Types of patients

Contributed by Paula Parentich and current to 1 September 2005

There are three types of patients within the mental health system:

• voluntary patients;
• involuntary patients; and
• mentally impaired defendants.

VOLUNTARY PATIENTS

There is no definition of voluntary patient in the Act, and no provisions regulate their admission or discharge. A voluntary patient is a person who gives informed consent to treatment from a psychiatrist. A voluntary patient must be treated in exactly the same way as a patient being treated for any other illness and can refuse treatment and leave the hospital whenever they wish. It is important to note, however, that a senior mental health practitioner may detain a voluntary patient seeking discharge from an authorised hospital for a period of up to 6 hours to allow a psychiatrist to examine the patient and decide whether he or she should be made an involuntary patient.

The provisions relating to prohibited treatment and psychosurgery apply regardless of the patient’s status or ability to consent to treatment.

INVOLUNTARY PATIENTS

The Act sets out specific criteria which must be satisfied in order for a psychiatrist to make a person an involuntary patient. A person can be an involuntary patient in either of two ways: as a detained patient in an authorised hospital, or as a patient living in the community subject to a Community Treatment Order (see below). All four limbs of the involuntary order criteria must be present for an involuntary order to be made. If the patient fails to meet the criteria, he or she must be received and treated as a voluntary patient.

The four limbs of the involuntary order criteria which must be met are:

1. the person must have a mental illness which requires treatment; AND
2. the person must have refused treatment or, because of the nature of their illness, is unable to consent to treatment; AND
3. the treatment must be needed to:
– protect the health or safety of the person or any other person; OR
– protect the person from self-inflicted harm (including serious financial harm or harm to their reputation resulting in lasting or serious harm to important personal relationships);OR
– prevent the person doing serious damage to any property; AND
4. the treatment cannot be provided in another way which would be less restrictive of the freedom of choice and movement of the person.

CONSEQUENCES OF INVOLUNTARY ORDER

The two main consequences of the making of an involuntary order are:

Forced detention in an authorised hospital

An involuntary order for the detention of a person in an authorised hospital precludes the person from leaving the hospital unless they are granted leave of absence by a psychiatrist.

Non-consensual psychiatric treatment

A person subject to an involuntary order may be given psychiatric treatment without their consent. This includes treatments such as medication, but does not include electroconvulsive therapy or psychosurgery, which are regulated separately under the Act.

REFERRAL FOR ADMISSION

If a medical practitioner or authorised mental health practitioner has examined the person no more than 48 hours previously and believes the person meets the criteria for involuntary admission, a referral for assessment can be made. The referral must be on the proper form.

Within 7 days of the referral being made, the person must be taken to an authorised hospital or some other place for examination by a psychiatrist. If this does not happen, the referral lapses and no further action can be taken in respect of the person unless the whole process starts again.

If the person has to be collected and taken somewhere for examination, the police may assist with transport if necessary and there is no other suitable alternative.

Where the person is taken for examination somewhere other than an authorised hospital, the psychiatrist who sees the person may order that the person be admitted to hospital.

REFERRAL BY POLICE

Where the police believe someone is likely to harm or be a danger to anyone including him or herself, and that the person has a mental illness, an officer may apprehend them and arrange for examination to see whether the person should be taken to hospital.

The police may enter any premises, search the person and seize any item they believe is likely to be used to injure or harm anyone’s health or damage property.

ADMISSION TO HOSPITAL

If a person is referred by a doctor, the police or an authorised mental health practitioner for assessment under the Act, he or she must be seen by a psychiatrist within 24 hours of arrival at the hospital. If the person has been referred by a psychiatrist, the examination must take place within 72 hours of arrival. The psychiatrist at the hospital must decide to:

• discharge the person without making further orders; or
• detain the person for up to a further 72 hours to allow further examination; or
• arrange for the person to be compulsorily treated in the community on a community treatment order; or
• admit the person to hospital as an involuntary patient.

Unless the person is involuntarily admitted for treatment or placed on a community treatment order within the specified time-frames, he or she is not an involuntary patient and may not be treated without their consent, except in the event of a psychiatric emergency.

An order for involuntary treatment lasts up to 28 days. It can only be extended if a further examination by a psychiatrist shows the person still meets the legal criteria for involuntary detention. Extensions can last up to 6 months at a time. Before each extension, a further examination by a psychiatrist is necessary.

ADMISSIONS WHICH FAIL TO COMPLY WITH THE ACT

The Act and Regulations establish procedures and forms which must be complied with for any involuntary admission to be valid. Failure to comply due to clerical error, accidental or evident material fact may be amended, but failure to comply with the criteria for admission or processes for examination etc may render the admission improper.

LEAVE

Leave of absence may be granted by a psychiatrist for a patient to get medical treatment or where the psychiatrist believes the patient would benefit in some other way. Leave will not be granted unless the psychiatrist is satisfied the person, the public or property will not be put at risk. Conditions may be attached at the psychiatrist’s discretion.

Leave may be cancelled if the psychiatrist reasonably believes it is inappropriate for it to continue. The psychiatrist must first provide the person with written notice of the cancellation. If the person fails to return, hospital personnel or the police may apprehend and return him or her to the hospital. Reasonable force may be used and property may be entered without consent. Any item likely to be used by the person to prejudice the health or safety of any person or to damage property may be seized.

During any period of leave, the person remains an involuntary patient.

COMMUNITY TREATMENT ORDERS (CTOs)

Treatment should be provided in the least restrictive circumstances. Where possible, an involuntary patient should be treated in the community rather than detained in an authorised hospital. A Community Treatment Order (CTO) is an order for the involuntary treatment of a person while they are living in the community. A person who is the subject of a CTO is an involuntary patient.

For a psychiatrist to make a CTO, all four limbs of the involuntary order criteria must be met and the psychiatrist must also be satisfied that:

• treatment in the community is not inconsistent with the need to protect a person from self harm or harm to another person or property;
• suitable arrangements can be made for the care of the person in the community;
• a medical practitioner or suitably qualified mental health practitioner is willing and available to ensure the person receives treatment; and
• a willing psychiatrist is available to supervise the treatment.

Terms of a CTO

The CTO must specify the name of the psychiatrist supervising the order, a treatment plan, the medical practitioner or mental health practitioner responsible and the date the order will lapse. Orders may be made for up to 3 months, but can be renewed after reassessment by a psychiatrist.

Initial orders must be confirmed by another psychiatrist or a medical practitioner unless they are made when the person is already being treated in an authorised hospital, or unless made by a psychiatrist who is seeing a patient referred for assessment.

Revocation of a CTO

If the supervising psychiatrist believes a person is not complying with the terms of a CTO, notice of the breach must be given to the person including the reasons for the psychiatrist’s belief. It must be in writing and include a warning that failure to attend could result in the police being called to bring the person to a centre for treatment.

Where practicable, a copy of the notice must be given to the person.

If the breach continues and the psychiatrist believes that all reasonable steps have been taken to comply, and there is a significant risk of deterioration because of non-compliance, the order may be revoked and the person required to attend for treatment. The police may be requested to apprehend the person and bring him or her to a place where treatment can be given. The police can enter any premises and use as much force as is reasonably necessary in order to do this.

DISCHARGE OF INVOLUNTARY PATIENTS

There are two ways in which an involuntary order can be discharged:

• By the treating psychiatrist, when the patient no longer meets the involuntary order criteria; or
• By the Mental Health Review Board at a review of the patient’s involuntary status (see ‘Mental Health Review Board’ below).