Involuntary Treatment Burdened by Lack of Evidence

Kermit Cole

A review of Cochrane data finds a lack of evidence for the effectiveness of involuntary treatment; and an ethos of tradition rather than standards. Differences in criteria for involuntary admission, the study says, lead to differences in prognoses. The small number of people who may benefit does not justify the large numbers who are treated involuntarily, the author concludes. The study appears in Current Opinion in Psychiatry.

Abstract → 

Jacobsen, Torsten B.; “Involuntary treatment in Europe: different countries, different practices” Current Opinion in Psychiatry (published ahead of print, May 7, 2012)


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Kermit Cole
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

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  1. It’s really a study not to be relied on:
    1. They did not search terms “Assisted Outpatient Treatment” (None of their search terms used “assisted” and all substituted “commitment” for “treatment”) I think this resulted in AOT studies being excluded, since I didn’t see them in their list of ‘excluded studies’.

    2. Their criteria (intentionally?) ended up excluding all studies after 2001.

    3. NO studies of NY Kendra’s Law, CA Laura’s Law, FL Baker Act Reform, Maine, etc were included in Cochrain. The one Steadman study was a study of the Bellevue Outpatient Commitment Pilot, not Kendra’s Law and had numerous flaws, yet somehow they allowed it to be included. The lack of studies since 2001, means almost all states that have reformed laws had their studies excluded.

    This is an updated version of a review previously published in 2004 and 2005 (p. 25). The Cochrane Reviews are a series of studies utilizing only data that meets the highest scientific standards, in this case trials in which patients are randomized to the active treatment or a control group. This means that studies in which patients are compared before and after being placed on AOT, for example, are not included. Randomized controlled studies are rarely done in nonpharmacological studies of psychiatric treatment, because they are expensive, difficult to do, and some would argue unethical, if there is clear evidence that the treatment being studied is effective. Thus, by definition, this review had almost no studies to examine.

    The authors identified 71 published papers on this subject. These were theoretically “subjected to strict quality and eligibility assessment” that allowed them to eliminate 61 of the 71. The remaining 10 papers covered only two (TWO) studies: the 1999 Swartz et al study in NC and the 2001 Steadman et al study of THE BELLEVUE OUTPATIENT COMMITMENT PILOT PROGRAM. NO STUDIES SINCE 2001 WERE INCLUDED. STUDIES ON NEW YORK’S KENDRA’S LAW (ENACTED 1999); FLORIDA’S BAKER ACT (ENACTED 0/0/00), CALIFORNIA’S LAURA’S LAW (ENACTED 0/0/00), (OTHERS?) WERE ALL EXCLUDED. Thus, this review is based on only these two OLD studies. And to make any positive results even less likely, all data in these studies was changed to a binary outcome, i.e., it either worked or it did not. Thus, a 40 percent improvement in outcome would be recorded as a failure.

    This review, therefore, excluded virtually all studies of involuntary treatment and AOT because they did not meet the strict scientific criteria AND THEY DID NOT SEARCH FOR THE TERM “ASSISTED OUTPATIENT TREATMENT”. Their list of rejected studies (p. 20 ff) includes many that have demonstrated the efficacy of involuntary treatment, including Fernandez and Nygard, 1990; Geller et al 1998; Hiday et al 1987; 1989; 1999; Munetz et al 1996; O’Keefe et al 1997; Rohland 1998; Schwartz et al 2001; Swartz et al 1997; 2001; 2004; 2006; and Zanni et al 1986. The authors of the review apparently missed altogether other studies (e.g., Rohland et al, The long-term effect of outpatient commitment on service use, Adm Policy Ment Health 2000;27:383–394) and did not include any of the recent studies such as:

    · Zanni GR, Stavis PF. The effectiveness and ethical justification of psychiatric outpatient commitment. Am J Bioeth 2007;7:31–41.
    · Esposito R, Westhead V, Berko J. Florida’s outpatient commitment laws: effective but underused (letter). Psychiatr Serv 2008;59:328.
    · Gilbert AR, Moser LL, Van Dorn RA et al. Reductions in arrest under assisted outpatient treatment in New York. Psychiatr Serv 2010;61:996–999.

    Regarding the two studies on which this study was based, the 2001 Steadman study of BELLEVUE OUTPATIENT COMMITMENT PILOT PROJECT was extensively reviewed at the time of its publication by Jon Stanley et al and found to be both biased and flawed. The 1999 Swartz et al study was a good one and demonstrated the effectiveness of AOT if it was continued beyond 6 months. However, since all the data was reduced to binaries, that would not leave much to work with, especially if they just used the results of the first six months.

    Summary: Given its assumptions, this review is essentially useless for evaluating the published literature on involuntary outpatient treatment. It will undoubtedly be used by opponents of involuntary treatment, which may have been its original purpose.

    • DJ Jaffe, the above poster is the same man cited in this investigative piece from FAIR, the journalism watch dog.

      He is a forced drugging lobbyist, who has been long ago exposed as having zero objectivity on this matter, so it is laughable that he comment here and expect to be taken seriously.

      FAIR said:

      “Others at TAC have acknowledged that the focus on the violence of the mentally ill is in part a cynical ploy to encourage funding for treatment. “People care about public safety,” TAC publicist D.J. Jaffee told a workshop at the 1999 meetings of NAMI. “Once you understand that, it means that you have to take the debate out of the mental health arena and put it in the criminal justice/public safety arena.” He had earlier advised a local New York advocacy group (SIAMI Newsletter, Vol. 9/12, 1994), “It may be necessary to capitalize on the fear of violence.”

      While it is amusing that DJ Jaffe hangs around (a site that must stick in his craw), he has been exposed as a single minded forced drugging lobbyist, intent on spreading forced drugging laws throughout the land, using cynical media manipulation.

  2. This is a joke right? Anyone accused of being a Witch, IS a Witch.
    The Priests have declared a Witch, so its a Witch.
    “Witch” is a metaphor for being named “mentally ill”.

    The benefit of Involuntary Treatment is to prevent crime. If crime does not occur then you could say it worked. BUT our justice system is based on a person actually doing something BEFORE the state takes away a persons freedom.