Who should be authorized to define appropriate change of client environment and behavior? The Problem of Vanishing Treatment Effect Ongoing assertive community treatment, wanted or unwanted by clients, is justified by the claim that when such treatment stops, the intervention effect evaporates Test, , p. At most, they have demonstrated that force can get a client to the job site.
That clients do not attend work on their own after these PACT interventions are discontinued tends to corroborate this alternate explanation.
The "effect loss" Test, , p. Such program failure or "effect loss" is found in all of the PACT research. It is mistakenly explained by the alleged incurable nature of mental illness. This justifies indefinite treatment with long term PACT funding providing a steady source of income for the experts involved. The team sets no time limits for their involvement with patients, is assertive in keeping patients involved.
In addition to the day to day work Forcing treatment on clients who do not want it is also used pp. To validate the use of assertive outreach and treatment, the original PACT researchers rely on just two studies, one of which is their own Test, , p.
Through such contacts, subjects who dropped out were provided with further information. In those Respect for the wishes of people who choose not to be involved in the Fountain House program contrasts with the coercive methods used by Test and Stein : A staff person attempting to assist an ambivalent patient to a sheltered workshop in the morning is likely to receive a verbal and behavioral "no".
The latter method allows less room for the patient to "choose" passivity. The Fountain House model, by contrast, immediately discontinues outreach efforts if asked by the dropouts. This difference leaves the PACT experts with nothing except their own research to support the effectiveness of the assertive approach they advocate. Coercion appears to be a vital part of the PACT model, according to the candid admission of Diamond , a close associate of the original PACT group in Madison: Paternalism has been a part of assertive community treatment from its very beginning In the early stages of PACT, consumer empowerment was not a serious consideration.
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. 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.
This pressure can be almost as coercive as the hospital but with fewer safeguards. This claim has been primarily responsible for the enthusiastic response to PACT. This result is due to a fairly strict administrative rule not to admit or readmit any PACT clients for hospitalization regardless of the psychiatric symptoms and to carry out all treatment in the community, while at the same time freely readmitting any troubled client in the comparison group.
Similarly, in one of the acclaimed Australian PACT replications, "The project group patients were not admitted if this could be avoided: instead they were seen by members of the project team who took them back to the community. Several reviewers Olfson, ; Solomon, have noticed this maneuver. According to Olfson , "Restricting the clinical criteria for hospitalization is an explicit tenet of assertive community treatment.
Under such conditions, reducing hospital utilization becomes more of [a] process variable then an outcome variable" p. In sum, any decrease in hospitalization is not intervention dependent; it results from an administrative action.
Cost reduction could occur with any other treatment rigorously pursuing the same objective of not admitting patients to hospitals. For example, in the Australian study the claim of client satisfaction favoring the PACT methods is contradicted by the data. It appears that the greater autonomy provided by any community treatment, not the particular interventions of PACT cause this increased satisfaction.
Stated differently, "Treatment preference was explored by asking all patients whether they prefer admission to Macquarie Hospital or treatment at home by a community team. In fact, the experimental group felt that the most important elements of the PACT treatment were the availability of staff for frequent caring, supportive, personal contact and the enhanced freedom, elements not specific to PACT Hoult et al. Again, these attributes are not PACT specific and are applicable to all forms of "helping".
The least liked of the 25 elements associated with PACT treatment was "intensity of service". In a non blind study such as this one, all the measurement instruments requiring observer ratings such as the Brief Psychiatric Rating Scale or the Global Rating Scale are open to observer bias. The "finding" of significantly higher community living skills across treatment periods favoring the PACT group is belied by the data. At 6 and 12 months the "community living skills competence" scores favor the control treatment.
The seemingly positive result in the exit interview could have been caused by many factors including 1 relief at being free of a coercive program, 2 fear of offending a potentially dangerous authority in a coercive program, or 3 a desire to please the interviewer. Unintended research results The researchers identified post facto, two GMS study sites no. More to the point, eliminating these two sites created an unintended experimental situation to reanalyze clinical outcomes.
If the dropped programs were less effective the reanalyzed clinical outcome measures should have increased the statistically significant impact originally found. In other words, with over a third of the original sample removed, about half of whom were essentially in a no treatment group, no change occurred in "the clinical outcome data". Being or not being in PACT made no difference to clinical outcome. Rosenheck personal communication, October confirmed that in the original analysis the clinical results of the two excluded sites were in the same direction and with similar significance as the results found at the other sites.
Possible Negative effects PACT Another consistent justification for advocating the utilization of PACT, even where limited or no effectiveness can be attributed, is that it does no harm. In a subsequent study, Solomon and Draine found one of two key negative effects. The researchers subsequently compared 22 clients in the PACT to 29 clients in individual case management in order to explain this unexpected finding.
The significant findings of this second study were that clients of case managers who sought legal stipulations were more likely to return to jail, case managers were more likely to initiate a violation of probation process as an intervention strategy with clients for whom they sought legal stipulations and these clients returned to jail faster p.
These were all PACT specific activities. Solomon and Draine b note that "These findings raise provocative questions regarding the possibility of deleterious consequences of intensive case management services for seriously mentally ill people" p.
In addition Solomon and Draine a found no differences in any domain between the three treatment groups. Cohen, Test, and Brown , p. There may have been one additional suicide in this study. Test et al. Reporting on clients who were excluded from this interview they state, "It was not possible to interview five subjects: one committed suicide during the first three months" p.
Since Cohen et al. Another study by Hoult et al. These were project patients, who prior to and during the study period made repeated suicide attempts" p.
This points to the problematic nature of psychiatric evaluations. Psychiatric tools appear to be unreliable both in preventing suicides and in identifying suicidal individuals Gomory, Research is needed to explore the possible harmful coercive elements in assertive treatment that may contribute to both suicidal behavior and completed suicides.
We should question the scientific validity and professional ethics of using any coercive methods in working with such vulnerable patients Gomory, Marks et al. Conclusion Although PACTs are packaged by institutional psychiatry and its various supporters as a discrete, well tested modality of effective treatment, a critical review of the conceptual framework and the controlled experimental research reveals negative findings as well as possible harmful effects. It is consistent with current trends to resort to increasingly coercive approaches.
The paradigm of mental illness as brain disease organizes and restricts the vast majority of potential research into helping interventions for seriously troubled persons to the biomedical model, the one model asserted to be "scientific" by institutional psychiatry.
Despite the positive results demonstrated in controlled studies of this psychosocial approach, it was defunded and rejected by organized psychiatry Mosher, Researchers must attempt to find solutions that support and justify mental illness as brain disorder if they expect to be funded. The PACT model fully embraces this paradigm. By not looking critically at these studies and by reusing unreliable psychiatric measures and instruments from the earlier studies, newer research repeated the same mistakes.
Instead, contradictory evidence is ignored leading to ever more problematic results Popper, References Beard, J. Bentall, R. Reconstructing schizophrenia. London: Routledge. Brekke, J. A model for measuring the implementation of community support programs: Results from three sites. Brain disabling treatments in psychiatry: Drugs electroshock, and the role of the FDA. New York: Springer Publishing Co.
Boyle, M. Schizophrenia: A scientific delusion? Burns, B. Cohen, L. Suicide and schizophrenia: Data from a prospective community treatment study. Dennis, D. Monahan Eds. New York: Plenum Press. Diamond, R. Coercion and tenacious treatment in the community.
Draine, J. A critical review of randomized field trials of case management for individuals with serious and persistent mental illness. Fisher, S. From placebo to panacea: Putting psychiatric drugs to the test. Gambrill, E. Assertion skills training. Krasner Eds. Boston: Allyn and Bacon. Gomory, T. Does the goal of preventing suicide justify placing suicidal clients in care?
Pruger Eds. Coercion justified? Unpublished doctoral dissertation. University of California, Berkeley. Hayek, F. Indianapolis: Libertypress. Hoult, J. Community care of the acutely mentally ill. Psychiatric hospital versus community treatment: The result of a randomized trial. Knapp, M.
Lehman, A. DeForge, B. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Magee, B. Confessions of a philosopher. New York: Random House. Download Frostgrave books ,. Download Frostgrave Wizard Eye The Art Of Frostgrave books , Even before the original Frostgrave rulebook landed in players' hands, its artwork, previewed in the run-up to release, attracted widespread attention and acclaim.
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