Balancing Act

Ethics of involuntary treatment in Nova Scotia

BY JODI BUTLER, MSW, RSW

In the last year, NSCSW has begun to critically examine ways social work can expand practice mental health beyond the medical model. Indeed, this framework is not new for social work. Our profession has embraced the medical model since its development to gain credibility, demarcate a scope of practice and secure positions of employment. This relationship can obscure where our commonplace practices fit within each framework. One way of identifying ethical dilemmas is to hold the practice or situation up to our ethical standards.

Scholars, psychiatric survivors, critical psychiatrists and allies have demanded that professionals reconsider the medical model. They argue the framework leads to unjust treatment and control. Certainly unjust treatment and control fit with our definition of oppression. One of the most controlling interventions in mental health is Section 47 of the Involuntary Treatment Act otherwise known as a Community Treatments Order [CTO]. Social workers in Nova Scotia, especially those who work with individuals labelled with a psychiatric diagnosis are required to use CTOs in their work.

The frequency that social workers must work with CTOs warrants examination of the practice against our professional values and ethics.

Our profession has supported the use of evidence-based practice at least since Mary Richmond’s early campaigns encouraging use of methods supported by scientific methodology. However, there is a significant lack of evidence proving CTOs effectiveness. No research to date demonstrates that forced treatment reduces readmission to hospital or length of stay, nor does it result in symptom reduction. There is also no evidence to suggest that service users or the public are safer as a result of CTOs. Instead, there are findings showing the benefit of non-coercive approaches, including but not limited to: peer support, family support, community-based alternatives, supported decision making and advanced planning. Examples of these programs exist around the world. For instance, Soteria in the U.S, and Europe and the Open Dialogue approach developed in Finland.

The ambiguity found in the research around CTOs must be considered in light of the ethical imperative to demonstrate competence in our professional practice.

A dilemma emerges for social workers about the legal implications of CTOs. Sections of the act mandate the use of least restrictive measures; whether CTOs are the least restrictive measures as possible has been debated in legal circles. Moreover, they present potential violations of the Canadian Charter of Rights and Freedoms. There is legal ambiguity surrounding whether using CTOs creates undue hardship counter to section 7 of the Charter. These issues undoubtedly contribute to the United Nations recognition of any form of coercive treatment as torture. They suggest forced treatment violates individual rights of freedom from torture and poor treatment in addition to breaching autonomy in decision making for people with disabilities. In some instances the UN and their special rapporteurs have made appeals using the Convention on the Rights of Persons with Disabilities to stop their use. It seems that the UN would argue CTOs contradict our ethical obligation to uphold the integrity and dignity of all persons.

Ethical examination of our profession is particularly relevant in the current context of Truth and Reconciliation and the ongoing mistreatment of Indigenous and historically significant Black communities in the province.

This means practising in ways that address power imbalances and marginalized communities. Minority groups including racialized people are overwhelmingly subject to coercive treatment like CTOs. Any practice that targets disenfranchised populations contradicts our commitment to the value of social justice that underlies our ethics.

While the use of CTOs is questionable, ultimately this ethical dilemma challenges us to balance the demands of our work with our professional commitments. Hopefully, as the College pursues research to expand how social workers view and work with mental health, answers will emerge. Until then, we must broaden how and where we see contradictions with our professional values. When we move towards these contradictions and the discomfort they bring, we are also prompted to think about what we can do differently. It is this critical examination of our work, and the possibilities for change that emerge, that may ultimately be one of the effective ways to engage in ethical practice.

SOURCES

Burstow, B., LeFrancois, B., & Diamond, S. (Eds.). (2014). Psychiatry Disrupted: Theorizing Resistance and Crafting the (R)evolution. Retrieved from http://ebookcentral. proquest.com.qe2a-proxy.mun.ca/lib/mun/detail. action?docID=3332799 Goffman, E. (1961). Asylums: Essays on the social situation of mental patients and other inmates. Anchor Books.

Gooding, P., McSherry, B., Roper, C., & Grey, F. (2018). Alternatives to Coercion in Mental Health Settings: A Literature Review. United Nations Special Rapporteur on the Rights of Persons with Disabilities. LeFrançois, B. A., Menzies, R., & Reaume, G. (Eds.). (2013). Mad matters: A critical reader in Canadian mad studies (1st edition). Toronto: Canadian Scholars’ Press Inc.

LeFrancois, B. A. (2016). Why New Brunswick Should Not Legislate Community Treatment Orders (p. 3).

Nova Scotia Legislature—Involuntary Psychiatric Treatment Act. (n.d.). Retrieved 16 September 2019, from https:// nslegislature.ca/legc/bills/59th_1st/3rd_read/b203.htm

Nowak, M. (2009). Promotion and protection of all human rights, civil, political, economic, social and cultural rights, including the right to development [Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment]. https://doi.org/10.1163/2210- 7975_HRD-9970-2016149

Russo, J., & Sweeney, A. (Eds.). (2016). Searching for a rose garden: Challenging psychiatry, forstering mad studies. Wales, U.K: PCCS Books Ltd.

Szasz, T. (2011). The myth of mental illness:fifty years later. Psychiatric Bulletin, 35(5), 174–182. Retrieved from https:// stress.org/wp-content/uploads/2011/11/July-12-mentalillness-myth-after-50-years.pdf

Trueman’, S. (n.d.). Community Treatment Orders and Nova Scotia—The Least Restrictive Alternative? 35.