizing the person's apprehension and conveyance for examination where the psychiatrist "has reasonable grounds to believe that a person who is subject to a community treatment order has failed to comply" (41) with it. The wording is permissive. The psychiatrist has discretion to consider compliance in the context of the CTO understood in its entirety rather than detail by small detail.
Duration and renewal of CTOs
In Alberta and all other Canadian jurisdictions except. Saskatchewan, a CTO is valid for six months without renewal unless it is cancelled before this period expires. Saskatchewan limits CTOs to three months (42) but that is said to be too short. (43) Even in Ontario, where the CTO runs for six months:
[psychiatrists] ... are concerned with the necessity to repeat the labour intensive CTO initiation process every six months. Many are also of the view that the six-month period is too short for clinical progress to appear. (44)
Internationally, some jurisdictions ( e.g. the Australian state of Victoria) issue CTOs for up to I year. (45) Research suggests that CTOs take over 6 months before they start to have a positive effect. (46)
Failure to comply (recall issues)
If a person does not comply with a CTO condition, is reporting non-compliance obligatory, who can order apprehension and conveyance for examination (a "recall examination"), is the patient warned and helped, and what happens after the examination?
(a) Reporting Non-Compliance
Alberta appears to be unique in requiring mandatory reporting of non-compliance. Any person named in the CTO as a provider of care or treatment must report any failure to comply to the regional health authority on an official form. (47) While not as direct, the legislation in Newfoundland and Labrador provides the supervising psychiatrist with the authority to "require reports" from those involved. (48)
Mandatory reporting may cause providers to take responsibilities more seriously. On the other hand, it may dissuade families or others from formally signing a CTO because they may not want to jeopardize relationships with ihe person.
(b) Initiation of Recall Examination
In all Canadian and other jurisdictions, if non-compliance appears to be occurring, the psychiatrist involved can initiate procedures for a recall examination. Under a provision unique to Alberta, if the supervising psychiatrist does not arrange for the patient's recall, anyone can ask a judge to order apprehension and conveyance for examination. (49) Anotherunique provision is that where it would be dangerous to delay waiting for a judge a police officer may take the person directly to an examiner. (50) The possibility of making a request to a judge or depending on a peace officer parallels the procedures available to facilitate an examination conducted to determine the need for involuntary inpatient hospitalization. Since other jurisdictions do not have these mechanisms but instead rely solely on the psychiatrist, we do not anticipate frequent use of these provisions in Alberta.
In Alberta, before a recall examination can be ordered reasonable efforts must be made to inform the person that they have failed to comply and that an order for apprehension and assessment may be issued if noncompliance continues and reasonable assistance to help the person to comply must also have been provided. (51) These "assistance" requirements are in all Canadian statutes except Saskatchewan. (52) Not all international statutes address the assistance requirement, but good clinical practice would embrace assistance.
(d) Disposition options (after the examination)
Alberta's CTO conveyance and assessment order allows the person to be held for up to 72 hours for completion of the examination. The disposition options then are to cancel and release, continue the same CTO with any necessary amendments or cancel and hospitalize. (53)
In contrast, in Ontario a recall originally appeared to terminate the CTO certificate and hence, the obligations of the psychiatrist who issued the old certificate because the only option for community care was to issue a new certificate (with all the procedures that entails). Alberta appears to have learned from the experience of Ontario which amended its legislation to clarify that the CTO can continue despite recall. (54)
Rights and protections
Alberta's rights and protection provisions are similar to those in other Canadian CTO jurisdictions. They include: notification; mandatory reviews (after the first six months then yearly thereafter); requested reviews; and patient involvement in treatment planning. Alberta alone allows a patient to request the assistance of an official mental health advocate. (55)
Alberta also provides "stronger" protection for the patient than some other Canadian jurisdictions in the sense that two physicians one of whom must be a psychiatrist must issue initiating and renewal certificates whereas in Ontario only one physician is required. While we agree with the importance of a two physician system for initiation, where one physician must be a psychiatrist, we believe that one psychiatrist on renewal protects rights sufficiently.
In addition to reviews for individuals, all Canadian provinces (56) (except Saskatchewan) and some foreign jurisdictions (57) with CTOs legislatively mandate a review of their CTO law within a fixed period of time. Ontario completed its review of CTOs in 2005, after five years of operation. (58)
Response to Criticisms
In an article published in this journal shortly after Alberta's CTO legislation took effect, Professor Peter Carver questions the value of CTOs. (59) We will now discuss three important issues he raises: (i) CTOs and violence; (ii) effectiveness for non-compliant persons; (iii) and the restraint of freedom.
(i) Reduction of Violence
As noted above, in some jurisdictions violent acts perpetrated by people with untreated psychotic symptoms have become a "tipping point" for the enactment of CTO legislation. In Alberta, that violent act was the 2004 shooting death of RCMP Corporal James Galloway by Martin Ostopovich.
Two years previously on May 24, 2002, Mr. Ostopovich was admitted to a psychiatric unit, on a warrant issued pursuant to s. 10 of the Mental Health Act because he was making threats against RCMP officers. Mr. Ostopovich believed he had implants in his head that were transmitting messages. He was diagnosed as paranoid delusional. Because he was assessed to be insufficiently dangerous under Alberta's "old" Act, Mr. Ostopovich was allowed to discharge himself against medical advice on June 7, just 15 days after his admission. Mr. Ostopovich look medication only sporadically after discharge. (60) The question then becomes whether CTOs reduce violence and had the Alberta CTO been in place would it have facilitated the treatment of Mr Ostopovich and prevented the death of Corporal Galloway?
Mr. Ostopovich, with only 15 days of involuntary hospitalization, would not have met the 30 day precondition for a CTO. Nor would he have met the equivalent custodial facility requirement. However, Mr Ostopovich may have met the broader harm or deterioration criterion for inpatient admission (61) in the new Act and if so this would have allowed physicians to detain Mr Ostopovich in hospital involuntarily until his condition had stabilized. Furthermore, if he had stayed for a further 15 days he would have met the 30 day criteria for further supervision and treatment in the community on a CTO. In our opinion it is likely that had the physicians been willing to use the provision of the new legislation it would have helped to prevent the tragedy, because treatment can often address psychotic symptoms that lead to violence. (62)
We also note that even if he was not kept for 30 days in hospital, Mr. Ostopovich may have qualified on the "community criterion" as a person who had exhibited a pattern of recurrent or repetitive behaviour that indicates that the person is likely to cause harm to the person or others. Even if he did not qualify for a CTO, the new legislation requires notice of the discharge to be given to his family doctor along with the discharge summary, including any recommendations for treatment. That also may have been helpful in this case. (63)
Carver indicates that a "bare CTO" would not have been sufficient to maintain Mr. Ostopovich on medications whereas intensive case management wilhoul a CTO perhaps would have saved lives. (64) This ignores the fact that many individuals with psychotic illnesses refuse to avail themselves of the best of menial health services-Given Mr Ostopovich's paranoid condition and his refusal to accept recommended hospital based treatment and limited adherence to treatment in the community he may have rejected case management no matter how "intensive" unless required to do so under a CTO.
Society will never be able to prevent all homicides perpetrated by people because of psychotic symptoms. However, u appears to us that Mr. Ostopovich is the type of person who would likely have benefited from a CTO. It could have helped him adhere to treatment and regular follow-up with clinicians and thereby to remain free of his delusions. In order to bring stability to the lives of individuals such as Mr. Ostopovich and to reduce tragic homicides like that of Officer Galloway we need physicians and hospital administrators to use the legislation appropriately-Research demonstrates that CTOs do reduce the frequency of serious violence and arrests. (65)
(ii) Effectiveness for Non-compliant Persons
Carver examines the claim that "CTOs are not effective for those persons for whom they are most intended-individuals who are non-compliant with treatment plans while living in the community." (66) Clinicians recognize that some patients adamantly refuse all treatment and follow-up and a CTO is not then appropriate. However, for many who will not participate voluntarily the "incentive" of involuntary hospitalization, if they do not participate in treatment, is sufficient to persuade them to comply.
Many studies have shown reductions in hospitalization for people who were previously non-compliant with their treatment plans. (67) An Ontario study showed greater reduction in hospitalization for a group on CTOs compared with a non-CTO group despite the fact that both received the same high intensity case management services: "the Toronto experience has shown that CTOs are helpful in assisting individuals who historically refused services to remain engaged with treatment and support services". (68)
(iii) Undue Curtailment of Freedom
Carver discusses the proposition that "CTOs serve more as an alternative to living freely in the community than as an alternative to involuntary hospitalization." (69) We ask: what does "living freely in the community" mean? Studies show that the target group for CTOs are people who have serious mental illnesses that are treatable but, when not treated, often produce mind-controlling delusions, thought disorder, cognitive impairment, depressed or manic mood or some combination of these conditions. These symptoms often ''control" the person's life. In short, the alternative to no CTO does not appear to be "living freely" in the community in the sense of freely making autonomous decisions.
To the contrary, there is considerable published evidence that CTOs help people "live freely" with less interference to their autonomy than living with untreated symptoms and their sequelae. For example, when compared with the period they were not on a CTO, persons on CTOs have: more time spent in the community and less as involuntary patients in hospital; reduced victimization; reduced violence to others; fewer arrests and deprivation of autonomy and liberty in the justice system; reduced homelessness; and improved day to day functioning. (70)
If the proposition were right one would expect the persons subject to CTOs to express strong opinions against them. Most studies of the views of people who have been subjects of CTO show that they eventually are grateful for the stability the CTOs brought to their chaotic lives. (71) In the words of the Legislated Review of the Ontario CTO:
Many clients have reported to us that, they believe that their CTO has brought them a level of stability and allowed them to stay outside of hospital. ... Some have told us that the CTO kept them treated during periods of severely diminished insight. We have met clients who told us that their CTO has allowed them to find stable housing for the first time in years, complete their education, or reintegrate into the community after years of social isolation. It should be noted, however, that some clients felt that any benefits were outweighed by the loss of personal autonomy and control over their lives. (72)
Carver concludes that the compulsion thai accompanies CTOs is "largely unnecessary, impractical or illusory" Although he concedes that "[l]his does not necessarily mean that CTOs serve no purpose in mental health services" he ultimately concludes that "[t]he emperor may indeed be clothed-but more in rags than raiment."
We decidedly disagree. In our view, the move to treat people in community settings has produced a clear need for CTOs and, when used, they are effective and protect rights. Our view is soundly rooted in both national and international experience with CTOs. As stated in the findings of the Ontario mandated review of their CTO system:
... most of the mental health professionals with whom we spoke and who have experience with CTOs believe them to be a highly effective instrument. These professionals are of the view that readmission and length of stay rates for their CTO clients have plummeted and their quality of life has improved. (73) It is undeniable that CTOs have benefited many individuals and their families ... CTOs clearly have a place in the treatment options that are available to health care providers and some of their patients. (74)
Alberta's legislation adheres more closely than legislation in Ontario, or elsewhere in Canada, to the principle of using the least restrictive alternative. We therefore predict that the CTO experience in Alberta will provide greater benefits for persons with severe mental illness. Compared with other Canadian jurisdictions, more Albcrtans are likely to receive needed treatment for their mental illness in community as opposed to hospital settings. However, CTOs in Alberta are not as accessible as they are in countries which apply the same criteria to both CTOs and involuntary in-patient hospitalization.
(1.) John Dawson, Community Treatment Orders: International Comparisons (Otago: The Law Foundation, New Zealand, 2005). See also, John E Gray & Richard L O'Reilly, "Canadian Compulsory Community Treatment Laws: Recent Reforms" (2005) 28 Int'l J L & Psychiatry 13.
(2.) P Ayotte, Report to the Attorney General - Public Inquiry into the death of Corporal James Galloway and Martin Ostopovich (Edmonton: Justice and Attorney General, 2006), online: Justice and Attorney General (http://justice.alberta.ca/programs_services/fatality/Documents/fatality_inquiry_report_galloway_2006_11_21.pdf)
(3.) Peter Carver, "A New Direction in Mental Health Law: Brian's Law and the Problematic Implications of Community Treatment Orders" in Timothy A Caulfield & Barbara von Tigerstrom, eds, Health Care Reform and the Law in Canada: Meeting the Challenge (Edmonton: University of Alberta Press, 2002).
(4.) New York Slate Office of Mental Health, Kendra's Law, online: New York Office of Mental Health (http://www.omh.ny.gov/omhweb/Kendra_web/KHome.htrn); California Department of Mental Health, Implementation of Assembly Bill (AB) 1421, "Laura's Law", online: (http://www.dmh.ca.gov/dmhdocs/docs/letters03/03-01.pdf) (both CTO laws were named after the victims of persons with untreated mental illness).
(5.) Mental Health Act, RSA 2000, c M-13; Mental Health Amendment Act, SA 2007 c 35, s 8 (adding s 9,1) (CTO in force January I, 2010).
(6.) Mental Health Services Act, SS 1984-85-86, cM-13.1, S24.5 [Saskatchewan CTO 1995].
(7.) Mental Health Act, RSO 1990, c M.7, s 33.1 [Ontario CTO 2000].
(8.) Involuntary Psychiatric Treatment Act, SNS 2005, c 42, s 47 [Nova Scotia CTO 20051.
(9.) Mental Health Care and Treatment Act, SNL 2006, c M-9.1, s 40 [Newfoundland and Labrador CTO 2007].
(10.) Supra note 1.
(11.) Rachel Churchill, "International Experience of Using Community Treatment Orders" (2007), online: Institute of Psychiatry, University of London 1-222 (http://www.iop.kcl.ac.uk/news/downloads/final2ctoreport8march07.pdf).
(12.) Mental Health (Compulsory Assessment and Treatment) Act 1992 (NZ), 1992/46 (New Zealand) [New Zealand]. See John Ellery Gray et al "Australian and Canadian Mental Health Acts Compared" (2010) 44 Aust NZ J Psychiat. 11 (Australia); See Mental Health (Care and Treatment) (Scotland) Act, ASP 2003, c 13 (Scotland). See Menial Health Act 2007 (UK) c 12, Part l, Chapter 4 (United Kingdom and Wales); See Treatment Advocacy Center, "State Standards for Assisted Treatment: Civil Commitment Criteria for Inpatient or Outpatient Psychiatric Treatment (statutory language)" (September 2008), online: (http://wwwAreal.mentaiivocacycenter.org/storage/documenis/standards_-_the_text-_jan_201l_partial_update.pdf) (United States).
(13.) Supra note 5, gt ss 9.1(l)(b)(ii) and 9.1(2)(h). Where no psychiatrist is available a physician may be designated by an authority for CTO purpose s 9-7(1).
(14.) Supra note 7 at s 33.1 (4).
(15.) Supra note 5 at s 6(d)(ii) (the amendment substituting "harm" or "deterioration" for "danger" took effect on September 30, 2009, 3 months before January 1, 2010 when the CTO provisions came into force).
(16.) Supra note 6 at s24(2)(a).
(17.) Mental Health Act, RSBC 1996, c 288, s 22 [British Columbia]; Mental Health Act, CCSM c Ml 10, s 17 [Manitoba]; Menial Health Act, RSO 1990, c M,7, s 20 [Ontario]; Involuntary Psychiatric Treatment Act, SNS 2005, c 42 [Nova Scotia]; Mental Health Care and Treatment Act, SNL 2006, c M-9.1, s 17 [Newfoundland and Labrador].
(18.) See Mental Health Act 1986 (VIC), s 14 (this piece of Australian legislation provides that "If a person satisfies the criteria specified in sub-section (I A.) and the authorized psychiatrist considers that a community treatment order is appropriate, the authorized psychiatrist may make a community t real merit order instead of confirming the admission of the person to an approved mental health service as an involuntary patient.-.") [Australia]. See also New Zealand, supra note 12 at s 28(2) ("... the court shall make a community treatment order unless the considers t h a t the patient can not be treated adequately as an outpatient, in which case the court shall make an inpatient order"). See also NC GEN STAT [section] 122C-263(d) ( 1 )(d) (2010) ("The physician or eligible psychologist shall so show on the examination report and shall recommend outpatient commitment") [North Carolina].
(19.) Max Marshall et al, "Association Between Duration of Untreated Psychosis and Outcome in Cohorts of First-Episode Patients" (2005) 62 Arch Gen Psychiatry 975.
(20.) Supra note 5 at s 9.1 (b).
(21.) Supra note 7 at s 33.1 (4).
(22.) Supra note 6 at s 24.3(1 )(a)(ii).
(23.) Supra note 8 at s 47(3) (iv).
(24.) Supra note 9 at s 40(2) (b).
(25.) Supra Note 5 at s 9.1 (l) (b) (i) (B).
(26.) Ibid, s 9.l (I)(b)(iii).
(27.) Supra note 18.
(28.) Supra note 5 at s 9.1 (f)
(29.) Supra mite 7 at s 33.2 (f)
(30.) Supra note 8 at s 47(3) (v) (b).
(31.) Supra note 6 at s 24.3 (2).
(32.) Supra note 9 at s 35 (1) and s 46.
(33.) Supra note 18.
(34.) Supra note 5 at s 9.1 (1) (f).
(35.) Supra note 9 at s 42.
(36.) Supra note 6 at s 24.3 (c).
(37.) Mental Health Act Forms Regulation, Alta Reg 1 36/ 2004, Form 19.
(38.) Supra note 5 at s 9.1 (1) (d); see also supra note 17 and 18.
(39.) Stephen Dreezer, Michael Bay & David Hoff, Report on the Legislated Review of Community Treatment Orders uired Under Section 33.9 of the Mental Health Act (Toronto: Ontario Ministry of Health and Long-Term Care, 2005), online: Ministry of Health and Long-Term Care (http://www.health.gov.oo.ca/english/public/pub/ministry_reports/dreezer/dreezer.html) at 111 [Ontario Report].
(40.) Ibid at 87.
(41.) Supra mm 5 at s 9.6(1).
(42.) See John E Gray, Margaret A Shone & Peter F Liddle, "Assisted Community Treatment" in Canadian Mental. Health Law and Policy, 2, ul Ed. (Markham: LexisNexis, 2008) Table 8-1 at page 278 for a review of requirements across Canada.
(43.) Richard L O'Reilly et al "A Qualitative Analysis of the Use of Community Treatment Orders in Saskatchewan" (2006) 29 Int'l. J L & Psychiatry 516.
(44.) Ontario Report, supra note 39 at 112.
(45.) Mental Health Act 1986 (Vic), s 14(3) (a).
(46.) MarvinS Swartzfr Jeffrey WSwanson, "Involuntary Outpatient Commitment, Community Treatment Orders, and Assisted Outpatient Treatment: What's in the Data?" (2004) 49 Can J Psychiatry 585.
(47.) Community Treatment Order Regulation, Aha Reg 337/2009, s 6 (1).
(48.) Supra note 9 at s 45 (1)
(49.) Supra note 5 at s 10(1.1).
(50.) Ibid at s 12(1).
(51.) Ibid at s. 9.6(2).
(52.) supra note 42 at. 287.
(53.) Supra note 5 at s 9.6(4).
(54.) Supra note 7 at s 33.3(1.1).
(55.) Mary Marshall, "Everything You Wanted to Know About Changes to the Mental Health Act in Alberta" (2010) 19 Health L Rev 10.
(56.) Supra note 42 at 387.
(57.) New York State Office of Mental Health, Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment (New York: Office of Mental Health 2005), online: New York State Office of Mental Health (http://www.omh.state.ny.us/omhweb/kendra_web/finalreport/).
(58.) Supra note 39.
(59.) Peter Carver, "Fact or fashion? Alberta adopts the community treatment order" (2010) 19 Health L Rev 17 [Carver].
(60.) Supra note 2. See also The Edmonton Journal, "Mountie Killer Rejected Treatment" The Edmonton Journal (26. January 2006), online: Canada.com (http://www.canada.com/edmontonjournal/story.html?id=0871f2f8-7671-4251-84b3-93e01a4c51cf&k=53922).
(61.) Supra note 5.
(62.) British Columbia Schizophrenia Society "Statement on Violence" (undated), online: British Columbia Schizophrenia Society (http://www.bcss.org/wp-content/uploads/2008/04/2007-statement-on-violence.pdf).
(63.) Supra note 5 at s 32(1).
(64.) Carver, supra note 59 at 19.
(65.) Bruce G Link et al, "Arrest Outcomes Associated with Outpatient Commitment in New York State" Psychiatric Services" (2011) 62 Psychiatric Services 504. See also supra note 42, at 299-302.
(66.) Supra note 59 at 17.
(67.) Supra note 11; supra note 46.
(68.) Alison M Hunt et al, "Community Treatment Orders in Toronto: The Emerging Data" (2007) 52(10) Can J Psychiatry 647.
(69.) Supra note 59 at 17.
(70.) Supra note 42 at 292-303.
(71.) Supra note 42 at 304-306. See also Marvin S Swartz et al, "Assessment of Four Stakeholder Groups' Preferences Concerning Outpatient Commitment for Persons With Schizophrenia" (2003) 60 Am J Psychiatry 1139.
(72.) Ontario Report, supra note 39 at 116.
(73.) Ibid at 117.
(74.) Ibid at 9.
John E. Gray, Ph.D. is an Adjunct Assistant Professor in the Department of Psychiatry, University of Western Ontario.
Margaret A. Shone, Q.C. is Counsel Emeritus, Alberta Law Reform Institute.
Dr. Richard L. 0 'Reilly, is a Professor in the Department of Psychiatry, University of Western Ontario.