(2002). Ethical Human
Sciences and Services, 4 (1), 3-16.
W.
H. Auden (1968)
Programs of Assertive Community Treatment (ACT) are aimed at individuals labeled as “severely mentally ill”. According to two ACT experts, including psychiatrist Leonard I. Stein, one of the inventors of this approach, ACT
…is best
conceptualized as a service delivery vehicle or system designed to furnish the latest,
most effective and efficient treatments, rehabilitation, and support services
conveniently as an integrated package. …ACT services are mostly delivered “in
vivo,” that is in the community where clients live and work. (Stein & Santos, 1998, p. 2)
ACT has been researched for nearly 30 years. It began as a program called Training in Community Living (TCL):
Training in Community Living was the name given to the original ACT program; the name change took place many months into the experiment when it became clear that the program was doing much more than training and that the staff had to be quite tenacious in their work with clients. …The program was “assertive”; if a patient did not show up for work, a staff member immediately went to the patient’s home to help with any difficulty that might be causing the problem. …Medication was routinely used for persons with schizophrenia and manic-depressive disorders. (p. 20, emphasis added)
Stein and
No psychosocial intervention has influenced current community mental health care more than ACT. It has truly revolutionized how we provide services to help people suffering from severe mental illnesses … Further, the model is the most widely researched and validated service system available for the care of this group of disabled individuals. (1998, p. 3)
As of the year 2001, there were over 250 research articles on ACT in the PsycINFO database with 34 states using ACT or an adaptation and consuming well in excess of 160 million dollars per year. This apparent validation of the approach has led to a national effort begun in 1996 by the National Alliance for the Mentally Ill (NAMI)-- an organization made up of family members of psychiatric patients founded in 1979 in Madison, Wisconsin (Mosher & Burti, p. 343), the original site of TCL—and the TCL inventors to establish a national nonprofit agency (Allness & Knoedler, 1998) with the following agenda:
Design and
implement a means of rapid and effective replication of the PACT model of ACT;
Promote a
consensus among public mental health authorities, advocates, and service
providers for adoption of national standards to set minimum criteria for ACT
programs; and
Influence
state and local mental health authorities that have not already done so to
adopt ACT as a core program within their service delivery system.
To carry out the work of the NAMI/PACT
Initiative, a new organization will be established, Programs of Assertive
Community Treatment Incorporated (PACT, Inc.). PACT Inc. will be a private,
nonprofit corporation with national focus and representation of consumers,
family members, clinicians, administrators and researchers dedicated to the
dissemination of the PACT model as the gold standard of ACT. (Community Support Network News, 1997,
p. 10, emphasis added)
Given the number of publications, the expert consensus opinion, the political advocacy by supporters and the federal financial support all seeming to confirm the success of ACT, one could expect that no reasonable concern remains as to the efficacy of this program to
…lessen psychoses (duration,
intensity, frequency), maintain a substance free lifestyle, maintain decent and
affordable housing in a normative setting, minimize involvement with law
enforcement and criminal justice, acquire and keep a job, maintain good general
health status, [and ] meet other individual goals. (Stein & Santos, 1998, p. 2)
Indeed, one of the latest articles to appear in Psychiatric Services, a flagship journal of the American Psychiatric Association, is titled, “Moving Assertive Community Treatment into Standard Practice” (Phillips, Burns, Edgar, Mueser, Linkins, Rosenheck, Drake, & McDonel Herr, (2001).
However, when critically evaluated, the empirical evidence contradicts this vast justificationary confidence. I have elsewhere offered an analysis of all the major claims of ACT programs (Gomory, 1998, 1999) and have shown that the statistically significant findings putatively favoring these programs are not the result of ACT-specific technology but are clearly due to such factors as:
tautological
outcomes (for example reduced hospitalization) based on administrative rules
differentially applied to PACT and CONTROL groups, or are misattributions of
worker activity as patient outcome (in employment), or are based only on data
supporting various outcomes and the ignoring or minimizing [the] negative
results which contradict such claims, or are based on manipulation of data to
indicate significance for variables which are not supported by the data (by for
example collapsing various outcome variables some of which are statistically
significant, but are tautological, like number of hospital stays, and some
which are not statistically significant but empirically important like less
homelessness, or less time spent incarcerated, and suggesting that the
significance found [derived from the tautological components] indicates
treatment effectiveness for the non tautological components). Finally the
conceptual analysis of this model demonstrates that this model is coercive and
may lead to harm (excessive suicide among its treatment population for
example). (Gomory, 1998, abstract)
ACT and Coercion
Researchers and psychiatric survivors
have pointed out that ACT is highly coercive. For example, Diamond (1996),
intimately familiar with ACT, pointed out that, along with various similar
mobile, continuous treatment programs, [ACT] has made it possible to coerce a
wide range of behaviors … Paternalism has been a part of assertive community
treatment from its very beginning” (pp. 52-53). On the other hand, its
proponents contend that ACT, like any other treatment model “has some potential
to be used in a coercive manner” (Phillips et al., 2001, p. 777), but that
coercion is only an unfortunate result if the program is misused.
One of the difficulties of addressing such questions rigorously in the field of mental health is that its professional knowledge tends to be ahistorical; given the enormous practical importance of this knowledge, little critical interest exists among mental health workers or academics for reviewing how psychiatric concepts, diagnoses, diseases or treatments evolve or develop over time (Bentall, 1990; Boyle, 1990; Szasz, 1976). The historical review of the issue of ACT coercion, how it was initially conceptualized and refined over time by the consensus experts, can provide important information for analysis bearing on the validity of ACT and can help in understanding the professional development (the learning history) and subsequent work of such professional authorities. According to Karl Popper (1979), the historian’s task is
to reconstruct the problem situation as it appeared to the
agent, [so] that the actions of the agent become adequate to the situation. …
Our conjectural reconstruction of the situation may be a real historical
discovery. It may explain an aspect of history so far unexplained; and it may
be corroborated by new evidence, for example by the fact that it may improve
our understanding. (p. 189)
I propose to do this by an analysis of the ACT originators’ publicly available
writings and by testing their ideas against the particular era’s best empirical
research in an attempt to falsify the originators’ assertions. This approach is
associated with fallibilistic critical thinking explicated elsewhere (Gomory,
2001a, 2001b).
In
this article I contend that the ACT model is innately coercive and rests on a
view of mental health patients held by its developers as aggressive, willful
actors who use various “weapons of insanity”
in an unflagging war of attrition against staff’s therapeutic efforts. The “hard core” patients are those who have successfully met and worn down staff group after staff group. (Ludwig & Farrelly, 1966, p. 565)
ACT clients are forced by aggressive workers to comply
involuntarily with program demands and this activity results tautologically in
the misattribution of worker behavior for that of the client (i.e., client is
forced to show up at an employment site and is “helped” to stay there, which is
then counted as a day spent by the client in voluntary employment for the
purpose of ACT validation)
In the early stages
of PACT, consumer empowerment was not a serious consideration …it was designed
to "do" for the client what the client could not do for himself or
herself. Staff were assumed to know what the client
"needed." Even the goal of getting clients paid employment was a
staff driven value that was at times at odds with the client's own preferences....
A significant number of clients 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 client can then be pressured by staff to take
prescribed medication…. The pressure to take medication … can be enormous....
Housing is often contingent on continuing a particular treatment program or
continuing to take medication. While control of housing and control of money
are the most common … methods of coercion in the community other kinds of
control are also possible. (Diamond, 1996, pp. 53-58)
In a coercive climate, forced or imposed client change
is passed off as internalized or learned client change (Gomory, 1998, 1999).
The ACT technology does not do what
its promoters claim for it and other interventions are available which do not
present the additional burden of the possible adverse effects of ACT (Gomory,
1998, 1999). Coercive measures may result in involuntary compliance but may not
win the hearts and minds of those so treated. As I will show in this paper, the
development of the original model of ACT, Training in Community Living (TCL),
and its coercive core was strongly influenced by the early experiences of its
inventors doing research and providing community mental health treatment in a
Wisconsin state mental hospital. These experiences defined TCL founders’ view
of mental illness and of those who “suffer” from it, and have shaped the nature
of the theories and methods the founders applied in the development of the TCL
model. To evaluate whether or not coercion is the very essence of ACT, I offer
the following review of the historical record of the developers of this program
as they worked at
The Early Coercive Activities
of TCL Founders and of Their Teachers
The mainstream mental health historian Gerald Grob has
provided a useful description of some circumstances characteristic of the
problem situation in psychiatry between the two world wars that provided the
framework which influenced our ACT developers when they began their careers
some 20 years later,
Having
been trained and socialized as physicians, institutional psychiatrists were
receptive to somatic therapies that went beyond custodial care of patients. The
autonomy and independence enjoyed by physicians also precluded any legal or
informal barriers that might have been imposed against the introduction of novel
therapies whose effectiveness was questionable. … The receptivity toward
therapeutic innovation was understandable. In one sense it grew out of
psychiatry's attempt to emulate the alleged successes of scientific medicine. Just as surgery symbolized the success of scientific medicine, so
too novel psychiatric interventions would demonstrate the specialty’s ability
to influence the outcome of mental diseases (Grob, 1983, pp. 289-291).
The relevant Mendota State professionals
who impacted ACT development are (1) psychiatrist Arnold M. Ludwig, (2) the
inventors of ACT, psychiatrists Arnold J. Marx, Leonard I. Stein, and
psychologist and Professor of Social Work Mary Ann Test, and (3) somewhat less
directly clinical social worker Frank Farrelly and psychologist Jeff Brandsma
who together created a therapeutic approach called “provocative therapy” which
was developed and tested at Mendota State (see Farrelly & Brandsma, 1974).
Most of these individuals began their work at
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. (p. 7)
Stein and Test
describe in the previous quote and the one following, what they believe was
valuable about their experience at
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.
One
of Ludwig’s projects involved the formation of a Special Treatment Unit (STU),
a research unit whose primary goal was the development of new ... treatment
techniques for chronic schizophrenic patients that could reduce or otherwise
modify the chronicity that these patients had established. Through the programs
of the STU, Ludwig, Marx, and Test demonstrated that a variety of novel psychosocial
treatment techniques could make an impact on previously unresponsive patients
and significantly enhance their in-hospital functioning. .... When Ludwig left
in 1970 ... Stein took over his position as director of research and education,
and Marx and Test assumed leadership of the STU. These changes in leadership
made possible a ... shift in the direction that ... STU programs would take.
... The new project, ... Prevention of
Institutionalization Project (PIP) was an extension and outgrowth of findings
from the STU’s research treatment programs for chronic schizophrenic patients.
It extended what had been learned about chronicity and its treatment to ...
prevention of chronicity. (pp. 7-9)
This quote
establishes the intimate involvement of all the creators of TCL in the research
done at
Client Descriptions
It
is becoming fashionable to view mental patients, especially chronic
schizophrenics, as poor, helpless, unfortunate creatures made sick by family
and society and kept sick by prolonged hospitalization. These patients are depicted
as hapless victims impotent against the powerful influences which determine
their lives and shape their psychopathology. Such a view dictates a treatment
philosophy aimed at reducing all the social and institutional iniquities
responsible for the patient’s plight. However, in the process of leveling the
finger of etiologic blame for the production and maintenance of chronic
schizophrenia, theoreticians and clinicians have neglected another culprit--the
patient himself. Professionals have overlooked the rather naive possibility
that schizophrenic patients become “chronic” simply because they choose to do
so. … In our own experience, the problem is not so much modifying factors
outside the patient, but rather in changing certain patient attitudes and consequent
behaviors … 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)
Ludwig and Farrelly
(1966) identified what they describe as the “Code of Chronicity” through the
research conducted in the STU:
Implicit
in our discussion of the “code” are five important clinical “facts” which, we
believe, underlie the behaviors of chronic schizophrenics. First, these
patients can use their insanity to control people and situations. Second, they
have an indomitable will of their own and are hell bent on getting their way. Third,
one of the basic difficulties in rehabilitating these patients is not so much
their “lack of motivation” but their intense, negative motivation to remain
hospitalized. Fourth, insanity and hospitalization effectively pay off for
these patients in a variety of ways. Fifth, these patients are capable of
demonstrating an animal cunning in provoking certain reactions on the part of
staff, family, and society at large which guarantee their continued
hospitalization and its consequent rewards … in this article we shall term them
the “weapons of insanity.” (Ludwig & Farrelly, 1967, p.738)
The researchers found these
patients to be
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).
The treatment for such “tough
adversaries” as mandated by Ludwig and Farrelly was remarkably similar to the
powerful coercive paternalism practiced in ACT:
To
become well patients would have to think, feel, and behave as persons, similar
to staff. The concept of normality and sanity as therapeutic goals were too
intangible and vague; we would have to deliberately concretize these concepts
by insisting that patients employ staff persons as models for behavior. Despite
our visible faults, foibles, and inconsistencies, we would expect patients to
“be like staff – warts and all.” Furthermore, we would not play at
democracy in therapeutic community meetings; not the majority, but health and
sanity, as defined by staff, would rule. (pp. 566-567 emphasis added)
Compare Ludwig and Farrelly’s description of STU treatment to a description of TCL from a sympathetic insider, psychiatrist Ronald J. Diamond:
In the original PACT research
project that began more than 20 years ago in
Treatment Approaches used by this group
Stein, the
Director of Research and Education at Mendota State Hospital in 1973, by which
time TCL/ACT research was well on its way (see Marx, Test, & Stein, 1973),
co-authored a study with the “provocative therapy” advocate Brandsma entitled,
“The Use of Punishment as a Treatment Modality: A Case Report” (Brandsma & Stein, 1973). This
study examined the value of using electric shock by means of a cattle prod
without patient consent, as punishment to reduce allegedly unprovoked
assaultive behavior of a “retarded, adult, organically damaged” (p. 30)
24-year-old woman. This single case design study was a follow-up to Ludwig,
Marx (one of the ACT originators), Hill and Browning’s (1969) study of the use
of electric shock on a paranoid schizophrenic patient, “The Control of Violent Behavior Through
Faradic Shock.” These authors justified this last study by its “uniqueness.”
They listed four attributes of uniqueness, the third of which was “the fact
that this procedure was administered against the express will of the
patient” (p. 624, emphasis added). The selection of the cattle prod as the
“aversive conditioning agent” of choice by the STU researchers in both studies
was explained this way:
There were a number of reasons
for choosing the cattle prod as the means of delivering the aversive stimulus
or punishment. From a technical standpoint, this instrument (Sabre-Six model,
Hot Shot Products Co.) seemed to represent an excellent device for providing a
potent, noxious stimulus. It was capable of producing a faradic shock spike of
approximately 1400 volts at 0.5 milliamperes, the resulting pain lasting only
as long as the current was permitted to flow. … Moreover, when compared to the
dangers and relative unpredictability of onset and duration of action of other
aversive agents, such as emetic and muscle paralyzing drugs this instrument was
far safer and could be applied in a more specific manner with a minimal time
lag between appearance of the undesirable behavior and the aversive stimulus.
Also from a practical standpoint, the instrument was portable, inexpensive and
easy to use. (Ludwig et al., 1969,
p. 627)
Prior to Brandsma
and Stein's “experiment” the “organically damaged” subject named “Carol”, while
at an another institution, had been
secluded ... permanently and [had received] various drug
therapies including Mellaril, Prolixin, Stelazine, Compazine, Phenobarbital,
and Dilantin. These efforts failed to significantly affect her behavior and ...
Carol was transferred to ... the state hospital [
At
1) High doses of Phenothiazines and
combinations of phenothiazines: Results: no apparent effect on her behavior. 2)
Primidone in the vain hope that her attacks represented adherent psychomotor
seizures. .... 3) Dexedrine in the hope that the paradoxical inhibition often
found in hyperactive children would result. Result: the patient got “high,” but
there were no affects on her assaultive behavior.[1] 4) Daily
electroconvulsive therapy [twenty sessions]. Results: she became progressively
more aggressive. (Brandsma & Stein, 1973, p. 31)
Evidently, these
institutions were not providing thoughtful, high quality treatment, or even
“standard” treatment based on empirical research (see Gelman, 1999, for the
medication treatment research history on schizophrenia), but rather arbitrarily
throwing every available chemical and physical agent (most of them highly toxic
and dangerous) at this brain damaged individual who had been institutionalized
from the age of 9 months, to make her stop contextually problematic behaviors
which were likely, due to her real physical problems (which included abnormal electroencephalograms,
total Wechsler IQ score of 47, difficulties in moving about, partial deafness,
history of grand mal seizures, possible tardive dyskinesia), to have been out
of her control (Brandsma & Stein, 1973, p. 31).
The methodology of
the experiment itself reveals how the authors approached another human being. To get a “baseline” measure of this
brain-damaged patient’s assaultive behavior, she was baited and ridiculed in
order to get her to react aggressively,
During the
first session heavy canvas mittens were placed on the patient. ... The staff
(five or more) people would sit very close to patient with a young female
within striking distance. 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 and be generalizable to the frustrations she would
encounter outside of treatment. 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 above mentioned 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, p. 32-33, emphasis added)
In sum, rude, aggressive,
artificial incitement by the staff was used to provoke an angry response from
the patient; this elicited behavior then was used as a representation of the
allegedly natural unprovoked, “baseline” assaultive behavior of the client. A
true baseline for assaultive behavior would have to have been collected when it
occurred, in situ, without artificial provocation by staff.
The
administration of involuntary electric shock[2]
as punishment is a clear human rights violation, even in the case of war. This
“experiment” on a lifelong institutionalized person who is organically
diminished due to repeated grand mal seizures and suspected brain damage
(Brandsma & Stein 1973, p. 31), is reminiscent of the pseudo-scientific
justifications for the inhumane experimentation on the frail, the deviant, and
the racially impure during the Nazi era in Germany (Szasz, 2001, pp. 144-150).
Brandsma and Stein’s research is especially troubling because “punishment” had
by this time (1973) been shown to be ineffective in increasing desired
behaviors in human subjects (Azrin and Holz, 1966, pp. 438-443). Ironically,
Brandsma and Stein cite the Azrin and Holz source to support their use of
punishment: “These clinical reports back up the more controlled animal studies
on punishment. For example … Azrin and Holz” (Brandsma &
Stein, 1973 p. 36). In fact, Azrin and Holz’s classic review argued the
opposite, that punishment is ineffective in many situations, especially
those involving human subjects, as a method of behavioral change. These authors
actually argued that punishment has many disadvantages,
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 where not responsible for the punishment. These three
disadvantages seem especially critical for human behavior since survival of the
human organism appears to be so completely dependent upon the maintenance of
harmonious social relations. …We may conclude, therefore that the disruption of
social behavior constitutes the primary disadvantage to the use of punishment. The
changes in the punished response per se appear to be distinctly secondary in
importance to the social products of the use of punishment. (Azrin &
Holz, 1966, p. 441 emphasis added)
Despite the clear
refutation of their claims in the very article Stein and his co-author cite as
support for using a cattle prod for their brand of “behavioral” treatment, they
go on to argue that as a result of their research,
The extant
literature now supports the assertion that “punishment therapy” is a useful
tool to modify certain behaviors. … An ethical issue arises when it is
contemplated for patients who do not volunteer for it as in the present case.
Volumes can be written on that question. It seems to us, however, that when the
patient’s behavior is physically dangerous … it does seem ethical to utilize
this technique with professional if not familial or personal consent. (Brandsma & Stein, 1973, p. 37)
But a close reading
of their actual results demonstrates that the “punishment therapy” was not
effective.
Unfortunately the
intensity of her now low frequency, occasional attacks was still sufficient to
relegate her to a life of relative social isolation. (p. 36)
The researchers
declared rationales for using the cattle prod in the first place—Carol’s
violent behavior and her social isolation—both continued, even one year after
the experiment:
The punishment
contingency continues, Carol now continues in seclusion with only a few hours
out per day when accompanied by a male aide (p. 35).
The client was left
no better off after the coercive “treatment” than before and perhaps even worse
off by being relegated to permanent solitary confinement.
Special Treatment Unit
Research Publications
Overall the papers reporting on STU research activities cited by Stein and Test (1985) make for fascinating, if chilling, reading but are difficult to summarize briefly. A review of these articles suggests that the researchers followed their personal whims in deciding to what they should subject the captive STU clients. To obtain the full flavor of the researchers’ attitude toward the inmates requires extensive quotation from their work. For example, in one article, Ludwig (1968) described an artificial social system concocted by STU researchers to propel 16 male and 14 female patients who were residing in the STU, into “sanity” - that is, the researchers’ sanity:
Rather than
settle for the unhealthy and unstructured social system of patients, we
decided to create a new artificial system based on certain rational
principles of responsibility and sanity. Within the framework of this
artificial patient society, we wanted to minimize reinforcement for crazy and
maladaptive behavior and to maximize the rewards for responsible, healthy
behavior. Since we felt it would be helpful for patients to gain a clear
conception of where they stood in relation to other patients in terms of
sanity, we constructed a social caste and class hierarchy
consisting of seven separate levels. This artificial social system was designed
to encourage vertical mobility, whereby patients could move up or down the
levels depending on scores they received on their weekly behavior rating. The
privileges and responsibilities of patients are strictly contingent upon their
weekly social level. (p. 391, emphasis added)
Overall it appears that this early
pre-TCL research sets the methodological tone for all the future research. No validity measures were
reported for any of the numerous instruments described in this study. Ludwig
(p. 396) did report a very high (.95) inter-rater reliability for one
instrument, the STU Behavior Report, and claimed a study was done to
ascertain it. He provided no citation for such a study or the methodology used.
This behavior report (Chart D, Ludwig, 1968, p. 392) utilized a points system
ranging from 0 to 4, for various sets of behaviors. This chart is reproduced in
Table 1. Table 1 reveals the subjective and prejudicial nature of the various
“behavioral” categories. For example, the awarding of 0 points, a low score
(bad), to men for “queer” behavior (undefined), and a high score (good) of 4
for “masculine” behavior (undefined) or similarly for women, 0 points for
“lesbian” behavior (bad) and 4 points for “feminine” behavior (good) discloses
the biases held by the clinicians about sexual behavior.
These
behavioral ratings were made by the clinicians. Depending on the weekly totals,
which could range from 0 to 100 points, the clients were put in one of the
seven “social castes” each week with their commensurate rewards and punishments
(see Ludwig, 1968, Chart E, p. 393). No criteria were provided as to how these
assessments were made. Ludwig did write that:
Where disagreement concerning particular
[behavior] ratings occurred among the staff, a vote was taken in the presence
of the patient - the patient receiving the majority staff rating. (1968, pp.
391-392)
Another example of the approach
employed by the researchers is the name they gave to one of the social levels
(1968, see charts E & F, p. 393 & p. 395 respectively):
In order to handle certain forbidden patient behavior … we constructed a special punishment category … We christened this level the “Mortal Sin” category. This category was reserved for patients who exhibited certain tabooed behavior – namely provoking or initiating fights, elopement from the hospital, fornicating, or performing perverted sexual activities on the ward. (p. 394)
For a “mortal sin”, the following
immediate restrictions applied:
Discussion
From the
potpourri of experiments carried out by the STU staff emerges a bewildering
lack of ethics, logic, empirical coherence, scientific reliability or validity. It
appeared to be no problem for these researchers to replace science with the
methods of popularity contests (behavioral contingency points awarded to STU
clients by worker consensus, see Ludwig, 1968, pp. 391-392). The kinds of
coercive and intolerant approaches exemplified by these “research” efforts
speak for themselves as to their social and therapeutic usefulness. They have
none. The treatment methods and assessment instruments used were arbitrary,
subjective and biased, without any credible evidence offered by the authors for
their use or their reliability and validity. The authors simply declared the
scientific validity of their experiments while using professional authority to
impose them on the clients, who were all confined in the institution involuntarily.
It should be noted that all of these articles were published in “top draw”
psychiatric journals (e.g. Archives of General Psychiatry; Journal of Nervous
and Mental Disease).
These
researchers disregarded the then available scientific evidence invalidating
their approach; and disrespected the personal autonomy and human rights of
their clients. They substituted a justificationary euphemism “professional
consent” for the reality of their imposed coercive authority on unwilling
inmates when applying their “punishment therapy” (Brandsma & Stein, 1973,
p. 37). This empirical work is in dramatic contrast to the ACT/TCL model originators’
self-serving contemporary declarations about mental health client suffering and
courage, which do not mention these never repudiated experiments. The authors
theorized about the nature of the problems of their charges and contrived
experiments to alter the clients’ “problematic” behavior as if their imprisoned
status had no impact on their behavior or on the outcomes. I believe that this
research created the framework from which ACT/TCL grew. The expressed view that
these patients were cool calculating customers “hell bent” on making trouble
and therefore in need of severe punishment and “provocative” therapy in order
to force them to be “sane”, currently more palatably discussed as
aggressive/assertive treatment or involuntary treatment/paternalism, permeates
this early research.
The ACT inventors have continued to resist seeing their so-called treatment as the problem itself. In fact, against published evidence to the contrary (some of it quoted in the present article), they deny ever-using coercive methods in ACT.
The
assertive community treatment approach never was, and is not now, based on
coercion. (Test & Stein, 2001, p. 1396, see the extended debate between the
present author and Test & Stein: Gomory, 2001c; Gomory, 2002; Test &
Stein, 2001)
The ethical
disconnect is indeed deep in the field of mental health. There is a thriving
body of research examining the therapeutic value of coercion supported by the
National Institute of Mental Health and major foundations such as the MacArthur
Foundation (Dennis & Monahan, 1996, p. 15). The deprivation of autonomy and
freedom is increasingly seen as a therapeutic tool rather than a human rights
violation. An entire text entitled Coercion and aggressive community
treatment: A new frontier in mental health law, is
devoted to exploring and thereby legitimating this view (Dennis & Monahan,
1996). Coercion as treatment is manifested in the current ACT approach by
procedures which predicate the freedom of clients from being involuntarily
hospitalized on such things as taking highly-toxic psychotropic medication
prescribed by psychiatrists (regardless of research suggesting little if any
efficacy outside of tranquilization), or by submitting to court ordered
treatment, or by accepting mandated financial payees who control the clients’
entitlement monies. Even the power to coordinate community services among
clients’ treatment and support systems in ACT (argued to be a good thing by
proponents) “allows enormous pressure to be applied … [to] ‘follow the plan’ in
any number of ways [and] can be …as coercive as the hospital … but with fewer
safeguards” according to Diamond (1996, pp. 53-58).
The ACT
approach relies on the notion that any means including coercion of the
individuals composing the target population are justified to attain societally
“desired” “healthy” ends (for a strong critique of such putatively helpful
“public health” treatment policies see Szasz, 2001). Like many totalitarian and
authoritarian dogmas that rely on coercion (e.g., Communism or Fascism) once the
coercion is removed the oppressed group rejects the dogma. This is demonstrated
in our case both by the well-known disappearance of ACT “treatment effect” once
treatment is discontinued (Gomory, 1999) and by the existence of a very active
psychiatric survivors protest movement.
Assertive
Community Treatment or ACT is largely a euphemistic label for coercion, which
has a long history in institutional psychiatry and is exemplified by the
research done in the STU of Mendota State Hospital during the Ludwig, Stein,
Marx, Test, Farrelly and Brandsma era. This era was the proving ground for the
developers of ACT-type programs. If we ignore such history or the lessons to be
learned from it, then, as the adage goes, we might be condemned to repeat it.
I conclude
this paper by citing the views of Arnold Ludwig, founder of the STU and the
Director of Education and Research at
One of the immediate ethical issues involves the use of punishment for patients. Without delving into all the aspects of this problem, ... we will simply say that this issue is largely artificial or moot, for there are no psychosocial techniques for instituting human behavioral change which do not employ the very potent tools of both reward and punishment. Even those programs, which espouse only benevolent approaches, make liberal use of such negative reinforcements as withholding privileges, withdrawing love or approval, restraints, and seclusion, ECT, and drugs for the avowed purpose of “controlling” patient behavior, but the rationales offered are often only euphemistic or socially condoned excuses for subtle or blatant punishments. The issue is not whether punishments should be used; they are and will be--this is simply a fact of all clinical and social life. The real issue is whether punishments will be administered openly, non-apologetically, and in a consistent, systematic, goal-oriented manner rather then on a disguised, apologetic, whimsical and haphazard basis. (Ludwig & Farrelly, 1967, p. 746-747)
References
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Areas of Research and Application (pp. 380-447).
Auden, W.H. (1968). The dyer’s hand, and other essays.
Bentall, R. P. (Ed.).
(1990). Reconstructing schizophrenia.
Boyle, M.
(1990). Schizophrenia - a scientific delusion?
Brandsma, J. M. & Stein, L. I. (1973. The use of
punishment as a treatment modality: A case report. Journal of Nervous and
Mental Disease, 156 , 30-37.
Breggin, P. (1979). Electroshock:
its brain-disabling effects.
Crane, G.
(1968). Tardive dyskinesia in patients treated with major neuroleptics: A
review of the literature. American Journal of Psychiatry, 124
(February supplement).
Crane, G.
(1973). Clinical psychopharmacology in its 20th year.
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Farrelly,
F. & Brandsma, J. (1974). Provocative
therapy.
Gelman, S.
(1999). Medicating schizophrenia.
Gomory, T.
(1998). Coercion justified? – Evaluating the training in
community living model: A conceptual and empirical critique. Unpublished doctoral dissertation.
Gomory, T.
(1999). Programs of assertive community treatment (PACT): A critical
review. Ethical Human Sciences and Services, 1, 147-163.
Gomory, T. (2001a). A fallibilistic response to Thyer’s theory of theory-free empirical
research in social work practice. Journal of Social Work Education,
37, 26-50.
Gomory, T. (2001b). Critical
rationalism (Gomory’s blurry theory) or positivism (Thyer’s theoretical
myopia): Which is the prescription for social work research? Journal of
Social Work Education, 37(10), 67-78.
Gomory, T. (2001c). A critique of the effectiveness of assertive community treatment. Psychiatric Services, 52 (10), 1394.
Gomory, T. (2002). Effectiveness of assertive community treatment. Psychiatric Services, 53 (1), 103.
Grob, G. N.
(1983). Mental illness and American society; 1875 - 1940.
Kazamatsuri, H., Ching-piao, C.,
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Psychiatry, 27, 491-499.
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M. (1968). The influence of nonspecific healing techniques
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Ludwig, A. M., & Farrelly, F. (1966). The code of chronicity. Archives of General Psychiatry,
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Ludwig, A.
M., & Farrelly, F.(1967). The
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|
0
points |
2 points |
4
points |
|
|
Personal Appearance |
|
|
|
|
1. Dirty |
So - so |
Clean |
|
|
2. Sloppy |
So - so |
Neat |
|
|
3. Bad taste (clothes) |
So - so |
Good taste |
|
|
4 Lousy Posture |
So - so |
Good posture |
|
|
Personal Housekeeping |
|
|
|
|
5. Dirty |
So - so |
Clean |
|
|
6. Sloppy |
So - so |
Neat |
|
|
Work
|
|
|
|
|
7. Goof-Off |
So - so |
Good worker |
|
|
8. Snotty |
So - so |
Respectful |
|
|
9. Inefficient |
So - so |
Efficient |
|
|
General Behavior |
|
|
|
|
10. Crazy |
So - so |
Sane |
|
|
11. Obnoxious |
So - so
|
Pleasant |
|
|
12. Big mouth |
So - so |
Tactful |
|
|
13. Hating |
So - so |
Considerate |
|
|
14. Belligerent |
So - so |
Peaceable |
|
|
15. Greedy |
So - so |
Generous |
|
|
16. Irresponsible |
So - so |
Responsible |
|
|
17 Stubborn |
So - so |
Cooperative |
|
|
18. close-mouthed |
So - so |
Open |
|
|
19. Glob |
So - so |
Alive |
|
|
20. Lazy |
So - so |
Energetic |
|
|
21. Passive |
So - so |
Initiative |
|
|
22. Blah |
So - so |
Creative |
|
|
23. Vulgar |
So - so |
Polite |
|
|
24. Tramp |
So - so |
Modest |
|
|
25. a.
Queer |
So -
so |
Masculine |
|
|
b. Lesbian |
So - so |
Feminine |
|
|
Total
Behavior Points |
|
|
|
|
Less:
1/2 # wrong on weekly quiz |
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|
Total
Score |
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[1]
Surely some behavior was affected,
since these and other drugs Stein’s team administered at
[2] Not electroconvulsive therapy (ECT) or
electroshock which is a highly problematic and controversial but widely
accepted psychiatric tool (Breggin, 1979).