Community Treatment Orders Don't Work
Kermit Cole
Legislation in the U.K. that empowers psychiatrists to impose treatment on patients has lost the support of one of its key advocates. "The evidence is now strong that the use of CTOs (Community Treatment Orders) does not confer early patient benefits despite substantial curtailment of individual freedoms," said psychiatrist Tom Burns of Oxford University, whose recent research appeared in The Lancet this month; "We were all a bit stunned by the result, but it was very clear data and we got a crystal clear result. So I've had to change my mind. I think sadly – because I've supported them for 20-odd years – the evidence is staring us in the face that CTOs don't work."
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Editors' note: Hat tip to Anonymous for bringing this to our attention.
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Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected]
JeffreyC April 19, 2013 at 9:24 am
And this from a country that implemented it way better than the U.S.A could ever expect to. The outpatient commitment laws should be repealed at once.
David Ross, M.Ed., LPCC April 19, 2013 at 9:43 am
I've been following this issue for some time and the early Lancet publication seems to be persuasive but some folks will still deny its conclusions. Senate Bill 350 in Ohio continues to be debated and information like this is helpful in trying to defeat the legislation.
Francesca Allan April 19, 2013 at 9:55 am
I wonder what Fuller Torrey thinks of all this.
cannotsay2013 April 19, 2013 at 2:13 pm
You have to give this guy the ability to think rationally, even if it is of no help to those who have been abused so far. But that case shows again how psychiatry cherry picks and exaggerates cases of "public outrage" to justify itself rather than science. 1 psychiatrist thinking rationally, hundreds of thousands more to go!
John Hoggett April 19, 2013 at 2:47 pm
I am aware of two studies now that show that CTO's have very little of the effect they were desigend for, ie to prevent revolving door patients relapsing. Maybe news is getting out about this and into the mainstream medical press?
David Ross, M.Ed., LPCC April 19, 2013 at 2:52 pm
I hope you're right John. You're right that there are few studies of this issue and they all seem to lean towards "ineffective" or any "advantages outweighed by the violations to a person's civil liberties."
John Hoggett April 20, 2013 at 12:29 pm
here is a paper which references two studies both of which conclude they do not do what they were supposed to do: http://pb.rcpsych.org/content/32/4/154.1
Thanks John!
mcoma April 19, 2013 at 3:09 pm
If you do a close reading of the now called Ohio Senate House Bill 43 anyone who chooses not to opt for medication after or during a psychiatric hospitalization could fit under the new wording.This method of treatment slipped under my radar screen and I now realize how close I could have come to being forced into this treatment methodology. It was pure geography and timing.As anyone involved in the Mental Health profession can attest a patient can hold a number of wide varieties of psychiatric labeling and also a wide variety of medical views of one's ability to make informed decisions for themselves. The onus for the patient, who already is in a crisis situation, to adequately obtain professional support is heinous.It seems one must already have good legal representation if one has the bad luck to deal with a mental illness.
I am not against all forced hospitalization and I am not totally against all medication protocols but the trend toward the Orwellization of Mental Health is worrisome.
Good catch mcoma, I forgot the number of the bill changed when the new session started. S.B. 43 is the current bill in Ohio. My understanding is that there have been some hearings but little else. I've been in contact with a gentleman from Disability Rights Ohio and their organization is trying to push back on this really bad idea. FAQ sheet here:
http://www.disabilityrightsohio.org/news/disability-rights-ohio-creates-faq-senate-bill-43
I've been able to provide them with several articles (e.g., Lancet piece)because of the passion of people at MIA. Jack Carney has done particularly good work in this area.
Stephen Gilbert April 23, 2013 at 8:00 am
Worrisom? It's absolutely frightening!
BeyondLabeling a.k.a. Jonah April 19, 2013 at 3:58 pm
The Independent reports (on so-called 'Community Treatment Orders' in Great Britain):
"…the psychiatrist [(Tom Burns)] who championed them is calling for their immediate suspension."
This is *very* significant news, in that it is not 'just any' psychiatrist here, opposing CTOs.
I deeply believe that CTOs (and, the similar 'AOT' program, in the U.S.) can be ended.
It takes key opinion leaders in psychiatry opposing them.
Not long ago, I had someone from the UK rebut my view that Robbin Murray could do some good, by opposing CTOs.
He told me CTOs have, "become part of the furniture in the UK."
That being a rather hopeless, resigned attitude, so I did not respond.
Perhaps, I should say, it was 'Thearticulatepoet' (who comments frequently, here on the MIA website), who was telling me that…
He was rebutting a comment of mine.
Here I quote a portion of that rebuttal, of his (the most germane portion):
"Regarding CTO's. I'll just make the point that they have become part of the furniture in the UK. It used to be that when people who were detained in hospital went on leave they did so under section 117 of the mental health act. Now CTO's have replaced that as the leave tool of choice. There are a substantial number of jobbing psychiatrists in the UK who recognize that their use is being abused and refuse to use them. Sir (lol) Murray is a creature of the system and establishment though, the chance that he would take a stand against them must be very slim."
"The CQC (care quality commission) regulates providers in the UK and has published some quite critical reports regarding the usage of CTO's. Particularly the disproportionate use against black minority and other ethnic groups. However they don't go as far as to challenge their underlying assumptions."
Source: https://www.madinamerica.com/2013/03/100-years-of-schizophrenia-is-this-enough/#comment-21854
This latest news, that Dr. Burns now calls for the "immediate suspension" of CTOs, is *quite* promising, I feel — a possible harbinger of the coming *end* of these miserable programs, in the UK, at least…
Note: I have recommended the following 17 minute Youtube previously, here on MIA ("Depot injection robs artist of her creativity"):
http://www.youtube.com/watch?feature=player_embedded&v=BBJBMXw7-fw
It's a very powerful testament to miseries which are spawned by CTOs. (If you watch it, be sure to read the uploader "About" notes afterward — to realize the full tragedy of Jean's story.)
These court-ordered so-called "out patient treatment" programs have *decimated* many thousands of so-called "patients'" lives; so, whatever Dr. Burns does now, he must *not* relent in his newly forged opposition to them.
His efforts to carry his new message forward (seeking allied KOLs, etc.) must be vigorous and unyielding, for he is now the #1 best person to *convincingly* advocate and end such horrors, as we see, in that above-mentioned Youtube.
I figure Dr. Burns could go far and wide (at *least* online), fighting these procedures, until they are ended — not just in the UK — but wherever else they are spreading, as well.
In fact, truly tireless efforts, such as that, could become the basis for his redemption, in the eyes of many…
~Jonah
I knew Jean and went to her funeral.
I'm glad some professionals are at least realising how damaging CTO's are and how useless they are in preventing relapses. How could they as they are meant to put pressure on people to comply with the same old treatment?
I do want to point out that just what the exact powers of CTO's seem to be in dispute. Some say they should not be used to force medication on people and can in reality only be used to force a mental health act assessement at short notice. There seems to be dispute on the actual limits of the powers the services have. However it is clear clinicians use them to try to force people to take medication, often when they do not want it.
Today I read a report which says that CTO's in the UK are illegal as they are against the UNCRPD which the UK government has signed up to. Although it will take a lot of campaigning to revoke this law, or to see it's use seriously reduced, I think the UNCRPD provides a route to campaign under, as does the reports which show they are ineffective and also professionals who are starting to campaign against them
"I do want to point out that just what the exact powers of CTO's seem to be in dispute. Some say they should not be used to force medication on people and can in reality only be used to force a mental health act assessement at short notice."
That's exactly what DJ jaffe is doing here in the U.S., trying to convince people that AOT doesn't force people to take drugs. Steve Moffic once posted a comment on this site "testifying" to that, saying how the order could only force them to get treatment but that treatment could be anything the patient wanted to try… Yeah, right. Whatever.
John Hoggett April 20, 2013 at 7:08 am
What I'm saying here is what a lawyer in the Uk said. What that means in reality is a different matter.
It might be that if someone on a CTO has a good advocate and good friends who support there choice not to take drugs they might be able to negotiate with services what is enforced under the order. I have no evidence of that happening but that doesn't mean that it doesn't. I think it is worth keeping an open mind about and investigating as if there is anyway of the damage of CTO's being reduced it should be exploited and promoted until such as time as these laws are repealed.
I'd really like to hear about how people have resisted these laws: succesful appeals, succesful negotiations with sevice providers, runing away, using the Mind Freedom Shield (where lots of people write and e-mail in on your behalf) or anything else.
Being fully informed of the law may help design effective strategies to help minimise the damage on people of these orders until such time as these laws are repealed.
It will take a lot of campaigning and some considerable time to repeal these laws so anything that may reduce the impact is worth considering.
JohnB April 21, 2013 at 6:49 pm
UK government is routinely flouting human rights, that's why our "coalition" wishes to get out of the EU and the ECHR
Theinarticulatepoet April 22, 2013 at 11:51 am
@Jonah
It wasn't resignation it was just a statement of fact the CTO's are part of the furniture in the UK.
There are a sizable minority of psychiatrists in the UK who refuse to use CTO's. (15% i'm guessing??)
The were never intended to be so widespread. What appears to have happened is they are being used instead of section 117 leave, which still exists.
Part of the rationale is that they offer greater legal protection for the patient than 117.
Anyway they were intended to be used for people who had serious forensic histories not generally as has happened.
The most likely change in the short term is a relaxation of the requirement for a second opinion doctor as their use has become so common that requirement was becoming a burden on the mental health system. The mental health alliance http://www.mentalhealthalliance.org.uk/ has lobbied the Department of Health about the inequity of this.
CTO's may be abolished but they will be replaced with something. Untill then psychiatrists who use them will continue to and those that don't will feel justified.
None of this has anything to do with my opinions about them, it's just a statement about the facts on the ground.
On a final note they are fiendish to administer and the "correct" use of them is very poorly understood as the link to the CQC that I included and you reposted demonstrates.
It is not generally well understood that a patient should not be placed on a CTO unless they are in agreement to take medication anyway. Like all mental health law the logic is byzantine but that's not the particular point even if it's the whole point if you want mental health law abolition or reform.
http://www.mentalhealthlaw.co.uk/Community_Treatment_Order
Mental health law website is a reliable source of information.
As for the question about Torrey (you didn't ask this) I can say by way of return that for all intents and purposes he is an utter irrelevance in the UK….less than .0001% of UK psychiatrists would know or care who he is….
Cataract April 19, 2013 at 9:43 pm
"Both sets of patients were also remarkably similar in their social and medical outcomes." Do CTOs also do nothing to prevent violent crime by patients, which the article holds up as their original purpose? Seems the research must've tracked this, but there's no mention. Any info on this?
I don't know of any research on this, I haven't looked. But I know that psychiatric drugs increase violence in some individuals (there is another article on this site about that) due to akathesia and withdrawal psychosis. How big this effect is I don't know. My impression is that it is small but significant.
I also know that the "treatment," on CTO's and off them is the same: drugs and ofter a chat with a social worker/community psychiatric nurse once a fortnight. Often a patronising chat. Some workers are very nice and some are awful, the most are pretty meidiocre as they work with a medical model so they are expected to try to offer compassionate understanding.
One piece of research said CTO's didn't reduce relapse, and didnt on the whole increase compliance – people still stop their drugs if they don't like them whether you tell them to or not. I don't have the research any more, so I might be wrong on that one, but that was my impression.
So my overall impression is that it made no difference to the number of violent outburts by people who are diagnosed with mental illness. How could it as the treatment is the same whether there is a CTO in place or not? There might be a slight rise as there might be more people forced to take drugs which caused akathesia or more people forced to take them and then withdrawing suddenly.
Belinda April 21, 2013 at 3:32 am
This is common sense really. The belief if CTO's is the same belief about people needing to be kept on med's for life. The belief is that if people take med's they will stay as well as they can be.
In order for that to be the case, one would first need to have evidence that the medications actually do what they say they do, and to date we have no such evidence. A six week medical trail is not and never will be evidence that these drugs keep people well. Even the FDA and every other drug regulation agency in the world has said there is no evidence of the pills keeping people well.
If the drugs don't keep people well, then why on earth would forcing them to take them, keep them well??? That is the part that really does not add up to me.
The WHOLE reason people believe in these laws is because they believe the drugs will keep people well, but we all know that is not the case.
Forcing someone to have some form of psychological therapy is not going to work either. One cannot force someone to participate in CBT. Sure you can force them to sit in the room, but that is about the end of it. You cannot force a person to listen to you, if they choose to ignore you while next to you, they will. You cannot force them to speak to you, well not without torturing them. And if mental health treatment is now going to involve CIA torture tactics, then I think they are going to an even lower level.
Force does not work, never has, and never will. Having said that it is also unfortunately becoming a largely unneeded situation anyway, as the fact is compliance is now at an all time high, even in places with no or minimal forced treatment. The community today believes more than ever in fictional brain diseases and pills that cure them. With that belief at an all time high, complaince is also at an all time high.
There was a study I read, which I will try to find, that says that one would have to forcibly treat some 25,000 people to prevent ONE murder, hardly an ethical situation.
The fact remains though that while the community believes in fictional brain diseases and so called pills to cure it, then they will support CTO's, as the arguments for them, are that no sane person would ever refuse such treatment. Problem with that is that no sane person would ever consent to non evidenced based treatment and when they don't have the evidence to say the drugs work, then how can someone consent to taking them. CTO's are medical experiments, as there is NO evidence that the pills they are required to take will keep them well for a period of a year, the length of the orders. How can they be required to participate in medical experimentation?? And even if one wanted to say they needed some other treatment, again, provide the evidence that 12 months of such treatment is likely to keep them well?
Why would forcing people to participate in medical experimentation keep them well?? How can a CTO be anything else, when there is no evidence that the drugs they are forced to take keep will keep them well, as a six week medical trail is not proof that they will work for 12 months.
Actually people can be forced to participate in CBT [or anything else] if services withdraw support for welfare claims, that's a very effective way of ensuring compliance and are there not some US states where compliance with treatment is tied to welfare?
Changes to welfare are occurring in the UK where this could become more pertinent and there isn't a single UK user/survivor group which addressing this [because everyone is supposed to be recovered and employed].
The new assessments have strict physical/mental dividing line which mean that if you have physical difficulties [including side effects of medications] that are a result of "mental illness" then it doesn't count.
Likewise if you have physical symptoms such as chronic pain that give you depression, the depression doesn't count.
If you could be in a therapy but are not, or could be taking a medication but are not, then it won't count.
If the assessor thinks you could be taking more antipsychotics and attending CBT, you will fail the assessment [which means no income].
The bottom line is the changes will make it impossible for people to get through any future assessment or you could be obliged to take up any treatment physical or otherwise deemed appropriate. That would be the next logical step with our government who using the discredited Atos company which your country threw out.
Forced treatment are always the 'cool' subjects for survivor-led groups but welfare cuts, housing, loss of access to services [even though they are rubbish] are not what groups want to look at.
Political activism is needed more than ever, where are survivor-led organisations on this? Too busy waxing lyrical about the great recovery we're all supposed to be in but reality check – not everyone makes the grade and we don't hear from them because only 'recovery stories' are welcome on the conference circuit.
mcoma April 21, 2013 at 10:55 pm
I wanted to add a caveat to this discussion. In my remarks I mentioned I believed in forced meds and treatment but I didn't qualify it to say that only in rare occurences. Since I believe in speaking truth to power I let that in. I guess I feel the need to explain because I agree with much of your post. When I was a professional I had an experience when I had a client who was going with out meds and was supported by the doc and I. The client had severe life stressors and became really confused. There ended up being a situation where the client either had to be charged with assault and battery or go into the psyc unit.It was the lesser of two evils.If I had known what I know now afterwards I would have treated the incident as a traumatic experience and gone over the entire time period step by step. It would have been helpful not only to my client but to me and my supervisor.I guess we have to find away that in rare circumstances there is an ethically coherent and kind way to handle this. Avoiding the gray areas doesn't make them disappear. This is when talking and listening to hard things becomes extremely important.
There are also some British psychiatrists using CTO's as a way of 'guaranteeing' some of their service users a service or bed because cuts to services here have meant that accessing a service is actually very difficult [putting aside how rubbish they are!].
Some will use sections but discharge days later to crisis services and 'home treatment' which is little more than couriered medication.
Theinarticulatepoet explains, "As for the question about Torrey (you didn't ask this) I can say by way of return that for all intents and purposes he is an utter irrelevance in the UK….less than .0001% of UK psychiatrists would know or care who he is…."
@ Theinarticulatepoet,
You are saying fewer than one in a million UK psychiatrists either know or care who Torrey is. (Of course, that's hyperbole, as I believe there are approximately 12,000 psychiatrists in the UK? I may be wrong about that number; but, surely, there aren't a million.) Meanwhile, I have 'spoken' to at least a few UK psychiatrists online, who are well aware of him; but, it's true, I get a sense that, like you, they are not much concerned with his views and activities.
Nearly a month ago, you commented (under the March 25, 2013 MiA post that's titled, "Robin Murray – 100 Years of Schizophrenia: Is This Enough?"):
"[Torrey] owes his fame to a single large donor. Without that we would never have been likely to hear about him, he would just languish in obscurity. Murray on the other hand is a political operator…"
Under Sera Davidow's most recent blog, you commented (on April 16, 2013 at 7:58 pm):
"Isn't it time to get a new hate figure…some one with real influence…" and you explained, "No one would ever have heard of Torrey if he didn't have one big donor bank rolling him…" At the end of that comment, you offered a link to an article by Henry A Nasrallah, M.D.. (And, note: that comment of yours has unfortunately been deleted, but had I copied in the course of attempting to write a response.)
From those passages, of yours, I gather you believe Torrey has no real political skills, and you'd like psychiatric survivors who read this MIA website to pay less attention to him.
You'd prefer greater scrutiny of Murray – and of Henry A Nasrallah, M.D. (who pushes genetic theories of "schizophrenia" — as does Murray). I get that you're a critic of Nasrallah's theories – and of Murray's. Great. We share this criticism of them, in common.
But, I differ from you, in your view of Torrey – and your view of the American psychiatric survivor movement.
A couple of weeks back, under the recent MiA blog, by Deron Drumm (April 7, 2013), you offer a comment which includes the following line:
"The American survivor movement has sadly achieved very little other than provide solace to each other, that no bad thing but it's not an achievement in terms of changing anything."
Apparently, to you, American psychiatric survivors are ineffective politically (quite as you suggest, Torrey is); we do little more than, "provide solace to each other" (providing solace sounds like pretty meager activity, as you describe it). That you posted such commentary directly on this (MadinAmerica) website makes no sense to me; for, though I'm inclined to appreciate bold, frank and unbridled, honest opinion, I find that comment, of yours, somewhat patronizing. And, I wonder if it's true, that we (American psychiatric survivors) do little more than provide solace to each other. I keep coming back to that line, of yours, in my mind, wondering, is it true? I figure, *maybe* it's just cultural prejudice you're expressing; maybe you don't like the way we support each other, emotionally; and, so you're judging us as too sentimental and/or openly expressive of our feelings… (It's fairly well known, many Brits are dis-inclined to wear their hearts on their sleeves, as compared to many Americans… Of course, that does not accurately describe the ways of all Brits and Americans, and there are exceptions to such 'rules' of culturally acceptable behavior, yet my saying "many" are 'this way' and/or are 'that way' is really *not* stereotyping, I think.)
So, that is the light in which I view your recent, interesting response, in your comment dated April 15, 2013 at 8:27 pm (under Sera Davidow's above-mentioned blog), wherein you wrote: "I'm sure we have all seen countless shocking circumstances and observed painful situations, seen contemporaries die one by one and all manner of horrors." That was your opening line, in response to my reflections, on various horrors I'd observed in my first psychiatric "hospital" experience.
As I first read that line of yours, it seemed you were, perhaps, aiming to minimize my pain – and, moreover, minimizing the suffering of fellow "involuntary patients" I'd encountered, people whom I was describing, in my comment; but, maybe I misinterpreted you, and/or I was taking your words too personally.
But, in any event, you have repeatedly presented this fact, of Torrey's having had just "one big donor" — as though *that* should somehow prove to us, that he is an *insignificant* figure, in the culture of American psychiatry (and/or, as though it shows him to be politically weak/ineffective, and American psychiatric survivors shouldn't worry about him and his efforts to spread AOT programs).
I have already attempted to explain to you the significance of Torrey, from the point of view, of American psychiatric survivor movement. I did that in a comment (dated March 27, 2013 at 11:45 am). Under that above-mentioned post, about Robbin Murray, I was emphatic, stating that: my *main* concern, in these regards, is his terrible fear-mongering (e.g., check out not only his website, but also his many high-profile Op-Eds, published in major U.S. newspapers); and, realize: his work toward spreading laws that establish *court-ordered* psychiatric so-called "assisted out-patient treatment" (AOT) is tireless; more than any other psychiatrist, Torrey has been the primary driver of such laws, throughout the U.S.. My explaining that, to you, had no effect; you came back to repeating this fact, that he's had just "one big donor" (as though this makes him essentially *meaningless* in the grand scheme of things).
So… What is this about, "No one would ever have heard of Torrey if he didn't have one big donor bank rolling him…" I wonder?
Probably, no one would ever have heard of Christopher Columbus if he didn't have one big donor (that being the Spanish royal couple); would positing such a truism provide good reason to remove Columbus from American history books? — or from world history books???
I have just Googled, "The 100: A Ranking of the Most Influential Persons in History." Amongst other links, up popped one, that leads to a Wikipedia page featuring not only (A) a list of the supposed "100 most influential persons in history" — but also (B) a list of the supposed "Top 10" most influential person's in history. (It's called, "Hart's Top 10.") Number 9 on that "Top 10" list is Christopher Columbus. Of course, that's just one list, not 'scientific' or definitive; but, should we take Columbus *off* that list because he only had "one big donor"??? Many Americans are adamant that Columbus is vastly overrated, as a historical figure. I'll not argue with them; though, I do believe Columbus had a significant impact on history — regardless of the fact that he had only one big donor.
But, OK, maybe Columbus was, indeed, not such a big deal; if he hadn't received the support of the royals, someone else would have led an expedition from the 'Old World,' the the 'New…'
So, putting aside the question of whether or not it would have been possible for Torrey to make a name for himself without his "one big donor," and putting aside the question of why that even matters; putting aside also the question of how many *British* psychiatrists have heard of him and/or care about him, I ask you: Does it make any sense to speak (as you do), now, on this MIA site, of "fiendish to administer" CTO's, whilst yet failing to directly *oppose* them?
You describe American survivors as merely providing solace for each other – nothing more; I see many of us *opposing* "AOT" programs (roughly the equivalent of the UK's CTOs) and CTOs.
Can you not, likewise, agree to *oppose* court-ordered psychiatric "outpatient treatment" programs, in general… and cease aiming to *diminish* this fact (of relatively recent U.S. history), that E. Fuller Torrey has been their #1 foremost proponent, in American psychiatry???
Here's an interesting PDF document — from 1997, a letter from Torrey regarding his view of the American psychiatric survivor movement (it includes responses):
http://www.patrisser.com/family/TakingIssue_Torrey.pdf
P.S. (clarification) —
Directly above, I wrote, "Under that above-mentioned post, about Robbin Murray, I was emphatic, stating that: my *main* concern, in these regards, is his terrible fear-mongering…"
To be more clear, I should have stated, "Under that above-mentioned MIA post, about Robbin Murray, I was emphatic, stating that: my *main* concern, in these regards, is *Torrey's* terrible fear-mongering…"
Just one example of Torrey's relentless fear-mongering:
[That's a link to Torrey's Wall Street Journal Op-Ed, titled, "The Potential Killers We Let Loose" (which is subheaded, "The U.S. would have fewer mass killings if individuals with severe mental illnesses received proper treatment"); it appeared a little over four months ago — on December 19, which was five days after the tragedy in Newtown, Connecticut. Note how he puts forth *unsubstantiated* claims — e.g., the line, "In study after study, AOT has been shown to decrease re-hospitalizations, incarcerations and, most importantly, episodes of violence among severely mentally ill individuals."]
Regarding "outpatient commitment" …What follows below (in this comment) is re-posted from an MIA comment by commenter drtobywatson…
drtobywatson on June 14, 2012 at 10:07 pm said:
In case anyone wonders what research or evidence is out there on outpatient commitments…here are the studies. if there is any more…send them over to me at [email protected].
Dr. Watson
There are few studies that have attempted to determine the effectiveness of Outpatient Commitment Orders (OPC). In one of the first thorough reviews of empirical studies of OPC, Dr. Kathleen Maloy concluded in 1992, there was "almost no valid empirical evidence in support of the effectiveness of involuntary outpatient commitment vis-à-vis treatment compliance, success in the community for people with severe and persistent mental illness".[1]
This acknowledgement by Maloy in 1992 led Duke University researchers in North Carolina in 1999 and 2001 to examine if OPC reduced hospitalizations. They, Swartz and his colleagues, concluded "outpatient commitment had no clear benefit unless it was sustained for at least six months and accompanied by high-intensity community services and supports", despite no significant differences in hospitalizations between the non OPC controls and those under commitment at the one year mark.[2] [3]
In turn, the Bellevue Outpatient Commitment Study was conducted in 2001, which was the only controlled study that explicitly provided and offered enhanced community services to both OPC and non OPC groups. They reviewed if commitments were necessary for individuals to continue with treatment if they were offered it without the OPC. They concluded "individuals provided with voluntary enhanced community services did just as well as those under commitment orders who had access to the same services". Researchers found no additional improvement in patient compliance with treatment, no additional increase in continuation of treatment, and no differences in hospitalization rates, lengths of hospital stay, arrest rates, or rates of violent acts.[4]
This lead Drs. Kirsley and Campbell, who were highlighted by the Cochrane Database of Systematic Reviews, the gold-standard of peer reviewed psychiatric research, to look at the number of outpatient commitment orders (OPC) it would take then to prevent one re-hospitalization. They concluded "it takes 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent a future arrest".[5] Thus, 84 people would need to be subjected to a non-required forced treatment program in order to reduce just one re-hospitalization.
This was confirmed by researchers then in 2007 at the Institute of Psychiatry in Maudsley, UK, whereby they conducted "the most comprehensive and through review of outpatient commitments" at that time. They concluded, "it is not possible to state whether or community treatment orders (CTOs) [the equivalent to OPC] are beneficial or harmful to patients".[6]
In Contrast, the State of New York began investing their own OPC, under Kendra's Law and the Assisted Outpatient Treatment (AOT) program; however, their results now appear mixed, whereby the New York State Office of Mental Health in 2005 and later 2009 stated the AOT drastically reduced hospitalization, homelessness, arrest, incarcerations and adherence to medication compliance[7] [8]; however, non contracted independent researchers in 2004 had indicated that their sample of the AOT group and control group "did not differ significantly (with) rates of hospitalizations, homelessness, dangerousness and arrest/incarcerations". One additional major conclusion was that the AOT forced treatment group was significantly "less satisfied" with treatment than those not under commitment. [9]
[1] Maloy, Analysis: Critiquing the Empirical Evidence ; Does Involuntary Outpatient Commitment Work? Mental health Policy Resource Center (1992).
[2] Swartz MS, Swanson JW, Hiday VA, et al: A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52: 325-329, 2001.
[3] Swartz MS, Swanson JW, Wagner HR, et al: Can involuntary outpatient commitment reduce hospital recidivism? Finds form a randomized trial with severely mentally ill individuals. Am J. of Psychiatry 156: 1968-1975, 1999.
[4] Steadman HJ, Gounis K, Dennis D, et al: Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 52:330-336, 2001
[5] Kisely S, Campbell LA, Preston N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. The Cochrane Database of Systematic Reviews 2005, Issue 3.
[6] Churchill, R., International experiences of using community treatment orders, by the Institute of Psychiatry at the Maudsley (UK), Section of Evidence based Mental Health-Serv. Research Dept., March 2007. http://www.iop.kcl.ac.uk/news/downloads/final2ctoreport8march07.pdf
[7] N.Y. State Office of Mental Health (March 2005). Kendra's Law: Final Report on the Status of Assisted Outpatient Treatment.
[8] Duke University School of Medicine et. al. (June 2009). New York State Assisted Outpatient Treatment Program Evaluation.
[9] Perese, E.F. , Wu, Y.-W. B., & Ranganathan R. (2004). Effectiveness of Assertive Community Treatment for Patients Referred under Kendra's Law: Proximal and Distal Outcomes International Journal of Psychosocial Rehabilitation. 9 (1), 5-9.
https://www.madinamerica.com/2012/06/tuesday-dinner-with-the-nami-mommies/#comment-12172
Theinarticulatepoet April 22, 2013 at 8:51 pm
The original question was "What would Torrey make of a UK paper" so my response was to posit the alternate question "What would UK psychiatrists make of Torrey?"
My point is very very few people in the UK have even heard of him. In a UK context he is an irrelevance.
The distinction between Torrey and Murray, as I made clear in the post you partly quoted, was that Murray owes his influence to being a political operator. Torrey owes his influence to having a single large donor. But I agree with you he uses the cash that his influence buys to good effect. I'm not sure what point you are trying to tease out here to be honest.
The real difference between Torrey and Murray is that putting them on a spectrum Murray is more of a disease monger and Torrey more a fear monger. Not much to choose between the two….why this difference between them should translate into a difference between ourselves is a bit of a pity and I certainly can't see what is to be gained by it….
We agree about plently I am sure but message boards have a way of teasing out differences so that's what we focus on…..the nature of the communication being so poor that we (we being nearly everyone who uses message boards) end up haggling and arguing over points that we could sort out in five minutes in person. It's silly really but that's the way it is.
We do disagree as far as I can tell about something quite substantive though. I am far more concerned about the use of restraint and seclusion. You have posted that you are far more relaxed about these practices. (as I understand you) Fine. It's a much bigger issue than the one above that's so small I can hardly discern it.
You have mentioned my response to your own story a couple of times now. I haven't addressed that before but I will now because clearly you didn't appreciate my answer. I will try and be as clear as I can. In no way did I intend to belittle your own experience. My answer was, I thought, doing the exact opposite. I intended to impute that you were not alone in your experiences not that your experience was insignificant. That you took the latter interpretation is I hope just down to a cultural difference and what passes for the right response. I hope that clears that up.
As far as the efficacy of CTO's thanks for all the links but it's not me you have to convince….I was on that side of the argument while they were being considered.
I have made this point before but most of the differences between people in the survivor/user movement boil down to a difference of political perspective. We reject each other's politics and yet we are expected to get along and achieve something. I'm certainly happy to leave you to be the judge of what the survivor movement has achieved….it's not belief that it has achieved nothing or that it never will but that the majority of what it has achieved is solace. That's not patronizing….it's not a small thing to achieve. I think its important.
BeyondLabeling a.k.a. Jonah April 22, 2013 at 10:16 pm
@ Theinarticulatepoet: You are *misrepresenting* me as you write,
Please, allow me to clarify, as follows…
Nowhere have I condoned *any* amount of seclusion, ever; hence, I respectfully object to your calling me "far more relaxed" about the practice of seclusion.
And, you *repeatedly* fail to offer distinctions, when speaking of "restraint".
That lack of distinctions leads to a lot of miscommunications, in your arguments, I believe.
And, very important to note: you were speaking of *prison* protocols.
In my view, that has *nothing* to do with 'mental health' practices.
Furthermore, in my comments, to which you are referring, I very deliberately warned *against* seclusion.
On April 16, 2013 at 5:46 pm, I stated, emphatically: "No one should ever be left in isolation, imo."
As far as "restraint" goes, I told you, that: "restraint" is too vague a term; I don't know what it means to you.
What I do know is that, in my view, one cannot reasonably rule out some forms of 'restraint' when discussing *prison* protocols; after all, *prison* is — in and of itself — a form of restraint.
I.e., locking a person, bodily, behind bars, is *restraining* him/her, and I do not rule out the possibility that imprisonment may be justified.
Therefore, certainly, there are some forms of restraint which I may condone, in certain instances — imprisonment being one form.
But, there are also forms of restraint which I object to, in every instance.
E.g., I object to *chemical* restraints — always.
I.e., no human being should ever be *forcibly* "tranquilized" — in my opinion; in fact, I believe anyone and everyone should have a guaranteed (inviolable) right to refuse being injected with psychopharmaceuticals; and, no one should ever be forced to swallow such drugs in pill or liquid form.
(Likewise, no forced ECT — nor psychosurgery.)
Essentially: No forced brain treatments.
You — on the contrary — are in favor of applying chemical restraints, in some situations, yes?
(It seems to me, you have said that such is your position.)
You believe chemical restraints are 'necessary' tools, in the work of prison-keeping.
To me, that is your defense of a very serious human rights violation.
(Of course, you are not alone in defending such practices; very nearly everyone working in 'mental health systems' believes there are 'justifiable' uses of chemical restraints — especially, in prisons.)
So, you favor *chemical* restraints, in certain instances.
Meanwhile, unless or until you define "restraint," in terms of some subset of tools or protocols, which I might object to, I cannot reasonably rule out, as a potentially 'useful' programmed response, in *prison* settings, some forms of *mechanical* restraint — because I do believe prison guards restrain prisoners, mechanically, in various ways, necessarily… especially, by confining them, behind bars.
And, you were speaking, specifically, of a hypothetical prisoner.
You offered a hypothetical situation, in which a *prisoner* was ceaselessly punching himself in the face, and (you described) no amount of gentle consoling would stop him from doing that.
I offered a possibility, that: a straight-jacket and padded room might be helpful, in that situation.
Here, I need not repeat myself further; you can reread what I wrote, at the following link…
https://www.madinamerica.com/2013/04/slices-of-pies-a-dialogue-with-ronald-pies/#comment-22924
I sincerely hope I've not misrepresented your views; I urge to correct me if, by chance, you find any clarifications are needed…
Theinarticulatepoet April 23, 2013 at 3:54 am
I'll will try and distinguish between physical and chemical restraint in future when there is room for misunderstanding.
I understand you that you can envisage circumstances where physical restraint is justified.
I am less clear about the absolutism with regard to "brain drugs". Is this a position as clear as say Jehovah's Witnesses who won't accept blood in any circumstances?
If say a person was unconscious after a car crash they would perhaps be administered a muscle relaxant and a general anaesthetic prior to surgery. The general anaesthetic being very much a brain drug working at the level of the synapse.
I get the feeling that some people would regard the general anaesthetic as the "thin edge of the wedge".
I'm going to take it that in those circumstance you would be happy with the non-consensual, due to lack of capacity, administration of a "brain drug".
I don't feel you have willfully misrepresented me, certainly not to the extent I feel compelled to offer clarification but thanks.
Just to clarify
The trouble is that it does intersect with mental health. In the UK the special hospitals, Broadmoore, Rampton and Ashworth are staffed by NHS nurses but they are members of the Prison Officers Association.
Things are not always clear cut as is sometimes made out, that is what I was getting at generally.
Steve April 23, 2013 at 12:29 pm
Has anyone thought of sending this as a "press release" to the NYT? Seems they ought to be interested, given the recent amount of material they've published on this issue. I'd love some organization with some street cred to put this article out to a range of newspapers and TV news outlets and see what happens. Many times, newspapers only publish stuff they're spoon fed, and the psychiatrists are better at feeding them than we are.