For more than 200 years now the doctrine has been increasingly held that there is such a thing as mental illness, that it is a sickness like any other, and that those who suffer from it should be dealt with medically: they should be treated by doctors, if necessary in a hospital, and not blamed for what has befallen them. This belief has social uses. Were there no such notion, we would probably have to invent it.
Erving Goffman, 1970
To allow every maniac liberty consistent with safety; to proportion the degree of coercion to the . . . extravagance of behavior; . . . that bland art of conciliation, or the tone of irresistible authority pronouncing an irreversible mandate . . . are laws of fundamental importance . . . to the . . . successful management of all lunatic institutions.
Phillippe Pinel, 1806
This chapter addresses the community-based management and treatment, by public or state-controlled psychiatric agencies, of those judged to be mad in America. The employment of coercion (force or its threat, not requested or wanted) enabled the emergence of nineteenth-century American asylums with their state-granted legal authority that allowed mad-doctors to incarcerate people involuntarily with considerable discretion and little oversight. Today, the legal grounds for involuntary hospitalization have narrowed to include those who are deemed to be at immediate risk for harm to self or others as a result of a mental illness. Psychiatric coercion, however, has expanded to include coercing people outside hospital walls, in the community. Coercion made the emergence of public psychiatry possible. We argue in this chapter that coercion sustains its existence even today.
We believe it essential to differentiate, on the one hand, state supported involuntary psychiatry (the twenty-first century grandchild of “institutional psychiatry”) based on coercion from, on the other hand, contractual or voluntary psychiatry. In the second enterprise, the person seeking help and the psychiatrist or mental health practitioner offering it mutually agree to work together to address the intrapersonal or interpersonal difficulties identified by the help seeker. The relationship, which can be terminated by either person at any time, is based initially on mutual respect or neutrality, and usually involves persuasive discussion with no coercion imposed by the practitioner (to the extent that the practitioner shares what he or she knows about the treatments). This sort of practice occurs more frequently with the “worried well” and those who are more likely to be able to afford to pay for someone to work with them on their life difficulties.
By arguing that coercion sustains the existence of public psychiatry even today, we are not making the point that psychiatrists are more malevolent, mean, sadistic, or less caring than other people. Rather, we are making the simpler point that coercion applied with sufficient force and regularity works—if by working we mean obtaining people’s behavioral compliance. Coercion, we argue, has always been an essential method for managing the complexities of human misbehavior. Psychiatry, a profession specializing in managing complex human behaviors, has not only unfailingly chosen to employ coercion in this endeavor, but has unfailingly claimed that coercion was in the best interests of those coerced.
Getting caught by the police for speeding usually results in an immediate penalty of a steep fine on the driver. For most folks this penalty “works,” in that at least for a while after receiving the ticket they may not speed or will keep a sharper eye out for the enforcers. They are quite likely to alter their driving behavior to avoid further coercion or punishment. But do drivers learn as a result that speeding is fundamentally wrong and dangerous? We doubt it, if the continuing high rate of traffic citations is any indication (see, for example, Florida, 2010).
Yet few would suggest that what the police do to enforce driving codes is a therapeutic enterprise. No one would mistake this police activity for the treatment of a medical condition called automobile speeding disorder. The job of the police is to detect and punish drivers who breech socially and legally expected behavior: in this case, conformity with the traffic laws that manage potentially lethal activity (driving powerful vehicles). Society expects that punishment will alter the speeder’s behavior and reduce accidents. Similarly, psychiatry, the government-certified profession for maintaining “normal” behavioral order, is expected to detect and manage people who manifestly violate intrapersonal and interpersonal norms, codes, or rules. Psychiatry is also authorized to use force to gain the compliance of recalcitrant individuals.
Ultimately, force may be needed to ensure that people conform to the rules of normal life. The question is: Is the psychiatric use of force a scientifically derived therapeutic endeavor and is psychiatric coercion any different from other versions of institutional coercion in society? That is, is it to be considered treatment rather than punishment?
We begin this chapter by examining some of the findings of the 1961 report of the Joint Commission on Mental Illness and Health (JCMIH), the first federal commission ever created to review society’s formal governance of mad Americans and to propose a comprehensive national plan to “provide more humane care for the mentally ill” (p. xxix). We first describe the commission’s view of what mental illness is and then discuss briefly its findings on the historical role of force and coercion in the psychiatric treatment of mad Americans. Next, we describe how coercion operates in psychiatry, including its foundational role in the creation of public psychiatry, and review the contemporary literature to describe some of its current manifestations in community treatment. We also attempt (given the scarcity of national data) to estimate the prevalence of coercive practices in current psychiatry in America. We then briefly explore how and why the employment of coercion has become a leading area for academic research, especially regarding its “clinical effectiveness.” To frame that discussion, we found it necessary to examine the notion of evidence-based practice (EBP), which has gained immense popularity among mental health authorities and academics over the past decade and which we believe is used to justify the continuation of coercive practices in public psychiatry. We conclude this chapter by examining one of the most promoted and researched EBPs for those diagnosed with serious mental illness, assertive community treatment (ACT), exposing its use of administrative and clinical coercion to produce “successful” outcomes in the treatment of its recipients.
As America moved into the mid-twentieth century, the Joint Commission on Mental Illness and Health (JCMIH, 1961) was created under the auspices of the Mental Health Study Act of 1955 to review how mad people were previously managed in the United States. Its findings were expected to “make recommendations for combating mental illness in the United States” (p. v). Led by Jack R. Ewalt, chairman of the Department of Psychiatry at Harvard Medical School, the commissioners included notable mental health authorities like Kenneth Appel, a former president of the American Psychiatric Association; Ernest M. Gruenberg, an expert on the epidemiology and chairman of the Department of Mental Hygiene at the Johns Hopkins School of Hygiene and Public Health; and Mike Gorman, the executive director of the National Mental Health Committee (JCMIH, 1961). The commission’s ultimate advice to the federal government was to fully embrace the medical model of psychiatry and invest in a national mental health program. Although the commission members subscribed to the medical illness model of disordered behavior, they admitted that “[m]ental illness is different from physical illness,” being “a disorder with psychological as well as physiological, emotional as well as organic, social as well as individual causes and effects” (p. xviii) that are “so closely intertwined that so far science has been unable to unravel the causes and establish their relative importance” (p. 86).
This mid-twentieth-century effort to define or describe mental illness is a perfect example of a panchreston. Dictionary.com (2011) defines panchreston as “a proposed explanation intended to address a complex problem by trying to account for all possible contingencies but typically proving to be too broadly conceived and therefore oversimplified to be of any practical use.” To claim, as the commission does, that madness is a medical illness and that it occurs as a result of the impact of human physiology, sociology, biology, and psychology or any possible combinations of them (JCMIH, 1961, p. v), is merely making a vacuous statement.
In contrast to its definition of mental illness, the commission’s historical research on how the mad were managed displayed no ambiguity whatsoever. It argued that the mad—for centuries, both here and in Europe—have been subjected to “a superstitious and retaliatory approach . . . The instrument of this approach is punishment” (JCMIH, 1961, p. 25). The commission recognized that this was attenuated by periodic efforts to employ less directly coercive approaches (i.e., moral treatment) but which rather quickly were abandoned and replaced by more forceful and outright coercive manipulation and management. An entire section in chapter two of the commission’s report, “Punishment as Treatment” (pp. 25–28), is devoted to a discussion of its routine employment. The chapter quotes Benjamin Rush, a signer of the Declaration of Independence, whose visage adorns the official emblem of the American Psychiatric Association: “Terror acts powerfully . . . and should be employed in the cure of madness” (p. 27).
The report traces how the religiously inspired notion that sinful behavior causes disease justified interventions by the medical and occasional lay superintendents running America’s nineteenth-century’s madhouses. These interventions included “a wide assortment of shock techniques” (JCMIH, 1961, p. 28), such as bleeding to the point of fainting, near drowning, rapid spinning, forced vomiting, and applying an early form of electric shock to the body. The commission members acknowledged that all of these techniques forced on unwilling mad people were based on “fallacious medical rationales” (p. 28), implying either that some genuine medical rationales could today justify the employment of coercion on the mad, or else, as we shall see in other statements in the report, rejecting the use of any medical rationale for coercion and rejecting coercion tout court. In looking at some justifications for coercion and torture proposed by leading alienists of eighteenth- and nineteenth-century America, it is difficult to tell whether those who employed it did so because they thought it helped to “cure” or because it produced immediate behavior change, or both. Benjamin Rush designed a “tranquilizing” chair that he described as follows in a letter to his son:
I have contrived a chair and introduced it to our [Pennsylvania] Hospital to assist in curing madness. It binds and confines every part of the body. By keeping the trunk erect, it lessens the impetus of blood toward the brain. By preventing the muscles from acting, it reduces the force and frequency of the pulse, and by the position of the head and feet favors the easy application of cold water or ice to the former and warm water to the latter. Its effects have been truly delightful to me. It acts as a sedative to the tongue and temper as well as to the blood vessels. In 24, 12, six, and in some cases in four hours, the most refractory patients have been composed. I have called it a Tranquilizer. (cited in Scull, 1993, p. 73, footnote no. 104)
Another section of the JCMIH report, “The Tranquilized Hospital,” discussed contemporaneous treatments for the mad, namely, some chemical agents which the commission believed had “revolutionized the management of psychotic patients in American mental hospitals” (1961, p. 39). The authors described the effects of these “major tranquilizers” (known as antipsychotics or neuroleptics today): “tranquilizing patients who are hyperactive, unmanageable, excited, highly disturbed, or highly disturbing . . . [with] the most noticeable effect of the drugs . . . [being] to reduce the hospital ward noise level” (p. 39). They did not discuss whether the drugs were ever voluntarily requested or consumed by psychiatric patients. As we note later in this chapter, many of the coercive psychiatric techniques employed today have the principal aim of forcing patients to take their medications, which they abandon in large numbers as soon as they are given the opportunity. For example, a recent, major federally sponsored study on the effectiveness of antipsychotics in the treatment of schizophrenia found that 74 percent of those enrolled quit taking their assigned drug before the study’s completion due to the lack of drug efficacy, accompanied by many unpleasant and dangerous adverse effects they experienced (Lieberman et al., 2005, discussed in chapter 6).
The principal purpose of these chemicals was to make highly disturbing individuals “more appealing to all those who must work with [them]” (JCMIH, 1961, p. 53). These chemicals, contrary to current widely held beliefs that they target specific psychotic disorders, suppress the central nervous system activity of anyone—normal or diagnosed—taking them (Healy & Farquhar, 1998). By blunting emotions and dramatically curtailing physical activity, including the disturbing and violent dramatic behavior often attributed to diagnosed psychotics, they are touted as remarkable medical breakthroughs, rather than less conspicuous methods of restraint than were used previously for controlling problematic behavior in the asylum. The JCMIH report acknowledged that many professionals understood the pragmatic purpose of these drugs, having “dubbed them chemical straight jackets” (1961, p. 39). In its enthusiasm for the use of these new drugs, the commission neglected to discuss—given the long history and experience of psychiatry with aversive and shock treatments—what sort of morbidity these chemicals, which rapidly produced stupor and physical immobility, would have in the longer term on their recipients (for a fuller story see Gelman, 1999 and chapters 6 and 7 in the present book).
In sum, the commission’s overall review of America’s policy toward the mad from colonial times to the mid-twentieth century found that the policy had been to confine the mad in institutions against their will and subject them to various physically and emotionally brutal treatments. The commission went further, proposing that institutional confinement (the systematic employment of coercion) without any other effective means of treatment had “shown beyond question that much of the aggressive, disturbed, suicidal and regressive behavior of the mentally ill . . . is very largely an artificial product of the way of life imposed on them” (JCMIH. 1961, p. 47), and that “[t]o be rejected by one’s family, removed by the police, and placed behind locked doors can only be interpreted, sanely, as punishment and imprisonment, rather than hospitalization” (p. 53). The commission’s point was unmistakable: America’s approach to madness for the previous two hundred years, whether by a physician or by a policeman, relied on the use of coercion.
Psychiatry has carefully used medical rhetoric to reinforce its medical image and justify its coercive authority, without necessarily matching it with humane, effective interventions. This is not merely a feature of our distant past. Assertive community treatment was invented in Madison, Wisconsin, in an institution that began its life in 1860 as the Mendota Asylum for the Insane. Renamed in 1935 as Mendota State Hospital, it emerged in 1974 as Mendota Mental Health Institute. These name changes appear to reflect the changing functions of the institution over 150 years, moving from a place of involuntary custodial “asylum” care to a venue for conducting scientific research and treatment as a “mental health institute.” Yet the institution does today exactly what it has always done: manage involuntarily detained mad people. As explained in 2011 on the State of Wisconsin’s website, “Mendota’s Civil Program provides services to adults who are in need of psychiatric treatment. All admissions are involuntary” (Mendota Mental Health Institute, 2011).
Regardless of what they were named, insane asylums and their often inhumane practices had by the early decades of the twentieth century drawn a great deal of negative attention from the media and advocates. This resulted in the commission’s recommendations that state mental hospitals be dramatically deemphasized in a public system of care and that the mad be managed principally in the general community within a system of “integrated community service[s]” (JCMIH, 1961, p. 289). The community was, after all, where the mad were always expected to return after being released from confinement. The recommendation to move the inmates of state hospitals back to the community for treatment simply confirmed a visible, numerical shift that had slowly begun in 1955 (Scull, 1976). We often hear, and the commission report suggested, that the shift was due primarily to the introduction of major tranquilizers. A body of research and analysis since then, however, has established that this shift was more importantly due to the imposition of administrative policies “to prevent the accumulation of long-stay institutionalized patients” (Scull, 1976, p. 178). The beginnings of this administrative shift could be noted in some hospitals in the United States as well as in England, especially those which adopted a policy of “early discharge, or the avoidance of admissions altogether beg[u]n . . . well before the national swing was noticed in 1955” (p. 178). The initial modest decline in hospital populations began before psychoactive chemicals were routinely employed1. Gronfein (1985) notes in his analysis of psychotropic drugs and deinstitutionalization that “discharge rates were increasing before the advent of the drugs” (p. 448) and further demonstrates that the larger-scale transfer of patients truly began in the mid-1960s, more than a decade after the introduction of these drugs (see chapter 7).
The community was assumed to be, albeit with no real scientific evidence (Grob, 1994, Scull, 1976), a more supportive environment for enhancing the personal autonomy and freedom of the mad, conditions which it was further assumed would increase the likelihood of cooperation between mental health providers and their charges. This hypothesized, enhanced therapeutic alliance, aided by the use of the newly introduced major tranquilizers, was expected to reduce the need for institutional coercion while at the same time attenuating the problematic behaviors of the mad.
According to Scull (1992), the commission report was “[l]argely written by a specialist in public relations” (p. 568). This would account for its optimistic tone and its vaguely articulated and surprisingly nonspecific bureaucratic content. The optimism no doubt reflected attitudes in a country that had recently been victorious in a world war and was brimming over with enthusiasm and the can-do attitude. America had recently demonstrated its ability to alleviate the physical human suffering that resulted from war. Following the carnage and destruction that lay waste to the European continent during World War II, America successfully developed and implemented a European recovery and reconstruction strategy, the Marshall Plan. So it was not a great stretch, when turning to address another troubling area of human conduct arising at home, madness, that a new, concerted effort was expected to yield rapid success through energetic central organizing and planning by the federal bureaucracy. For a variety of reasons, however, detailed by Grob (1991), the commission’s plan failed to be “a precise blueprint that could serve as the basis for legislative action” (p. 209). Ultimately, it lost some of its credibility among powerful government bureaucrats: it was considered, for example, by the NIMH’s Philip Sapir, chief of that agency’s Research and Fellowship Branch, to be “pedestrian, platitudinous, rehashes of previous statements . . . so incredibly bad that there seems almost no point in making specific criticisms” (quoted in Grob, 1991, p. 217). Nonetheless, in some roundabout way, several basic proposals in the report did find their way into federal mental health policy.
Some ten months after its publication, a special Governors’ Conference of Mental Health endorsed its general findings and stated “that Federal, State, and local governments as well as private and voluntary efforts must be combined to achieve the goals we seek” (Connery, 1968, p. 46). This endorsement added impetus to President Kennedy’s appointing a cabinet-level committee on these issues, which then “developed proposals for action which accepted most of the Joint Commission’s findings and many of its recommendations, including its urgent pleas for extensive federal participation in combating mental illness” (p. 47). The Joint Commission findings were echoed by President Kennedy in his “Message on Mental Illness and Mental Retardation” to the US Congress in 1963, recommending a brand-new, community-focused approach to the problem which, as he stated, was “designed in large measure, to use Federal resources to stimulate State, local, and private action” (p. 48). We’ve cited the remarks from President Kennedy and the Governors’ Conference on Mental Health to illustrate, not their particular concern with coercion, but the redirecting of federal financing efforts toward new social goals identified under the “mental health” rubric.
Despite President Kennedy’s congressional message and the subsequent congressional activity (discussed in chapter 2), the grim psychiatric reality was that by the mid-1960s the mad, who were previously managed through total institutions and involuntary confinement, were now being discharged to mostly unwelcoming rather than accepting communities whose “residents . . . fought hard to ensure that . . . patients . . . released . . . are not released into their neighborhoods” (Scull, 1976, p. 197). This new wave of hospital discharges was due principally to changing patterns of funding for state mental hospitals and the rising hope about the psychotropic drugs (Gronfein, 1985) induced in decision-makers and others. This posed a number of professional problems for psychiatry and the mental health professions.
First, the publicly dependent mad constituted a heterogeneous mix of individuals (e.g., elderly, senile, physically disabled, abandoned, destitute, deviant) confined together mostly to keep them from disturbing others and also to remove them from the public’s consciousness (out of sight, out of mind). But the aggregation of such different individuals and their different problems under the presumption that they were all suffering from medically treatable illnesses was not supported by the research conducted in or outside institutions (Scull, 1976).
Second, there was no indication that those discharged from the state institutions would voluntarily seek psychiatric help, and yet state legislatures, beginning in the late 1960s, were tightening criteria for involuntary institutionalization. Third, short of chemical sedation for subduing and managing agitated behavior (Davis, 1965), no effective treatments existed to bring people to conform or act normally. In addition, the drugs had a host of debilitating effects (Crane, 1973). And, finally, the psychiatrists actively promoted the belief that they had a handle on the “medical” problem of madness and that the public mental health system could be responsible for helping the former asylum inmates to be better off in the community.
In short, psychiatry had to devise a community-based approach of managing their mad patients that appeared to be medical, noncoercive, humane, and effective. It did this in part by creating a new pseudo-medical rubric for the mad—the severely mentally ill (SMI)—and concocting new forms of coercion usable in the new settings.
The profession of psychiatry or mad-doctoring emerged in the eighteenth century in parallel with the decision to construct a few specialized buildings especially for the mad in order to confine and manage them involuntarily. (The first involuntary admission in America occurred in the City of Brotherly Love, Philadelphia, in 1752 [Anfang & Appelbaum, 2006].) This fortuitous development allowed for “unparalleled scrutiny of lunatics under controlled conditions, particularly while interacting with keepers, [to form] the matrix for the practical (experimental) discipline of managing the mad” (Porter, 1987b, pp. 174–175). Many of these keepers turned out to be medical men looking for stable employment. This early, loosely organized, fledgling economic enterprise for managing the mad had been institutionalized by the middle of the nineteenth century (see Rothman, 1990, chapter 5), with mad folk “incarcerated in a specialized, bureaucratically organized, state-supported asylum system which isolated them both physically and symbolically from the larger society . . . [a]nd . . . now recognized [madness] as one of the major varieties of deviance . . . a uniquely and essentially medical problem” (Scull, 1993 pp. 1–2). This state-sanctioned confinement gave free reign to mad doctors to experiment on their charges and claim that these approaches were prima facie scientific medical techniques to control the behaviors of this group and, coincidentally, confirm the doctors’ authority. These assertions gave credence to psychiatrists’ claim to be doing effective medical treatment when actually they were constructing a “new apparatus for the social control of the mad” (Scull, 1993, p. 3).
The singular authority granted to psychiatry to imprison mad individuals for treatment in specialized facilities, whether called asylums, mental hospitals, or community-based mental health clinics, is the key to its professional importance. The undisputed historical fact of psychiatry’s authority to employ coercion, however, has not been adequately recognized for what it has meant for mental health practice: police authority makes truly voluntary psychiatric treatment in the current public mental health field a near-impossibility.2 All the relevant “stakeholders” (the mad, their families, their friends, the psychiatrists that treat them, and society at large) are on notice that involuntary commitment and the use of force are ready to be deployed on any diagnosed mad person refusing to follow prescribed psychiatric treatment. That knowledge shapes the behavior of all the parties to the psychiatric encounter as surely as the knowledge that one’s parent regularly but inconsistently uses physical punishment shapes the behavior of a child. The uncertainty of not knowing when punishment will be employed makes compliance by the victim more likely. So voluntary medical treatment, in the sense that most people think of it when they consult their physician for a physical health problem, is less likely to occur in public psychiatric practice.
Those who can afford medical care or purchase health insurance go to their personal physician by choice, whether for an annual checkup or over a concern about some possible ailment. Regardless of the doctor’s recommendation, they can choose to follow it entirely, partly, or reject it all together because the power imbalance between a medical patient and the doctor is only marginally in favor of the doctor. It is based on the doctor’s presumed better informed opinion about the problem, attributed to her because of her specialized education, training, and experience—the particular reasons a patient would seek a physician’s advice in the first place. But once informed about his medical condition and having received advice or even exhortation from the physician, the patient retains full control over his course of action from that moment onward. This is true even if the health problem diagnosed by the doctor, if left untreated, will lead to death shortly. (Our physicians cannot force us to take statins for our coronary heart disease or involuntarily inject insulin into our bodies to control our runaway diabetes.)
In contrast, if the diagnosed mad person resists “emergency” psychiatric treatment (in which the person is deemed to be at risk for harm to self or others), she knows that she can be rapidly involuntarily hospitalized in a locked facility and treated against her active protests and physical resistance. This knowledge colors and shapes all engagements between mental health patients and mental health professionals. No true voluntary treatment can ever occur, because no mad person can freely walk away from the recommended treatment if there is a serious disagreement between the psychiatric professional and that patient. It is true that the problematic behavior of the patient must be judged to place the patient or others at risk for harm in order to involuntarily commit and treat, but only if this behavior is judged to result from a mental illness (e.g., Evel Knievel’s undoubtedly dangerous, death-defying motorized leaps never earned him the unwanted attention of psychiatrists). Since this judgment is a “clinical decision” (a statutorily authorized personal judgment of the professional), this is not a difficult standard to meet. In involuntary psychiatric treatment, psychiatric decisions and legal power intertwine to become virtually indistinguishable.
In 1961, when the JCMIH published its report, 527,500 people were inmates in state and county mental hospitals in the United States (Scull, 1976, p. 176), and fewer than one million people in total were diagnosed mental patients using services in community mental health clinics and state and county mental hospitals (Grob, 1994, p. 248). Today, the NIMH (2011) declares that “[m]ental disorders are common in the United States . . . An estimated 26.2 percent of Americans ages 18 and older . . . suffer from a diagnosable mental disorder in a given year . . . this figure translates to 57.7 million people.” The NIMH further specifies that about 6 percent of those individuals are diagnosable with a major mental illness (3.5 million people). Assuming that these figures are accurate, and considering that we have almost doubled our population since 1961 to about 310 million in 2010, we are left to contemplate the meaning of having 3.5 million adult American citizens—equivalent to the population of the State of Connecticut—diagnosed as having a “major mental illness” or being “seriously mentally ill” (SMI)3, terms used interchangeably in the academic literature.
This amazing epidemiological uptick in psychiatric diagnoses (problems regarding the validity of psychiatric diagnoses are addressed in chapters 4 and 5), especially the functional diagnosis of SMI, has occurred despite the huge increase in the number of mental health professionals, treatment centers, and funds devoted to preventing or treating mental illness. In 2010 the NIMH budget was $1.5 billion, most of it earmarked for research on SMIs and their treatments. Almost a third of the funding, about $400 million, was spent on brain and basic behavioral research (NIMH, 2011), designed to verify NIMH’s institutional assumption that mental illnesses are brain diseases. The federal government has increased its funding for NIMH (2011) from $288 million in 1986 to $1.5 billion in 2010, making that agency the seventh highest funded of the twenty-seven institutes and centers that comprise the National Institutes of Health (NIH).
To estimate the total spent by both private and public funding sources annually on behavioral research and services, we use the data from 2005 (the latest comprehensive national figures available for mental health service expenditures). NIMH research funding that year was approximately $1.4 billion (NIMH, 2011), while the total national private and public expenditures for mental health services totaled roughly $113 billion—about 60 percent of it coming from tax revenues (Garfield, 2011). The huge increase in mental disorder diagnoses in the last few decades suggests that we have failed to effectively treat the problem despite the substantial dollars spent annually on research and services to develop effective treatments. NIMH director Thomas Insel proclaimed to an audience of researchers attending the 2006 NIMH Alliance for Research Progress meeting that “[w]e know a lot about evidence-based treatments” (NIMH, 2006, p. 1). If this is true, what actually is being done with the mad may be surprising.
In Hospitals. The threat of involuntary hospitalization and the use of coercion is no idle one. Given how the American tradition and political system conceive of the loss of liberty, one might expect such loss under any state-sanctioned circumstances to be meticulously documented, as it is in connection with criminal arrests and incarcerations. Nonetheless, there currently exist no national data regarding involuntary hospitalization or even unduplicated counts of the number of individuals hospitalized psychiatrically in a single year. Thus, one is forced to rely on extrapolations from state and local data for any such estimates. In an earlier publication (Gomory et al., 2011), based on the data released by two large states (California and Florida), we conservatively estimated that around 1.37 million American adults are the subjects of involuntary hospitalization each year. This number makes up about 62 percent of those hospitalized for any psychiatric reason but does not include the unknown proportion of those deemed to be “voluntarily” hospitalized but who are aware that they might or will be forced into hospitalization if they do not submit (Sorgaard, 2007). Our own guess is that the large majority of psychiatric hospitalizations, perhaps all, are involuntary.
In Prisons. Another group of involuntarily confined mad people are those currently confined in US jails. The data are not based on actual national counts, since no such comprehensive data exist and must be estimated from studies conducted on subsamples of this population. Recent research (Steadman, Osher, Robbins et al., 2009) suggests that the average prevalence of serious mental illness among the approximately 2.1 million people incarcerated in US jails, prisons, and penitentiaries is 14.5 percent for men and 31.0 percent for women. Conservatively, these percentages convert to roughly 330,000 mad people confined in our penal institutions as a result of having been found guilty of criminal offenses.
In the Community. New developments in the application of force and coercion on the mad have emerged from the community, where the mad mostly live and are treated today. Not surprisingly, here too no national prevalence data exist, but again, by reviewing some of the most recent studies on community-specific psychiatric coercion, one can make educated guesses. One study conducted in five US cities (Swartz, Swanson, Kim et al., 2006) found that 44 to 59 percent of the sampled individuals reported having been subjected to at least one of four coercive measures (the researchers call them “tools,” p. 38) while in outpatient community treatment.
In Toto. Using the above information, our tentative, evidence-informed guess is that at least 50 percent of the mad in the above three settings are the regular recipients of at least one form of psychiatric coercion. We can put numbers to this percentage by using the latest data available from the federal government on “patient care episodes” (the odd name the federal government uses for the count of the total number of persons under psychiatric care4 in any one year in the United States). We find that there were 9.5 million patient care episodes in 2002 (Manderscheid, & Berry, 2006, p. 209), translating at a minimum to 3 to 4 millions of our mad citizens subjected to coercion in the name of mental health in any single year.
Community-based mechanisms of coercion are deployed by the judicial and the public welfare systems—the two major institutions outside the mental health system in which the mad are located (Monahan, 2008). The judicial system employs several coercive civil mechanisms on noncriminal mad persons to keep them out of hospitals and force them into community treatment, by far the cheaper option (Swartz, Swanson, Kim et al., 2006). The most well-known of these is court-ordered outpatient commitment, and it usually comes in three forms: first, conditional release from involuntary hospitalization if the person is willing to submit to mandated community treatment; second, as a substitute for involuntary hospitalization for those meeting commitment criteria; and third, as a form of preventive detention for those who are not legally committable but are considered to be “at risk.”
Mad individuals who are adjudicated of a minor or nonviolent crime are further subjected to mental health courts, such as so-called “drug courts.” These courts use judges’ recently expanded extralegal role to force some mad criminals into psychiatric treatment by “play[ing] a hands-on, therapeutically oriented, and directive role at the center of the treatment process” (Monahan, Bonnie, Appelbaum et al., 2001, p. 1200). The research indicates that such courts appear to have at best a moderate effect in reducing criminal recidivism among those who complete their programs (a high dropout rate is common). However, because the participants are often selected by judges “based on personal knowledge of an individual’s history” as those “most likely to succeed,” even this outcome is not generalizable (Sarteschi, Vaughn, & Kim, 2011, p. 14).
The social welfare system uses two prominent coercive measures to gain behavioral compliance. One is by controlling any funds to which the mad may be entitled. This is done by appointing for recalcitrant individuals payees, who control the patient’s access to public disability benefits, predicated on the patient’s level of cooperation with psychiatric treatment. The second measure is by providing access to subsidized housing only to those who comply with treatment, an effective mechanism of subjugation because most of the public mental health patients cannot afford to pay fair market rents from their monthly disability checks. These coercive tactics are today ordinarily called “leverage” by academics (Monahan, Redlich, Swanson et al., 2005). John Monahan, the dean of psychiatric coercion scholars, goes as far as to argue “that framing the legal debate on mandatory community treatment primarily in terms of coercion has become counter productive . . . [and it is] unhelpful and [a] misleading assumption that all types of leverage necessarily amount to coercion” (2008, p. 284). Apparently he forgets that “mandated community treatment” means, if it means anything, treatment not voluntarily sought but forced on the patient. The scientific work of some eminent scholars of coercion might be summed up in one phrase: Coercion by any other name is not coercion.
To illustrate how reputable researchers and mental health professionals can come to such judgments, we devote the next section to examining some of the purportedly scientific bases for the acceptance and dissemination of coercive practical interventions designed to change the behavior of mad people who reside in the community. This involves looking first at the evidence-based practice movement and its progenitor, evidence-based medicine.
The relatively recent phenomena of evidence based practices (EBPs) proliferating currently in all of the helping professions are derived from the dramatic growth and legitimation of their parent movement, evidence-based medicine (EBM). The latter emerged during the 1990s when its advocates promoted it as a “new paradigm” for selecting the best options among available medical treatments (Haynes, 2002) and governments saw in it a method to control expenditures on medical care. Looking at the Medline bibliographic database shows that prior to 1990, zero publications were indexed with the terms evidence-based medicine, evidence-based treatment, or their abbreviations. For the 2000–2005 period, however, 13,989 hits for EBM and 1,331 hits for EBP or EBT were recorded (Flaum, 2007). These data indicate the suddenly increased popularity of this new terminology among academics and clinicians. The terminology is new, but EBM methodology is not.5
EBM is defined by its developers as:
[T]he conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, pp. 71–72)
It is extremely difficult to resist the allure of a protocol that proposes (1) combining the best objectively derived evidence of treatment effectiveness, with (2) the application of caring and sensitive clinical expertise of individual clinicians, to (3) choose those specific treatments that mesh with particular patients’ “predicaments, rights and preferences” while simultaneously (4) ameliorating specific patient illnesses. Perhaps the popularity of the EBM idea is due to this seductive linguistic combination of all that scientific medicine aims to accomplish as a healing enterprise and for suggesting that such a utopian research program is actualizable. Clinical epidemiologist Alvan Feinstein and a colleague warned about EBM in 1997: “[h]ardly anyone can disagree with the goal of getting clinicians to make ‘conscientious, explicit, and judicious use of current best evidence’ for decisions in patient care” (p. 529). The devil is in the details.
Despite its popularity, EBM has come under serious criticism. Here are the most problematic issues. First, the randomized controlled trial (RCT) that EBM identifies as the gold standard for determining effective outcomes uses group aggregated averages in the data analysis and cannot as a result provide useful information on how to select an effective treatment for any particular individual, the goal of all clinical practice. Alvan Feinstein, credited by EBM developer and epidemiologist David Sackett (2002) with putting clinical epidemiology on the scientific map, notes that “randomized trials were not intended to answer questions about the treatment of individual patients” (Feinstein & Horwitz, 1997, p. 532).
Second, in order for RCTs to be used validly, the sample of patients must be a random sample selected from a population, all having the same underlying disease. This proves well nigh impossible in psychiatric samples (as we will discuss in the next two chapters) since psychiatric diagnoses are neither reliable (Kirk & Kutchins, 1992) nor valid (Boyle, 2002), and therefore cannot be used as a method to identify a sample of people with the same mental disorder (Wolf, 2000, p. 101). As the DSM states, “In the DSM-IV there is no assumption that each category of mental disorder is a . . . discrete entity . . . dividing it from other mental disorders or from no mental disorder. . . . [T]herefore . . . individuals sharing a diagnosis are likely to be heterogeneous even in regard to the defining features of the diagnosis” (APA, 2000, p. xxxi). We understand that our assertion of unreliability and invalidity may strike some readers as unduly harsh, yet even prominent DSM architects acknowledge it, as we discuss in chapters 4 and 5.
Third, although RCTs may be useful in deciding if an active drug is better than a placebo (i.e., a nonactive pill or process also known to influence the outcome being researched) to treat, say, an infection, they may not be the best way to evaluate the effectiveness of socially complex bundles of services usually provided by public social welfare and mental health systems. These services include various components, such as case management, psychiatric medication monitoring, cognitive-behavioral treatment, employment training, activities in daily living, and budgeting classes. Depending on a particular agency’s philosophy and funding requirements, each service package and each component therein may be organized and implemented differently across agencies, and even within a single agency. The resulting “lack of precision makes it difficult to model the causal pathways of interventions, which is central to the RCT model” (Wolf, 2000, p. 101). To further complicate the portrait: if attempts are made to test the various components’ separate effects on the patients, that is, to unbundle bundled services, the strong possibility exists that some important elements of the bundled intervention will be overlooked because they are hard to measure or so idiosyncratic that they cannot be standardized and transferred uniformly to another setting. For example, it may be that the most “highly effective aspects of the intervention are those unmeasured aspects that are associated with highly stylized characteristics of the staff, say their interactional style or level of motivation” (p. 101).
Fourth, comprehensive evaluations of treatment outcomes from multiple studies carried out by combining data from all the studies have their own limitations. Such systematic pooling of study results, known as a meta-analysis, has come to be seen in EBM as the gold standard for deciding on an intervention’s effectiveness. Meta-analyses now number in the thousands in the psychiatric outcome literature alone. Yet the limitations of meta-analyses need closer scrutiny. One such limitation is that meta-analyses often take the information given in individual RCT studies as factually accurate. As many scholars have pointed out, those who conduct meta-analyses do not necessarily assess independently how well each individual RCT was implemented or evaluate the impact of potentially bad implementations on the quality of the data gathered (Bailar, 1995; Feinstein 1995; Feinstein & Horwitz, 1997; Oakes, 1986; Rothman, Greenland, & Lash, 2008, p. 682; Williams & Garner, 2002). In addition, no meta-analysis considers the impact of the administrative organization of an intervention program and its rules and regulations on the success of the intervention. As we argue later for ACT, these rules and regulations, not its hypothesized clinical6 interventions (the foci of analysis for such systematic reviews), are often responsible for reported successes. The American statisticians Richard Berk and David A. Freedman go further and advise:
[W]ith respect to meta-analysis, our recommendation is simple: just say no. The suggested alternate is equally simple: read the papers, think about them, and summarize them. Try our alternative. Trust us: you will like it. And if you can’t sort the papers into meaningful categories, neither can the meta-analysts. (2001, p. 21)
In fact, an editorial in January 2012 in the BMJ (formerly known as the British Medical Journal, and perhaps the staunchest proponent of EBM in the world) introducing a series of articles on missing clinical data and their impact on the methodology of EBM, noted the flaws of quantitative findings in systematic reviews of clinical trials:
These articles confirm . . . that a large proportion of evidence from human trials is unreported, and much of what is reported is done so inadequately. . . . What is clear from the linked studies is that past failures to ensure proper regulation and registration of clinical trials, and a current culture of haphazard publication and incomplete data disclosure, make the proper analysis of the harms and benefits of common interventions almost impossible for systematic reviewers. (Lehman & Loder, 2012)
A fifth issue regards what kind of evidence is best for determining if the treatment is effective. Should we rely strictly on statistical analyses of numerical data as EBM advocates urge, or should we more broadly incorporate other systematically reviewed empirical evidence currently disallowed under EBM? Some doctors argue that “the general priority given to empirical evidence derived from clinical research is not epistemologically tenable” (Tonelli, 2006, p. 248) but should only be considered as one source along with others. These other sources could be evidence obtained from well-conducted observational and naturalistic studies, gathering of individual case studies into a searchable database (sometimes referred to as experience-based evidence), studies on human and animal physiology, as well as evaluations of patient goals, values, and specific features of the delivery system relevant to practice (Tanenbaum, 2006; Tonelli, 2006). Even if expanded sources of evidence were considered, how should different forms of evidence be weighed and in what order in distinguishing better from worse interventions? These methodological conundrums may have no resolution since each form of evidence may derive from different and irreconcilable theoretical perspectives.
Sixth, the part of the EBM definition urging the need to consider clinical judgment (i.e., the subjective calculation of the helping professional regarding the problem), as well as the patient’s personal wishes when choosing the proper EBM treatment, greatly appeals to common sense. EBM proponents, however, have consistently admitted that they have not a clue as to how to incorporate these two subjective elements into the protocol of EBM (Cohen, Stavri, & Hersh, 2004, Haynes, 2002). Without a procedure for selecting, organizing, and integrating the best research evidence, best clinical judgment, and patients’ preferences, the EBM approach for choosing an effective treatment for a given individual presenting with a given illness is no more “scientific” than the approach used by ethical clinicians in the past. These clinicians carefully weighed the best information available to them from multiple sources in order to choose the best care based on their education, training, experience, and positive therapeutic alliance with their patients (Feinstein & Horwitz, 1997). Feinstein and Horwitz note that “most good clinicians have regularly assembled evidence when they reviewed their own experience, developed clinical judgment, read the medical literature, attended medical meetings, and had discussions with one another. This activity seems entirely compatible with the . . . practice of EBM” (1997, p. 529).
A seventh crucial issue is that deciding what constitutes EBM requires experts “certified” as authorities in the subject. Such an EBM certification must be done by authorities who themselves were certified in such expertise by prior certified authorities, and so on. So, rather than dramatically reducing or eliminating arbitrary or authority-based individual medical decision making or substituting an objective for a subjective decision-making process in choosing best practices as some have argued (Gambrill, 1999), EBM has turned out to represent merely another form of expertly justified authority. The subjective judgment of individual clinicians now becomes the subjective judgment of the authorized EBM evaluators7 who are expected to come to consensus regarding which studies meet the consensus protocol for systematically evaluating RCTs (see especially, Fenstein & Horwitz, 1997; Gupta, 2003), leading to a new “orthodoxy” promoted now as scientifically objective (Williams & Garner, 2002). To illustrate this reliance on inside experts, examine how the authors of one of these “rigorous” systematic reviews (in this case, of intensive case management), explain their approach:
The authors of this review do include an active pioneer of developing and implementing the experimental intervention model across the scientific community and clinical world [Dr. Marshall] and one included study is his (Marshall-UK). As a team we have tried to ensure that decisions are made by rational consensus and not to have an expert in the team would have been an inadvisable omission. In some cases protocol rules were not clear enough and need for subsequent clarification arose and post hoc decisions had to be taken. (Dieterich, Irving, Park & Marshall, 2011, p. 50)
They appear to rely on “expert” authority and group consensus in their meta-analysis, precisely the sort of contamination by authority figures that EBM was supposed to combat.
Finally, and perhaps most problematically, the effectiveness of EBM itself has never been tested according to its own principles. Do clinicians who practice EBM achieve better outcomes then those who do not? Nobody knows. That question has never been put to an EBM-favored test, for example, by conducting a controlled trial of evidence-based-medicine–trained clinicians versus those not trained to assess an ability to select and implement effective treatment to help their patients. Thus, the optimistic claims of EBM effectiveness are not themselves evidence-based (Cohen, Stavri & Hersh, 2004). The whole EBM project is untested, even though it has been promoted and marketed for over twenty years. Such uncertainty regarding the validity of EBM would suggest caution in marketing its wholesale adoption. Unfortunately, there is little doubt that it has been heavily marketed with resounding success, judging from its adoption as an organizing, pedagogical, and practice principle in Western medicine and the helping professions.
These criticisms have not gone unnoticed, and recent warnings have come directly from some EBM developers. Haynes (2002) wrote that “accelerating the transfer of [EBM] research findings into clinical practice is often based on incomplete evidence from selected groups of people, who experience marginal benefits . . . raising questions of the generalizability of the findings” (p. 1) and that at best it should be “an adjunct to healthcare decisions” (p. 6). The EBM developers have also concluded that “EBM has long since evolved beyond its initial (mis)conception that EBM might replace traditional medicine. EBM is now [instead] attempting to augment rather than replace individual clinical experience” (p. 1, emphasis added). This is a more modest stance by the EBM creators, demoting it to an “adjunct” role in medical decision making, and a withdrawal from their original claims that EBM represents “[a] NEW paradigm for medical practice” (The Evidence-Based Medicine Working Group, 1992, p. 2420). Nevertheless, other helping professions continue to view EBM as a research and training panacea.
EBM and its methodology is now the “best practice” approach used in the broad field of mental health, albeit under a slightly altered name, evidence-based practice (EBP). American researchers working with the SMI explain:
Over the past two decades, we have witnessed amazing strides in the development of effective service models for people with SMI . . . in 1998 . . . a national consensus panel identified six practices . . . attaining the status of EBP.
. . . EBP in mental health is part of a larger evidence-based medicine movement which quickly has become a dominating influence in medicine . . . Following the model of evidence-based medicine, EBPs are founded on the meta-principles of (1) using the best available evidence, (2) individualization, (3) incorporating patients’ preferences and (4) expanding clinical expertise. (Bond, Salyers, Rollins, Rapp, & Zipple, 2004, pp. 576–577)
Relying on the professionals’ and perhaps the general public’s resonance to the simplicity and seductiveness of the idea of EBM, implementations of evidence-based mental health practices for the SMI have been moving full steam ahead, its promoters ignoring the deep questions raised concerning the construct and the application of EBM.
The supporters of evidence-based medicine have developed a sophisticated research infrastructure, including prominently the Cochrane Collaboration. This enterprise uses volunteer medical professionals and academics who constitute work groups, conducting systematic rankings and reviews of the numerous randomized controlled trials of treatments available for many physiological problems, some psychiatric problems, and more general behavioral issues, such as the effectiveness of smoking-cessation programs. These systematic reviews, used to determine which treatments should be designated as evidence-based, are stored in Cochrane’s researchable electronic database available by paid subscription and in virtually all medical libraries. The evidence base for mental health interventions that is subjected to these procedures is far more limited and generally lacks the kind of consistent methodological scrutiny that physiological medical interventions have usually undergone (Drake at al., 2001).
A further fundamental difference characterizes how EBM and mental health EBP determine their recommended interventions. EBPs, specifically the ones receiving support from American psychiatric science’s key political patron, the NIMH, are selected through expert consensus rather than by formal protocols as recommended by EBM: “[strict] rules for designating a practice as an EBP . . . were not imposed in the Implementing EBPs Project; rather panels of research scientists were asked to review controlled studies” (Mueser et al., 2003, p. 389). Perhaps to minimize the reaction to such a major alteration of EBM protocol, the participating researchers promised to disclose their method of arriving at consensus, along with their findings, by publishing them during 2001 in one of the leading mental health journals, Psychiatric Services (Mueser et al., 2003, p. 389). In reviewing that journal, we could find no such content regarding what is probably the highest-profile community intervention EBP for the severely mentally ill: assertive community treatment.
Usually, in reaching consensus, a group, regardless of its purpose or membership, must get all members to agree to one expressed, or explicit, understanding. This is not a scientific but rather a social and political process. Unless explicit procedural and methodological criteria of the process are agreed to before starting, consensus reaching is arbitrary and may be captured by those in the group who are most persuasive rhetorically rather than scientifically. How the expert consensus agreement for the EBPs was reached is not described in the published literature, but it is noteworthy that this process was carried out with the sanction of NIMH under the auspices of the Robert Wood Johnson Foundation (Mueser et al. 2003, p. 388), funded by the family fortune derived from Johnson & Johnson, the eighth largest pharmaceutical company in the world (five former executives of which sit on the foundation’s board of trustees as of this writing).
Since the identification of EBPs is meant to reduce clinicians’ uncertainty in choosing effective treatments, the certification of treatments as EBPs by a consensus vote of approved experts should be based on consistently demonstrated success of the intervention. If, however, the evidence used to make the certification is weak, faulty, or ambiguous, then the certification can have the unintended consequence of institutionalizing coercive, ineffective, or even harmful treatments with almost no possibility of reversing those decisions. Statistician Kenneth J. Rothman observes:
Many of the commonly used modes of causal inference are fallacious . . . one such method of inference, the method of “consensus,” has been embraced, presumably for political reasons, by the National Institutes of Health. . . . The National Institutes of Health regularly convenes Consensus Development Conferences to address specific questions and draw inferences. . . . Were consensus a correct basis for inference, then a once flat earth must have become spherical . . . Consensus itself requires no further justification, and may be based on shared beliefs that are irrational. (Rothman, 1988, p. 6)
This difficulty is illustrated by the fact that among the consensus, some certified mental health EBPs are considered more valid than others: “[A]mong EBPs identified by the RWJ conference . . . three practices (supported employment, ACT [Assertive Community Treatment], and family psychoeducation) have strong and convincing evidence for effectiveness whereas the evidence is weaker for the remaining three” (Bond et al., 2004, p. 580). Unfortunately, whether based on strong or weaker evidence, once an intervention is labeled an EBP, its authority has immeasurably increased and rarely if ever will it be reevaluated.
The distortion of the original EBM approach in American mental health practice can be seen by the rhetorical turn taken in two articles published five years apart with the same lead author, psychologist Gary Bond, a leading replicator/evaluator/promoter of assertive community treatment. As we have earlier noted, Bond et al. stated in 2004 that mental health EBPs were founded explicitly on the EBM process and its key “meta-principles of (1) using the best available evidence, (2) individualization, (3) incorporating patients’ preferences and (4) expanding clinical expertise” (Bond, Salyers, Rollins, Rapp, & Zipple, 2004, pp. 576–577). In 2009, however, Bond and his colleagues declared that those explicit principles were unnecessary for mental health EBPs:
Evidence-based medicine sometimes refers to a process—the judicious use of the best scientific evidence, combined with clinical expertise and consumer preferences in making decisions in health care . . . The term EBP, has been used similarly in the mental health field . . . The term EBPs also refers to specific evidence-based (or empirically supported) interventions . . . (usually randomized controlled trials). Thus the acronym, EBP, is used throughout this article to refer to specific interventions and not to the process of clinical decision making. (Bond, Drake, McHugo et al., 2009, pp. 569–570)
Providing two distinct and independent definitions of EBP in mental health—one as a specific intervention to be used preferentially because it has been deemed to be effective and the other definition as a process of clinical decision making identical to the definition of EBM—allows Bond and his colleagues to change the scientific rules of the game for mental health EBPs. Talking about mental health EBPs in the first sense as “effective” interventions gives the impression that they are identical to EBPs identified for physiological medical problems through the EBM protocol (using systematic reviews) and have the same scientific credibility as the EBM-identified interventions (weak though they may be to informed observers). But the reality is that these mental health EBPs are not identified through the same procedures (systematic reviews of RCTs, but instead through expert consensus) and cannot be considered as analogs to EBM-derived treatments.
The various problems regarding mental health EBP that we have discussed here have not been adequately addressed or solved by the EBP experts. These experts are well aware of most of the problems, an awareness that prompted at least one meeting to gather and summarize the concerns regarding EBPs “voiced by members of diverse stakeholder groups; consumers, family members, policy makers, administrators and researchers” (Essock et al., 2003, p. 920). The resultant report was authored by fourteen of the self-styled leaders of the EBP mental health movement who magnanimously state that they in “the spirit of science being transparent and welcoming a public discussion . . . offer this collection of concerns [regarding EBPs] . . . hop[ing] that these summaries will be useful to others” (p. 921).
Their report is a confirmation that the criticisms we have raised are shared by many who are affected by EBPs. But this sort of mea culpa exercise seems to be geared for public relations more than anything else, since, after admitting that many problems exist with EBPs, the authors do not suggest revisiting the procedures and methods used to name EBPs or reevaluate their selections. Instead, they praise their original choices, saying that the “National Evidence-Based Practice Project study groups identified six EBPs for community mental health treatment of persons with severe mental illness . . . [which] provide a strong foundation for defining minimal services for people with severe mental disorders” (p. 932). Further, they insist that these EBPs are characterized by “sensitivity to individual differences, by attention to choices and preferences, by client centeredness, by empowerment, by diversity of methods, and by reliance on clinical skills and judgment” (p. 937). Evidence-based practice apparently means “trust us.”
Earlier in this chapter we traced the relentless use of coercion to control the mad in America for four centuries, with each iteration marketed, not as the use of force to manage a disobedient and troubling group, but rather as the application of better and more progressive treatments to aid a group suffering from a serious medical condition. These treatments are presented as having been developed through the latest and most advanced science available in any particular era and progressively building upon previous work to create increasingly more effective treatments that now have arrived in full scientific glory as EBP. We think these claims were bogus in the eighteenth century and we believe they are bogus in the twenty-first century, as we will demonstrate in our review of the most “validated” of the EBPs for serious mental illness, ACT.
The common claim is that assertive community treatment is “widely recognized as an evidence-based practice for adults with severe mental illness” (Bond, Drake, Mueser, and Latimer, 2001, p. 155). ACT appears to be well-credentialed, having built its credibility more than a decade ago on “a research base includ[ing] 25 well-controlled studies” (p. 155). The National Alliance on Mental Illness states that ACT is the most widely replicated and frequently used community treatment for SMIs throughout the world. Only five states in the United States do not have ACT teams, while forty-three states make their Medicaid funds available for its reimbursement (Aron, Honberg, Duckworth et al., 2009). ACT is without question the leading community treatment for SMIs:
Since the deinstitutionalization era began nearly 50 years ago, several models of community-based care for persons with severe mental illnesses have been developed. Of these models, the assertive community treatment (ACT) program has by far the strongest empirical support. (Essock et al., 1998, p. 176)
We will now scrutinize the veracity of these claims and the allegedly convincing evidence for its effectiveness. Originally called training in community living (TCL), ACT was one of those mental health programs developed during the late 1960s and early 1970s to respond to the federal mandate for shifting the locus of care and control of psychiatric patients from isolated institutions into the community (Stein & Test, 1985). It was considered to be an immediate success: soon after its first randomized controlled study (Marx, Test, and Stein, 1973), ACT received the Gold Achievement Award in 1974 from the American Psychiatric Association. Its developers stated that ACT fit closely the prevailing psychiatric disease model and its concomitant reliance on psychiatric drugs: “Congruent with our conceptual model, we tell our patients that indeed we believe they are ill, otherwise we would not be prescribing medication for them” (Stein & Diamond, 1985, p. 272).
ACT originated at Mendota State Hospital in Madison, Wisconsin, in the 1960s and 1970s. Key protagonists in the hospital at the time were: (1) psychiatrist Arnold M. Ludwig, the hospital’s director of research and education; (2) the creators of ACT, psychiatrists Arnold J. Marx, Leonard I. Stein, and psychologist and Professor of Social Work Mary Ann Test; and (3) less directly, clinical social worker Frank Farrelly and psychologist Jeff Brandsma. Farrelly and Brandsma together fashioned and tested at Mendota State a therapeutic approach they called “provocative therapy” (Farrelly & Brandsma, 1974) and influenced the treatment approaches of those involved with ACT.
In 1985 Stein and Test edited a book reporting on the first ten years of the TCL/ACT effort, The Training in Community Living Model: A Decade of Experience. They describe the development of their professional thinking this way:
Ideas rarely arise de novo; they are generally formed from the building blocks of prior knowledge and experience. To become lasting, they must be nourished in an environment that is willing to set aside the accepted attitudes and practices that resist new concepts. . . . In the mid 1960’s . . . several psychiatrists [Marx and Stein] who had just finished their residency joined the hospital staff. These psychiatrists were imbued with the therapeutic zeal frequently found in young, uninitiated physicians. In addition, Arnold Ludwig joined the staff as director of research and education. His first two projects involved many members of the hospital staff. The projects represented . . . an effort to transform the hospital . . . into an institute whose primary goals were research, demonstration, consultation and training. (pp. 7–9)
This quote identifies most of the key TCL/ACT players and describes their intimate involvement in the research conducted at Mendota State after the appointment of Ludwig as director of research and education and suggests that what they learned from these projects informed their understanding and treatment of patients.
The Mendota State researchers, despite their view that their patients are medically ill (a perspective that ordinarily does not hold the patient responsible for the consequences deemed to flow from having an illness), appeared to have entertained if not hostile, at least negative attitudes toward patients. Patients in a locked ward (the STU) at Mendota State Hospital are not described in medical terms but as adversaries:
Professionals have overlooked the rather naive possibility that schizophrenic patients become “chronic” simply because they choose to do so . . . If he so desires, he can defecate when or where he chooses, masturbate publicly, lash out aggressively, expose himself, remain inert and unproductive or violate any social taboo with the assurance that staff are forced to “understand” rather than punish behavior. (Ludwig & Farrelly, 1967, p. 737–741)
These two authors wrote an earlier article (in 1966) which is entitled “The Code of Chronicity.” The code, according to them, is employed by the mad, along with other “weapons of crazyness” (p. 565). They concluded that these patients were:
Obviously . . . not . . . a group of fragile, broken-spirited persons but rather . . . tough, formidable adversaries who were “pros” and who had successfully contended with many different staffs on various wards in defending their title of “chronic schizophrenic.” (Ludwig & Farrelly, 1966, p. 566)
As a result, Ludwig and Farrelly felt that the only medical cure was to coerce the patients to mimic the “sane” behavior of the staff:
To become well patients would have to think, feel, and behave . . . similar to staff. The concept of normality and sanity as therapeutic goals . . . would have to [be] deliberately concretize[d] . . . by insisting that patients employ staff persons as models for behavior. . . . Furthermore, we would not play at democracy in therapeutic community meetings; not the majority, but health and sanity, as defined by staff, would rule. (1966, pp. 566–567, emphasis added)
The psychiatric commitment to use coercion to cure, exhibited throughout the profession’s history, could not be better illustrated than by these experts’ efforts to force their inmates to conform in order “to become well.” The similarity to the later ACT approach, as described by ACT insider, psychiatrist Ronald J. Diamond, is uncanny:
Paternalism was to a large extent accepted with little question. . . . Staff were assumed to know what the patient “needed.” Even the goal of getting patients paid employment was a staff-driven value that was at times at odds with the patient’s own preferences. Current assertive treatment programs continue to be influenced by traditions . . . from this . . . history. Paternalism continues to be reinforced by mandates from the community to “control” the behavior of otherwise disruptive patients. (Diamond, 1996, p. 53)
Leonard Stein, after replacing Arnold Ludwig as the director of research and education at Mendota State Hospital, coauthored a study with “provocative therapy” advocate Brandsma, entitled “The Use of Punishment as a Treatment Modality: A Case Report” (Brandsma & Stein, 1973). The study examined the value of using involuntary electric shock to reduce the “unprovoked” assaultive behavior of a “retarded, adult, organically damaged” (p. 30) twenty-four-year-old woman. This publication appeared during the time that TCL/ACT community research was already well on its way (see Marx, Test, & Stein, 1973) and was apparently part of a line of research focused on force and violence as treatment, begun earlier at Mendota State. Ludwig, Marx, Hill, and Browning (1969) had previously published a single-case study on a paranoid schizophrenic patient, entitled “The Control of Violent Behavior through Faradic Shock.” The authors justified this study by its “uniqueness,” because “this procedure was administered against the express will of the patient” (p. 624, emphasis added). They used an electric cattle prod as the “aversive conditioning agent,” because it was “an excellent device for providing a potent, noxious stimulus . . . capable of producing a faradic shock spike of approximately 1400 volts at 0.5 milliamperes, the resulting pain lasting . . . as long as the current was permitted to flow” (p. 627).
The methodology of Brandsma and Stein’s experiment reveals what can only be termed sadism. To obtain a “baseline” measure (a requirement of single-subject design research) of this patient’s assaultive behavior, she was baited and ridiculed so she would respond aggressively:
The patient was required to sit in an armchair throughout. . . . During the base rate week the staff quickly developed a consistent provocative approach in order to ensure a high frequency of behavior from the patient . . . This consistently involved: 1) ignoring the patient in conversation; 2) refusing to give the patient candy or snacks when others were eating them; 3) denying all requests, for example, during the session if she asked if she would be able to go for a walk that afternoon, she was immediately told, “No you can’t.”; 4) refusing to accept her apologies or believe her promises of good behavior; 5) The . . . female sitting next to her often leading the provocation; 6) using provocative labels for her behavior, i.e., “animalistic, low grade”; 7) discussing family related frustrations, i.e., her mother’s refusal to write or visit, how her dead grandmother would be displeased with her present behavior if she were alive. It should be noted that throughout the program the patient was kept in a seclusion room at all times except when involved in a baseline or treatment session. (Brandsma & Stein, 1973, pp. 32–33)
Brandsma and Stein’s research exemplifies mad science at its worst, by daring to torture an imprisoned, nonconsenting subject and by publishing an article full of scientific misinformation and distortion. Brandsma and Stein cited the classic behavioral study by Azrin and Holz (1966) to support their use of punishment, stating that “our clinical reports back up the more controlled animal studies on punishment. For example . . . Azrin and Holz . . .” (Brandsma & Stein, 1973 p. 36). In fact, the Azrin and Holz had argued that punishment is ineffective as a method of behavioral change, especially for human subjects, listing its primary disadvantages as follows:
The principal disadvantages of using punishment seem to be that when the punishment is administered by an individual, 1) the punished individual is driven away from the punishing agent, thereby destroying the social relationship; 2) the punished individual may engage in operant aggression directed toward the punishing agent; and 3) even when the punishment is delivered by physical means rather than by another organism, elicited aggression can be expected against nearby individuals who were not responsible for the punishment. (Azrin & Holz, 1966, p. 441)
Despite this clear refutation of their brand of behavioral treatment that Brandsma and Stein cited to support their own therapeutic use of an electric cattle prod, they falsely concluded that “the extant literature now supports the assertion that ‘punishment therapy’ is a useful tool to modify certain behaviors” (Brandsma & Stein, 1973, p. 37). Their research demonstrated that “punishment therapy” was not effective. As they report about their subject, “[u]nfortunately the intensity of her now low frequency, occasional attacks was still sufficient to relegate her to a life of relative social isolation” (p. 36) and even a year after the intervention “the punishment contingency continues . . . in seclusion with only a few hours out per day when accompanied by a male aide” (p. 35). The patient was not better off after the coercive treatment and was relegated to permanent solitary confinement.
What is noteworthy in this publication is how easily actions like baiting, punishment, and torture could be applied to a difficult patient by “doctors” and be described as scientific research on “treatment.” The early transformations of control and punishment as treatment at Mendota State appear to have influenced research on ACT over the next several decades.
According to Test (1992), ACT has four essential characteristics:
Core Services Team [made up of 3-5 members, with at least a primary case manager, psychiatrist, and backup case manager per patient]: The team’s function is to see that all the patient’s needs are addressed in a timely fashion. . . . Having one team provide most of these services minimizes the . . . fragmentation of . . . care systems and allows for integrated clinical management. . . .
Assertive Outreach and In Vivo Treatment: An essential ingredient . . . is the use of assertive outreach . . . [staff] reaches out and takes both biological and psychological services to the patient[in the community]. . . .
Individualized Treatment: Because persons with serious mental illnesses . . . are greatly heterogeneous and both person and disorder are constantly changing over time, treatment . . . must be highly individualized. . . .
Ongoing Treatment and Support: . . . even very intensive community treatment models do not provide a cure for severe mental illness, but . . . a support system within which persons with persistent vulnerabilities can live in the community and grow. It appears these supports must be ongoing rather than time limited. (1992, pp. 154–156)
A 2001 article in the journal Psychiatric Services claimed that ACT was to be deemed an EBP because it had shown superiority over alternate treatments:
Research has shown that assertive community treatment is . . . more satisfactory to consumers and their families. Reviews of the research consistently conclude that compared with other treatments under controlled conditions, such as brokered case management or clinical case management, assertive community treatment results in a greater reduction in psychiatric hospitalization and a higher level of housing stability. (Phillips, Burns, Edgar et al., 2001, p. 771, emphasis added)
The clinical effectiveness of any treatment is usually measured in symptom reduction, reduced disability, better functioning, or improvements in behavior, self- or other-rated. What is noteworthy about the quote above is that keeping people out of a hospital or in a community residence is used as the markers of success. It might come as a surprise then that an award-winning “treatment” program made few claims that it improved patients’ clinical condition. In fact, Philips et al. admit that “[t]he effects of assertive community treatment on quality of life, symptoms, and social functioning are similar to those produced by these other treatments” (p. 771, emphasis added). In other words, ACT does not reduce the mad behavior or improve the functioning of the severely mentally ill any more than any other approach. Decades earlier the ACT inventors admitted: “a change in the site of treatment [from the hospital to the community] says nothing about whether the patient’s clinical status or functioning has improved. Some would argue that only the place of a person’s suffering has changed” (Test & Stein, 1978, p. 360).
Nonetheless, ACT aspired to do more. In 1992 Mary Ann Test indicated that they always “target[ed] goals for the model . . . going far beyond the reduction of time in hospitals. Additionally, improvements in patients’ psychosocial functioning and quality of life are sought” (Test, 1992, 164). But over time, the ACT model failed to achieve these clinical outcomes that would be routinely expected of any treatment in medicine. If traditional clinical effectiveness was not achieved by ACT, what was the basis for its purported success? Let’s examine five core claims of success.
Claim #1. ACT significantly reduces hospitalization when compared to alternate treatments.
Evidence. Reduced hospitalization and inpatient treatment costs are the only consistent outcomes found across studies. On the surface, reducing hospitalization rates can be mistaken as reducing symptomatic behaviors and therefore the need for hospitalization. But, in fact, ACT methods have no direct bearing on reducing symptoms or the need for hospitalization. They simply reduced hospital stays by using a fairly strict administrative rule not to admit or readmit any ACT patients for hospitalization, regardless of the psychiatric symptoms, but to carry out all treatment in the community. The comparison group of troubled patients at the same time could be freely readmitted.
Test and Stein (1978) provided an early clue to the importance of program control over hospitalization and discharge: “Community treatment results in less time spent in the hospital. This finding is certainly not surprising since experimental patients were usually not admitted to hospitals initially and there were subsequent concentrated efforts to keep them out” (p. 354). Many ACT articles acknowledge that reduced hospitalization in ACT is the result of administrative rules, not clinical treatment. Scott and Dixon (1995), examining the impact of case management and ACT programs, observe that “the effectiveness of ACT models in reducing hospitalization may be a function of their capacity to control hospital admissions, length of stay, and discharge” (p. 659). Several studies have noted that the length of hospital stay returned to pre-intervention levels when ACT team . . . control of discharge was blocked by hospital authorities” (Craig & Pathare, 1997, pp. 111–112). Finally, Minghella, Gauntlett, and Ford (2002), discussing the failure of some assertive outreach teams in England to reduce hospitalization, write that “[w]hile the teams partly adhered to the ACT model, there were major areas of deviation. The teams had little influence over admissions and discharge” (p. 27).
In short, if one does not allow particular people to be hospitalized, they won’t be. A crucial point to be made here is that the identical type of psychiatric administrative activity is used either to force people into hospitals for treatment (involuntary civil commitment), to prevent them from entering hospitals, or to force people out of them into the community for treatment (ACT). All these approaches are coercive: they do not consider whether any of the patients being forced into the hospital want out or whether those being kept out want in. Client choice is not an option.
Claim #2. ACT is more cost effective than standard interventions.
Evidence. Since hospitalization is by far the more costly treatment, the cost savings are not dependent on specific ACT clinical interventions but on keeping people away from hospitals, which, as we have just reviewed, is a byproduct of the ACT administrative coercion. Cost reduction could occur with any other treatment rigorously pursuing the same objective.
Claim #3. ACT provides significantly greater patient satisfaction.
Evidence. Most people prize their freedom; few prefer to be confined in hospitals. ACT’s clients are the same, but patient satisfaction appears to be independent of distinct ACT activity. The greater autonomy provided by any community treatment (as compared to a locked hospital ward), not the particular interventions of ACT, would explain increased satisfaction. In the Australian study previously mentioned, the patients were surveyed at a twelve-month follow-up: “The majority (80%) of experimental group patients who were not admitted to the hospital were pleased and grateful about it; only 30% of control group patients were pleased and grateful about being admitted to hospital, whereas 39% were upset and angry” (Hoult, 1986, p. 142). Stated differently, “Treatment preference was explored by asking all patients whether they prefer admission to Macquarie Hospital or treatment at home by a community team. The majority of the project (87%) and control (61%) patients preferred community treatment” (Hoult et al., 1983, p. 163, emphasis added). A majority (61 percent) of the group that did not experience the ACT treatment still preferred community treatment rather than incarceration in an institution. In fact, the experimental group reported that the most important elements of the ACT treatment were the availability of staff for frequent caring; supportive, personal contact; and the enhanced freedom—therapeutic elements not specific to ACT (p. 163).
Lending further support, a survey of “patient perspectives” on ACT “ingredients” (McGrew, Wilson, & Bond, 1996) identified in order of preference: “helping relationship, attributes of therapist, availability of staff, and non-specific assistance” as what patients liked most (p. 16, table 1). These attributes are not ACT specific; they apply to all forms of “helping.” The least liked of the twenty-five elements associated with ACT was “intensity of service”—the component most representative of ACT-intrusive philosophy. The survey’s authors, themselves longtime ACT experts, admit, “Somewhat surprisingly, non-specific features of the helping relationship emerged as the aspects of [ACT] most frequently mentioned as helpful” (McGrew et al., 1996, p. 190).
Claim #4. ACT increases [independent community] housing stability (Bond et al., 2001, p. 149).
Evidence. We conclude, in agreement with most other reviews, that the evidence supports this claim. ACT patients, but not control group patients, are more likely to find rooms and apartments in the community, rather than using many specialized residential settings (Test, Knoedler, Allness, Kameshima et al, 1994, p. 4). But just as ACT patients are not allowed to be hospitalized, ACT patients are administratively directed only to “independent” housing. So what is achieved is not a clinical treatment success, as much as an assertive administrative rule to help patients find independent-living settings.
Finally and most importantly:
Claim #5. “The assertive community treatment approach never was, and is not now, based on coercion” (Test & Stein, 2001, p. 1396).
Evidence. One of the rationales which the ACT inventors cited to explain the shift from psychiatric institutional care to community care was the reduction of coercive management and the promotion of autonomy to improve the social functioning of the SMI (Marx et al., 1973). Another was the desire to reduce the harmful effects of institutional living. Test and Stein’s unequivocal rejection of accusations that ACT is coercive (as quoted above) was in response to an article in APA’s community psychiatry journal, Psychiatric Services.
The historical record suggests that the Test and Stein denial is open to debate. For example, here is how Stein (1990) describes the role of the ACT team:
[S]erves as a fixed point of responsibility . . . and is concerned with all aspects of . . . the patients’ lives that influence their functioning, including psychological health, physical health, living situation, finances, socialization, vocational activities, and recreational activities. The team sets no time limits for their involvement with patients, is assertive in keeping patients involved . . . In addition to the day work . . . the team is available 24 hours a day, seven days a week. (p. 650, emphasis added)
This methodology appears highly intrusive. ACT activities may include such coercive moves as becoming the representative “financial payee” of the patient, providing opportunities to blackmail the patients by enforcing medication compliance or threatening to withhold monies belonging to the patient (Stein & Test, 1985, pp. 88–89). This appears to be forcing treatment on ACT patients who do not want it (pp. 91–92). Even bribery may be appropriate ACT treatment: “it might be necessary to pay a socially withdrawn patient for going to the movies in addition to buying his ticket” (Test & Stein, 1976, p. 78).
To validate the use of assertive outreach and treatment, the original ACT researchers rely on two studies, one of which is their own (Test, 1981, p. 80). The other study is by Beard, Malamud and Rossman (1978), who describe their Fountain House outreach program as follows: “Phone calls, letters, and home and hospital visits [were] made by both staff and members. Through such contacts, subjects who dropped out were provided with further information. . . . In those . . . instances when an individual requested that no further contacts be made, his wishes, of course, were respected” (p. 624). Respect for the wishes of people who choose not to be involved in the Fountain House program contrasts with the coercive methods used by Test and Stein (1976):
A staff person attempting to assist an ambivalent patient to a sheltered workshop in the morning is likely to receive a verbal and behavioral “no.” . . . If . . . the staff member approaches the patient with a firm, “It’s time for you to go to work; I’ll wait here while you get dressed,” the likelihood of compliance increases. The latter method allows less room for the patient to “choose” passivity. (p. 77)
Two questions come to mind: why is the patient described as ambivalent, when the patient’s reported behavior indicates a resolute opposition to going to work? Second, why is the patient’s active refusal redefined as “passivity”? The disregard of patients’ expressed wishes and the reinterpretation of their behavior to justify programmatic interventions appear to be characteristics of ACT—in fact it appears to give meaning to “assertive” treatment. The Fountain House model, by contrast, discontinues patient outreach efforts if asked.
Coercion and control, despite Test and Stein’s denial, appear to be integral parts of the ACT model when it appears to be effective. According to the candid admission of Diamond (1996), a close associate of the original ACT group in Madison:
Paternalism has been a part of assertive community treatment from its very beginning . . . Paternalism continues to be reinforced by mandates from the community to “control” the behavior of otherwise disruptive patients. . . . A significant number of patients in community support programs . . . have been assigned a financial payee . . . This kind of coercion can be extremely effective.
. . . Obtaining spending money can be made . . . dependent on participating in other parts of treatment. A patient can then be pressured by staff to take prescribed medication. . . . [T]he pressure to take medication . . . can be enormous. . . . While control of housing and control of money are the most common . . . methods of coercion in the community, [and] other kinds of control are also possible. This pressure can be almost as coercive as the hospital but with fewer safeguards. (pp. 53–58)
The fact is that discussion of ACT coercion is routinely found throughout the psychiatric literature. A large body of literature now addresses the “therapeutic” value of community-based coercion of mental health patients, an ongoing discussion that can be tied directly to the existence of ACT. A 1996 edited book legitimated the study and use of such coercion with the title specifically identifying ACT and its coercive approach: Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law (Dennis & Monahan, 1996). More recently, the importance of conventional psychiatric coercion research has been further validated by a major new book published in 2011, also coedited by John Monahan, Coercive Treatment in Psychiatry: Clinical, Legal and Ethical Aspects. While some psychiatric experts are busy asking “Is Assertive Community Treatment Coercive?” (Appelbaum & LeMelle, 2007), ACT experts acknowledge that “assertive engagement” or “assertive outreach” is a core element of ACT. These concepts are included in the most popular scale for evaluating ACT program replications’ fidelity to the original Madison model, the Dartmouth Assertive Community Treatment Scale (DACTS). Assertive engagement is measured (in DACTS) primarily by counting the frequency of formal coercive legal mechanisms (i.e., mandated outpatient treatment or appointed financial payees). Its developers state transparently that “[i]t should be noted that the criterion for assertive engagement was operationalized in such a way that it emphasized use of legal mechanisms” (Teague, Bond, & Drake, 1998, p. 229). Davis (2002) has suggested that “[c]oercion in assertive community treatment may take formal or explicit form, such as the enforcement of conditions of a treatment order. Usually, however, coercion is less obvious and by extension more difficult for workers to come to terms with” (pp. 245–246). A report prepared in 2000 for the Federal Health Care and Financing Administration and the Substance Abuse and Mental Health Services Administration devotes a whole section to ACT coercion. The report notes that “[w]ithin the context of ACT programs, coercion can include a range of behaviors including, friendly persuasion, interpersonal pressure, control of resources and the use of force. . . . Research generally suggests that coercion may be harmful to the consumer” (LewinGroup, 2000, p. 43). It is noteworthy that “friendly persuasion” is included as an example of “coercion” in a federal report on psychiatric treatment. This appears like a simple error. Or is it in fact part of a strategic effort to broaden the meaning of coercion? Is the inclusion of noncoercive interpersonal activity (friendly persuasion appears to us as an essential ingredient of voluntary talk therapy) in the preceding list of coercive activities an effort to domesticate externally imposed force as treatment? Similar strategic inclusions have occurred in psychiatry before. The most common examples of this are the linguistic efforts to authenticate “mental illnesses” as physical diseases by lumping together problems such as depression and schizophrenia within lists of common neurological disorders or “brain-based disorders” that have identifiable neurological signs, such as Parkinson’s disease or Alzheimer’s disease, though neither depression nor schizophrenia have any such signs.
ACT appears merely as a recent manifestation, adapted to the exigencies of life beyond hospital walls, of the longstanding, coercive strain that has characterized psychiatric interventions with mad persons to this day and that duplicitously assumes the cloak of scientific activity and scientific progress.
Psychiatric practice, by our reading, appears to have lost even the semblance of moral rectitude regarding the employment of coercion. It used to pretend that when men and women of science, motivated by the desire to heal, forced mad persons to submit to their ministrations, this was not coercion but medical treatment. Today such a pretense no longer seems necessary. A thriving body of research, supported among others by the NIMH and the MacArthur Foundation (Dennis & Monahan, 1996, p. 15), fully explores the therapeutic value of coercion. The deprivation of autonomy and freedom is increasingly being redefined as a therapeutic tool rather than a violation of human rights.
When we searched the Medline database up to and including 2007 for indexed articles about psychiatric coercion (using coercion, outpatient commitment, and civil commitment as independent key words), we identified 796 articles. Only 22 articles were published before 1970, in contrast to 665 articles between 1991 and 2007 (39 articles a year). The first noticeable spike in publications occurred in 1971, around the time community treatment became a focus of research. In the abstracts, we note only a handful of voices dissenting from the general view that coercion, though “controversial,” is ultimately just another therapeutic mechanism deserving examination.
Indeed, some eminent psychiatric scholars have recently unabashedly defended the use of psychiatric coercion, without any pretense that it is somehow a form of medicine. It is just plain coercion. Jeffrey Geller (2012), professor of psychiatry and director of public sector psychiatry at the University of Massachusetts Medical School, asserts that “the psychiatrist’s option to employ coercion is an integral component of functioning in this recovery oriented paradigm . . .” (p. 493, italics added). Geller is candid about the level and forms of coercion in outpatient treatment:
Coercive interventions, with little or no review by anyone other than a physician or a treatment team or administrator, are rampant in entitlement programs; they include leveraged housing (for example, “If you want to live in this residence, you have to take your medication as prescribed and go to a day program”); representative payeeships; “bargained” psychopharmacologic regimens (for example, “You take your antipsychotic and you can have a benzodiazepine”); waiver of civic responsibility (for example, jury duty); treatment “contracts” through Individual Service Plans; and threats of emergency detention (for example, civil commitment). (p. 494)
Geller proposes that regardless of psychiatric status, individuals routinely get coerced in the community, which he finds equivalent to “prevention and treatment”:
A person who repeatedly gets stopped for speeding loses his or her license and must attend classes to get it back (treatment). . . . Someone who disrupts a public event is removed from the venue (treatment, behavior modification). If you park illegally, the car is towed and you get fined . . . (treatment and prevention). (p. 495)
After medicalizing drivers’ education, Geller feels he must now demedicalize forced treatment by medical doctors: “If a person behaves in a way that is dangerous to others, and the danger can be mitigated by psychiatric treatment, the person gets treatment. . . . It is coercion in the same way that others in the community are subjected to coercion. It is not coercion because of ‘psychiatric status’: it is an intervention to address behavior. Just as we all experience” (p. 495).
But Geller is clearly mistaken here. He confuses public laws that all citizens must obey to avoid punishment with coercion that only the mad endure precisely because they are deemed mad by psychiatrists. Society does not enact special laws to coerce speeding drivers on the basis that they suffer from a mental illness that is responsible for their speeding. But society coerces dangerous people into psychiatric treatment only on the basis of special laws that require a diagnostic evaluation by a psychiatrist. Actually, Geller is on to something, but not what he intended. Geller repeats that coercion occurs everywhere in society, not just in psychiatry, because he wants to make psychiatric coercion palatable. But as he makes this argument, he is forced to recognize that no existing psychiatric treatment can compete with coercion: “the notion that we can eliminate all coercive interventions by using our current array of psychopharmacologic agents, psychotherapies, and rehabilitation interventions is without precedent” (p. 494). Undoubtedly, Geller is admitting that psychiatry relies on a foundation of coercion.
Another eminent psychiatric scholar, Allen Frances (2012), best known as the Chair of the DSM-IV Task Force and whose views on diagnosis we discuss in chapters 4 and 5, goes even further than Geller in acknowledging the nature of coercion in psychiatry and, probably unintentionally, deals a fatal blow to the claim that coercion has anything to do with medical treatment.
In a reply to an article by psychologist Jeffrey Schaler (2012), Frances writes: “I agree completely with Schaler and Szasz that mental disorders are not diseases and that treating them as such can sometimes have noxious legal consequences.” He singles out “schizophrenia”: “. . . mental disorders are constructs, nothing more but also nothing less. Schizophrenia is certainly not a disease; but equally it is not a myth. As a construct, schizophrenia is useful for purposes of communication and helpful in prediction and decisionmaking—even if . . . the term has only descriptive, and not explanatory, power” (p. 1). If schizophrenia is “not a disease,” as psychiatry has long claimed, Frances must come to terms squarely with the nature of psychiatric coercion: “I have evaluated [patients who ‘desperately needed to be protected from hurting themselves or others’] many hundreds of times. While it is never comfortable to coerce someone into treatment, it is sometimes the only safe and responsible thing to do, and occasionally it is life saving. . . . Coercive psychiatry, however unpleasant, must be available as a necessary last resort when nothing else will do” (p. 2). Frances’ makes the simple case for psychiatric coercion, namely, that the functioning of society requires force when the intermediary social control functions of persuasion and seduction fail (Peckham, 1979). Normally, the imposition of force or violence is entrusted to soldiers and policemen. When psychiatrists or mental health professionals defend and engage in coercion, they are essentially police posing as doctors or therapists.
The use of coercion to control the mad in America for four centuries has continually been marketed not as the use of force to manage a disobedient and troubling group, but as the application of better and more progressive treatments to aid a group suffering from a serious medical infirmity. The presumed treatments are presented as having been developed through advanced scientific techniques and building on previous work to create increasingly more effective interventions. Over the last couple of decades, many of these interventions have been anointed as “evidence-based practices” (EBPs), as we have discussed in this chapter.
It is apparent that coercion is increasingly seen in psychiatry and in other mental health professions and the legal profession as an acceptable form of treatment needing no critical scrutiny beyond meeting the technical criterion of effectiveness. “Psychiatric scientific authority” has transformed coercion into a routine intervention, leaving the average psychiatric researcher to focus on the technical details of the issue (i.e., how well does coercion “work” to produce this or that outcome?) and to lose sight of larger moral issues regarding human freedom, dignity, and autonomy (Cherry, 2010); of the perspectives of those subject to coercion (Oaks, 2011; Olofsson & Jacobson, 2001); and even of the narrower issues of whether coercion should ever be used as a “tool” of helping professionals, free of the safeguards that surround its uses outside of the mental health system.
As we have suggested in this chapter, the two roles of psychiatry—that of social management (involuntary psychiatry) and therapeutic helping (voluntary psychiatry) of the mad—are irreconcilable. In order for one to work the other cannot. Effective social management may require a coercive social technology (ultimately, incarceration) to enforce compliance if social seduction (i.e., friendly persuasive rhetoric or incentives) fails. The availability of psychiatric coercion greatly constrains the choices the mad have about their treatment. Police are not therapists, even when they act to deescalate anger and potentially violent behavior. But psychiatrists, rhetorically equipped by medicine—doctor, mental illness, diagnosis, treatment—can use police-like coercion over the mad. To us, force is force, regardless of how it is labeled. The intentions of those who wield force may be benevolent, but force hurts equally—whether we call it punishment or “punishment therapy.”
We believe that a voluntary psychiatry and an involuntary psychiatry cannot both be the same enterprise, evaluated by the same criteria, scientific or otherwise. The small number of dissenting voices concerning the legitimacy of psychiatric coercion does not indicate the rightness of the approach, only the numbing of moral and critical faculties. The historical role of punishment of the mad has conveniently been imbedded in the medical model because of the ways in which control and coercion easily slip into the benevolent rubric of treatment for the relatively powerless and vulnerable. Outside hospital walls, control and coercion have been embraced by various professionals and institutions in society, justifying it as a relatively small price to pay to ensure proper “medical” treatment of distress and misbehavior. The next two chapters scrutinize the evolution of one “scientific” tool of psychiatry that converts personal turmoil into disease and the socially misbehaving into medical patients—the expanding dictionary of psychiatry, the Diagnostic and Statistical Manual of Mental Disorders.
1.The famous study by Erving Goffman described in his 1961 book Asylums discusses the toxic effects of being confined in “total institutions.” Based on Goffman’s field observations of ward behavior at St. Elizabeth’s Hospital in Washington, DC in 1955–1956, it makes not a single allusion to the use of major tranquilizers. The first of these drugs, Thorazine was commercially released in the United States less than a year before, in mid-1954. St. Elizabeth’s is best known today for detaining the infamous John Hinckley Jr., who attempted to assassinate President Ronald Reagan in 1981.
2.Think of the payment of income taxes. Because the Internal Revenue Service is able to enforce the tax code through criminal and civil sanctions, it would be naïve to conclude that people pay taxes “voluntarily.”
3.The rubric of seriously mentally ill or having a serious mental illness (SMI) (sometimes also referred to as “major mental illness” or “serious and persistent mental illness”) has been formalized by the federal government. It began to be used in the 1990s. The government definition of SMI “includes all [DSM] diagnoses, substantial disability, and no required duration (some estimates show this [label] as encompassing 5–7% of the U.S. population ages 18+ [about 3.3 million adults])” (Kuntz, 1995, p. 6). What individuals placed in this category share as a group, despite their differing DSM diagnoses, is their “substantial disability,” which justifies psychiatric intervention. A “substantial disability” could be physical, such as being blind or having a chronic physical disease such as diabetes or severe coronary disease that may limit full social participation. In this instance, however, “substantial disability” means lacking skills that cause serious and “specific limitations in work, school, personal care, social functioning, concentrating, or coping with day-today [sic] stress” (p. 6). Most SMIs are unemployed and may show little ability in maintaining traditional relationships. They depend on others to take care of them because they appear unable to do basic life chores such as manage their funds, use public transportation, launder their clothes, cook, or dress conventionally (Test & Stein, 1978). As psychiatric epidemiologists Ronald C. Kessler and Shanyang Zhao explain, “Epidemiologic information about the prevalence of individual disorders is much less important than . . . the prevalence of functional impairment, comorbidity, and chronicity” (1999, p. 77). The terms comorbidity and chronicity mean having several personal difficulties that have lasted for a long time.
4.The counting of patient care episodes tracked by the federal government since 1955 is a duplicate count, since a person may be admitted to more than one type of service or can receive the same service more than once in any one year. The number of individuals who receive multiple service episodes is unknown, so we are unable to have a total unduplicated count of the number of persons under care in any one year.
5.EBM is clinical epidemiology on steroids. David Sackett, EBM’s most well known developer explains: “Clinical epidemiology has played a central or major role in five recent evolutions (some say revolutions) in healthcare: in evidence generation, its rapid critical appraisal, its efficient storage and retrieval, evidence-based medicine, and evidence synthesis. As more and more clinicians, armed with the strategies and tactics of clinical epidemiology, cared for more and more patients, they began to evolve the final, vital link between evidence and direct patient care. Building on the prior evolutions, and manifest in clinically useful measures and often incorporating the patient’s own values and expectations, the revolution of Evidence-Based Medicine was introduced by Gordon Guyatt. Since its first mention in 1992, its ideas about the use (rather than just critical appraisal) of evidence in patient care and in health professional education have spread worldwide, and have been adopted not only by a broad array of clinical disciplines but also by health care planners and evaluators” (2002, p. 1164).
6.Clinical treatment effect is defined as some specified non-administrative clinical/biological/behavioral component(s) of a treatment program that can motivate or cause internalized/volitional change, or the “acquisition of coping skills” by clients, which leads to clients’ improved functioning that results in reduced hospital stays and greater “independent” community tenure in a community mental health program such as ACT.
7.The Cochrane Collaboration is the leading organization carrying out and maintaining a database of EBM systematic reviews. It does this through voluntary work groups whose members apparently are only cursorily checked for expertise before joining. As their website informs the curious:
NOTE: Membership of a Cochrane group is not based on formal qualifications. There are no membership fees. The key requirements are that you:
•have suitable skills (and willingness to learn new ones);
•can volunteer some of your time over an extended period;
•support the aims of the Collaboration; and
•share the Collaboration’s spirit of goodwill. (Cochrane Collaboration, n. d. Retrieved from www.cochrane.org).
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