CHARLOTTETOWN — Marlene Bryenton still gets emotional describing the months she spent searching for her son on the streets of Toronto.
She says Andrew was a father of two, with a home in Charlottetown and a job as a bank manager, before mental illness upended his life. Andrew travelled to Toronto and became homeless, and it took nearly a year to locate him and bring him home safely.
When he returned to P.E.I., Marlene says Andrew was hospitalized, but his doctor suggested another option that could allow him to be treated outside a psychiatric facility.
“If Andrew didn’t have a community treatment order, he wouldn’t be here today,” Marlene said.
A community treatment order, or a CTO, is a legal order issued by a psychiatrist that sets out a treatment plan and requires the person to comply with it while living in the community, rather than in a psychiatric facility.
Under P.E.I.’s framework, one condition is that the person is considered not capable of giving or refusing consent to treatment. Another condition is that they must have been admitted as an involuntary patient in a psychiatric facility at least twice, for a combined total of 30 days or more.
Bryenton says her son didn’t realize he was ill and was reluctant to accept help. He had two prior hospitalizations in Ontario and qualified for a CTO under an interprovincial agreement. She’s not sharing his diagnosis because of the stigma associated with mental illness.
The CTO has been life-changing for Andrew, but Bryenton says provincial rules are too narrow, and many more families could be benefiting.
“It’s like we have our old Andrew back, and he’s so much healthier and so much happier.”
She wants to see P.E.I. follow New Brunswick’s model, which can allow CTOs based on a documented pattern of behaviour likely to lead to harm or deterioration, even without prior hospitalization.
Dr. Richard O’Reilly, a practicing psychiatrist in London, Ont., says Prince Edward Island’s criteria for issuing a community treatment order is “clearly too restrictive.”
“The number of psychiatric beds available has fallen dramatically,” he said. “It no longer is possible to have people stay for prolonged periods in hospital.”
O’Reilly added that when Saskatchewan first introduced CTOs in the mid-1990s, it also required more significant hospitalization before someone could qualify. But since then, he says that requirement has been removed or reduced in several provinces.
“P.E.I., I think, dropped the ball on this issue,” he said.
The use of CTOs has been the subject of vigorous debate, says Archie Kaiser, a professor of law at Dalhousie University with a cross-appointment in the psychiatry department. His perspective is that CTOs are “coercive measures” designed to control people’s behaviour in the community.
“They do represent massive intrusions into the civil liberties and human rights of persons with mental illness,” Kaiser said.
On P.E.I., if a psychiatrist has reasonable grounds to believe an individual is non-compliant, they can issue an order for an involuntary psychiatric assessment. The province’s Mental Health Act allows police to apprehend the person and take them to a psychiatric facility, where they can be detained, restrained and observed for up to 72 hours.
Similar mechanisms exist in other jurisdictions under different names, including mandatory outpatient treatment, outpatient commitment and conditional leave from an inpatient facility
“These are prone to misuse,” Kaiser said. “They’re just a convenient tool of control. They cause more stigma. They permit coercion.
He argues that laws are not made on the basis of “apparent necessity,” and that any changes to legislation should be assessed against human rights guidelines
Kaiser points to concerns raised last year by the United Nations’ Convention on the Rights of Person with Disabilities. It called on Canada to repeal federal, provincial and territorial laws and policies that allow involuntary detention and treatment, including through CTOs
“In that sense, Prince Edward Island and other provinces are, in my mind, in willful and knowing noncompliance with their international human rights obligations,” Kaiser said
He contrasts the Island’s approach with Nova Scotia’s Involuntary Psychiatric Treatment Act, which sets out guiding principles that include cultural safety, promoting self-determination and providing services in the least restrictive manner
O’Reilly agrees that a CTO can infringe on certain rights, but he says in some cases, it can be justifiable.
“When severe mental illness robs that person of the ability to understand and appreciate that they need treatment, then society must ensure that treatment is available to them,” he said.
John Gray, a retired hospital administrator and psychologist in Victoria, B.C., and lead author of the second edition of Canadian Mental Health Law and Policy, said CTOs can also prevent a harmful cycle, when patients feel better, stop taking medication, then relapse and end up back in hospital.
He points to data cited by the B.C. ombudsperson, showing a 37 per cent re-hospitalization rate among involuntary patients within one year.
Gray also pushed back against calls to abolish all involuntary admissions and CTOs. CIHI data show 22,030 involuntary psychiatric inpatient admissions in B.C. in 2023 to 2024, and 82,990 across Canada in 2023 to 2024, excluding Quebec and Alberta.
“Many of them would be on the street,” Gray said. “We would have a great number of people not in school when they should be, and a huge amount of family disruption.”
He acknowledges, however, that “there will always be errors” in any type of medical intervention.
“I believe there are sufficient protections built into mental health legislation,” Gray said. He points to safeguards such as patients being told their rights, the ability to ask a review board to lift an involuntary hold, regular reassessments to extend it, and the option to appeal in court.
For its part, P.E.I’s Department of Health and Wellness says it will be reviewing the Mental Health Act and its implementation in collaboration with Health P.E.I. and provincial and territorial partners in the upcoming months.
