Academic journal article Ethical Human Psychology and Psychiatry

The Limits of Evidence-Based Medicine and Its Application to Mental Health Evidence- Based Practice (Part Two): Assertive Community Treatment Assertively Reviewed

Academic journal article Ethical Human Psychology and Psychiatry

The Limits of Evidence-Based Medicine and Its Application to Mental Health Evidence- Based Practice (Part Two): Assertive Community Treatment Assertively Reviewed

Article excerpt

This article is the second of two published in Ethical Psychology and Psychiatry; the first appeared in Volume 15, Number 1. The first article argued the very serious limitations of evidence-based medicine (EBM) and its very popular mental health offshoot evidencebased practice (EBP; Gomory, 2013). This article is meant to be a consolidation and update of a 1999 analysis of Assertive Community Treatment (ACT), the best "validated" mental health EBP according the National Institute of Mental Health (NIMH) and academic researchers. This analysis reconfirms the failure of ACT as a treatment modality and a platform for successfully reducing hospitalization; its touted consistent effect except when ACT can apply administrative coercion to keep its clients out of the hospital or quickly discharge them. When ACT fails to have such administrative coercive control, it does no better than other community mental health delivery systems. The use of ACT coercion begun over 40 years ago, the article further argues, set the table for conventionalizing psychiatric coercion as evidence-based best practice.

Keywords: coercion; evidence-based practice; clinical social work; mental health; psychiatry; Assertive Community Treatment

Although there are no absolute criteria for assessing the validity of scientific evidence, it is still possible to assess the validity of a study. What is required is much more than the application of a list of criteria [such as done for evidence-based practice]. Instead, one must apply thorough criticism, with the goal of obtaining a quantified evaluation of the total error afflicting the study. This type of assessment is not one that can be done easily by someone who lacks the skills and training of a scientist familiar with the subject matter . . .

Neither can it be applied readily . . . by scientists . . . who do not take the time to penetrate the work.

-Kenneth J. Rothman (1988)

This article is the second of two published in Ethical Human Psychology and Psychiatry; the first appeared in Volume 15, Number 1. The first article argued the very serious limitations of evidence-based medicine (EBM) and its very popular mental health offshoot evidence-based practice (EBP; Gomory, 2013). It should be noted that the popularity of the phrase "evidence-based" and its apparent power to convince that effective science is being referenced merely by its incantation when attached to almost any social science enterprise (e.g., the law [Rachlinski, 2011] or education [Biesta, 2007]) has spread like wildfire. Academia now has evidence-based anything and everything that you could call social science and even beyond, such as evidence-based art (Baum, 2001). All of this has happened as demonstrated in the first article without any rigorous test of the superior efficacy of EBM or EBP over alternative approaches used before and after EBM/EBP was invented in medicine and distilled to other domains such evidence-based mental health.

This article is meant to be a consolidation and update of my analysis of Assertive Community Treatment (ACT), the best "validated" mental health EBP according to the National Institute of Mental Health (NIMH) and academic researchers, published in Ethical Human Sciences and Services (Gomory, 1999), which concluded that:

Although [Program of Assertive Community Treatment] PACTs [sic] 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. Why PACT remains aggressively marketed may be explained by the failure of institutional and biopsychiatric treatment efforts in general. . . . It is consistent with current trends to resort to increasingly coercive approaches. (p. 160)

These conclusions, as I show in this article, hold just as true today as they did then, even though hundreds more articles on ACT have been published over the 14 years since that publication and the EBP marketing rhetoric for it has only increased. …

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