Put the coffee on, we’re about to dig deep. I was at my desk from 10 AM til 10 PM yesterday educating myself on Programs of Assertive Community Treatment. I’m still looking to volunteer on a local mental health board but will not collaborate with oppression, so am in pursuit of policy which I believe I approach with a moderate, multi-perspective fair mind, the one contribution I bring to the table. But it is so hard to find out what goes on, the well is poisoned by officious propaganda, it takes a long time just figuring out you’re being fed bullshit driven by hidden agendas. Paranoid? Maybe you should be.
If I’m going to volunteer anywhere in Texas I have a right to know what I’m in for. Try getting the truth on ACT, which is a core program in my state and heralded as an unqualified good. I first heard about Assertive Community Treatment a year ago while covering a legislative committee, where the witness for Advocacy Inc. casually waved away my concerns, looked me in the eye and said no, no, it’s a great intervention that keeps people out of hospitals and jails. What’s not to love?
What they didn’t say is it keeps people out of jails due to built in administrative policy, therefore, if a person participates in ACT they won’t have to go to psych wards and jails. This has nothing to do with the healing properties of psychotherapy, and everything to do with leverage. Use ACT or go to hell. A threat, presented by professionals as an “offer.” Took me a year to figure this out, no thanks to Advocacy Incorporated.
Other red flags: expansion is a top priority of NAMI, and the Wikipedia page on ACT is a great big valentine kiss, presented as uncontroversial, using words like “exemplary” “fantastic” and “gold standard.” Wrong. Everything is open to debate, in other words this falls under protesting too much.
Both NAMI and SAMHSA say that ACT is nothing to get worked up about as it’s used for a relatively minority population of the severe and persistent mentally ill “who have not responded well to more traditional services.” Really? Though I am an asocial recluse I know a number of people who meet the criteria. NAMI and SAMHSA both say the model is under constant pro-consumer revison, and that participants can refuse medication. But according to the Texas state health services website ACT is used for people who “forget” to take their medications. SAMHSA’s website suggests anyone uncomfortable with the intrusive aspect of ACT should join an advisory committee or get involved as (presumably unpaid) ACT enforcers themselves. Needless to say that sucks my butt, I believe I’ll turn to the academy. Critics, who write papers about what life is really like for people under ACT. And as an aside, these papers have been hell to find online, there is still a priestly caste, information is not free, the most tantalizing scholarship is in subscription journals that average 25 bucks a paper to read. That’s a week’s lunch money for the population that needs access to these journals.
What I did find has had such an impact I don’t know where to start. It’s too much to process, so will just start with the history on ACT, the fantastic, exemplary model that the practice is based on. It began in Madison Wisconsin in the 1960s, known then as Training in Community Living.
And, we’ve been talking about the dearth of humanistic psychotherapists in psychiatric settings, lately, well, no wonder, read the following and ask yourself how a humanistic psychologist could stand working in any such setting for a minute, which is not to let them off the hook for abandoning consumers who need them most, but a piece of the puzzle falling into place.
From The Origins of Coercion in ACT: Tomi Gomory, Ph.D FSU.
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.
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).
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. …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 Mendota State Hospital….I will highlight the research done and the “lessons” learned by this group of professionals credited with pioneering ACT.
…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. … 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 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)
…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)
…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)
Example from chart:
Table 1: Behavior Report ( Ludwig, 1968, chart D, p. 392)
1. Dirty (0 points)>>>So – so (2 points)>>>Clean (4 points)
2. Sloppy (0 points)>>>So – so (2 points)>>>Neat (4 points)
3. Bad taste (clothes) (0 points)>>So – so (2 points)>>Good taste (4 points)
4 Lousy Posture (ibid)
5. Dirty (0 points) >> So – so (2 points)>> Clean (4 points)
6. Sloppy (ibid)
7. Goof-Off (0 points)>>So – so (2 points)>>Good worker (4 pts)
8. Snotty (0 points)>>>So – so (2 points)>>Respectful (4 pts)
9. Inefficient (ibid)
10. Crazy (0 points) >>>So – so (2 points) >>Sane (4 points)
11. Obnoxious (0 points)>>So – so (2 pts) >> Pleasant (4 pts)
12. Big mouth (0) >>So – so (2)>>Tactful (4 points)
13. Hating (0) >>So – so (2) >> Considerate (4 points)
14. Belligerent (contrasted with “peaceable”)
15. Greedy (contrasted with “generous”)
16. Irresponsible (v. “responsible”)
17 Stubborn (v.”cooperative”)
18. close-mouthed (constrasted with “open”)
19. Glob (0 points)>>So – so (2 pts)>>Alive (4 pts)!!?!
20. Lazy (v. “energetic”)
21. Passive (constrasted with “initiative”)
22. Blah (contrasted with “creative”)
23. Vulgar (contrasted with “polite”)
24. Tramp (contrasted with “modest”)
25. a. Queer (0 points) So – so (2 points) Masculine (4 pts)
b. Lesbian (0 points) So – so (2 points) Feminine (4 pts)
Total Behavior Points
Less: 1/2 # wrong on weekly quiz
Another example of the approach employed by the researchers is the name they gave to one of the social levels:
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:
a. Restricted to ward
b. No visitors, no presents—packages; restricted mail
c. No money
d. No desserts; no milk or coffee at all
e. No tobacco in any form.
f. No RT; no TV
g. None of other usual privileges
The offending patient … additionally … will be required to confess his sin before his fellow patients in Community Therapy, to apologize to other patients … and to express his intent to behave better in the future. (Ludwig, 1968, p. 395)
…Although brainwashing procedures at first appear alien to healing practices, they are indeed often similar in terms of techniques and desired goals. … Given these considerations, we have formulated a group designed to produce the maximal amount of emotional response and arousal in patients. In general, the group leader openly confronted patients with taboo topics and voiced criticisms of an unsympathetic society toward their deviant attitudes and behaviors. The crazy behaviors of patients were parodied and caricatured. Patients were badgered, pestered, confronted, challenged, derogated,
ridiculed, and belittled in an effort to provoke protest, anger,
irritation, discomfort and self-assertion. (pp. 387-388)
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… they deny ever using coercive methods in ACT. The ethical disconnect is indeed deep in the field of mental health….The deprivation of autonomy and freedom is increasingly seen as a therapeutic tool rather than a human rights violation.
Given that history ACT strikes me as a bad apple, rotten to the core. Of course invoking history makes me a gay scientologist tramp, which I can live with while awaiting the penance.