The Law’s Flaw


Tom Burns, M.D., Psychiatrist and Professor of Social Psychiatry at Oxford, was recently interviewed by the LA Times about the implementation of Assisted Outpatient Treatment (AOT) in California.  The three most populous counties, LA, SF and Orange, have now voted to implement AOT. Burns cited the main conclusion from his recent “thorough research,” based on randomized control trials, that “compulsion added to otherwise decent care makes no difference.”

His blunt assessment stands in stark contrast to E. Fuller Torrey’s web-site comments which indicate that AOT has been proven successful — “spectacularly so.”  This was no easy conclusion for Burns, who for twenty years “argued ardently” for Community Treatment Orders (CTO’s), which are described as the British version of California’s newly passed AOT laws.

When asked what does work, Dr. Burns identified three components of decent mental health care;

  • Providing steady, flexible, “low-grade” outreach that can go on for months or years (not exactly sure what is meant by low-grade)
  • Helping to stabilize a person’s social life
  • Ensuring the person gets their medication

Dr. Burns ends the interview with the following challenge about evaluating the impact of this new law.  He states; “if people are going to evaluate it, then evaluate it in a way that’s sufficiently rigorous to distinguish differences in access to better treatment from the effects of compulsion.”  I would urge Dr. Burns and LA program evaluators to consider another line of inquiry that seeks to distinguish differences between access to voluntary, recovery-oriented, non-pharmacentric approaches from ones that do fixate on medication compliance and treatment adherence.  It appears that Burns’ scientific curiosity and imagination could not envision this bold hypothesis.

I thought of Burns’ comments in the context of The Village, a recovery model program run by the Mental Health Association in Los Angeles (which opposes AOT).  The Village supports “member” choice and never requires or coerces medications.  It offers long-term outreach, housing, job development and a strong sense of community and relationships.  Fellow MiA author Mark Ragins practices his own unique style of collaborative psychiatry there.  (Full disclosure: I worked at The Village for 19 years.) The Village focuses on helping people pursue their own goals to improve their lives, rather than concentrating on the treatment of symptoms and diagnoses.

So; the availability of potential comparison groups already exists. Does the willingness for rigorous evaluation?

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  1. Not much use psychiatrists having the moral code set out in the DSM and only have powers to enforce it on the few people the can incarcerate and drug in hospitals.

    These types of laws extend the enforcement of their moral code to basically the whole community without the need for infrastructure.

    It’s working well for the Mad Mullahs in my community, not so good for those being subjected to it.

    Need examples of how much of a failure it is look no further than Australia.

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    • Boans – good pts. Some have asked whether the “commitment” is a 2 way street? Is the MH system/community commited to offering empowering, client driven care that asks “what happened to you?” (rather whan what’s wrong?) This infrastructure needs to be in place before people get commited to care they don’t want.

      Could you say more about the “failure” in Australia? Any articles?

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      • I have an unpublished paper from a psychologist here. She has obviously read Dr Breggin and has made some points about the CTOs that are being used. I have contacted her and asked if she might submit her paper to MiA. There are references to other work that shows some of the failures.

        If you like I will pass the paper on to you, as I’m sure the good doctor wouldn’t mind. She was more than happy to send it to me after speaking at a community forum.

        I made a comment in the current Rob Wipond article about the failures.

        One of the problems is that the people who are benefiting from the new system (mental health professionals) are the ones who are producing the data, and therefore present a positive picture of the situation.

        I know I met one young man who had been put on a CTO, tried desperately to get the psychiatrist to change his medication, and when he failed put a gun into his mouth and blew part of his jaw away. The psychiatrist reviewed his decision and changed his medication, and all’s going well for him now.

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  2. When doctors are given the right to force medicate people, based upon scientifically invalid disorders, they will defame and force medicate people merely to prevent a possible malpractice suit. Doctors should not have this right to harm others for profit. And it’s deplorable doctors are force medicating people with drugs known to cause atrophy of the brain, diabetes, extreme weight gain, tardive diskinesia, tardive akathesia, lactating breast growth, suicides, mania, violence, and a host of other problems.

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  3. “Providing steady, flexible, “low-grade” outreach that can go on for months or years:” I suspect he means a communty psychiatric nurse or social worker visiting someone in thier home once a fortnight for a patronising chat. Because that is what is on offer in the UK.

    Plainly Dr Burns has not investigated what does work. Open Dialogue, Soteria House, competant therapy and other kinds of help are all based on intense social support based on the ideas of understanding and encourgement within a supportive community. I hope that is what The Village does too

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    • I think he simply concluded that the coerced treatment as usual sucks just as much as uncoerced one (and how much less coerced it really is without AOT is also an open question – there are all the different ways force is being used). Which is fair enough, he simply stated one is clearly not better than the other and I’d assume both are abysmal.
      Now the trick is to show that out preferred approach actually works better in a massive way (one or two studies will not be enough). Plus of course defeat all the pharma PR propaganda machine and their paid bit**es politicians.

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  4. The surprising thing about a Community Treatment Order (CTO) in the UK is that taking the prescribed medication is not a mandatory requirement.

    The only mandatory condition is that you make yourself available for examination.

    Mental Health workers don’t tell you this, and pretend that the CTO means you must take your medication – whatever the side effects. This can make people desperate – I heard of one woman who committed suicide due to being forced to take monthly injections.

    As long as you make yourself available for examination, which is a good thing, you can be on a CTO but slowly reduce medication yourself. It’s important to make your doctor aware that you intend to do this, and to do it very slowly.

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    • I am assuming MikeT that if one doesn’t take the medication whilst on the CTO then one would be subjected to an involuntary detention.

      So you present yourself for assessment, medication is offered, and if you refuse then into the slammer where you dont have a choice. Good way of making it look as if people are consenting when if they were given an ACTUAL choice they would likely say no.

      Clever when you think about it.

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      • I believe there were legal problems with making medication mandatory.

        I have a regular appointment with a psychiatrist, who threatened to put me on a CTO. What would be the advantage or benefit of doing so when I attend regularly of my own volition? What she was saying, and we both knew it, was you dont shut up i’m going to drug you without consent. It was as plain as that.

        I did offer to take her to my local Outlaw Motorcycle Gang clubhouse and teach her a little about forced drugging, consent, and deprivation of liberty, but she doesn’t seem to want to understand the patient perspective.

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        • that’s not quite true, boans. You have to be nutty to get locked up, ie acting strange or a danger to yoursel or others. The CTO just makes it easier to do a mental health assessment.

          Coming off your drugs without consent of services can be enough to drive people nutty. I’ve seen it happen.

          In fact they have not made people adhire to drugs more than before they were in use. What has happened is that they have increased patients worries about being locked up. Also, they have been used to put pressure on people to do other things, such as not leave the house in case they buy street drugs or alchol – this is illegal but I have heard of it happening.

          If a patient refuses an injection but says they are willing to take pills they will generally prescribe pills. However the stress of going against the dr’s will is more than most people can bear. Advocates are available in the UK and they maybe able to help in negotiating with services, howere they vary in quality

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          • I know people on CTOs have the right to an IMHA (specialist advocate), I am sure there is variation in the quality of worker available. I think people are not necessarily told about this right until they are on a CTO. I think people should be given access to an IMHA at the time of discussion around the CTO and the conditions being considered.

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          • @ John Hoggett.

            The danger to self or others is a little loose when it comes to a standard for locking someone up though John.

            I was thinking if the psychiatrist took me up on the offer to come to the Outlaw Motorcycle Gang clubhouse she could stay busy filling out forms all night and having people detained. Or maybe she wouldn’t be so willing to pull a bullying act in that environment? I don’t know if it’s me but where a decision to involuntary detain someone is concerned they only seem to pick people who will make easy victims. Sort of like the teenagers who bully the kids in the kindergarten.

            Might just be where I live, but CTO’s are being used for purposes other than they said they were designed. It’s more of a stick to threaten people with here than any real method of ‘helping’ people.

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  5. It is true that the only mandatory conditions for a CTO (in the UK) are relating to the patient being available for examination. However other conditions are put on by the Responsible Clinician and may state to take medications as prescribed. If a person breaks a condition of a CTO they can be recalled to hospital and even treated in hospital, a CTO has this power of recall. CTOs do not give any authority to treat a person against their will in the community, but there is a big threat over people on them and I think the Octet study showed this to be so.

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  6. “This was no easy conclusion for Burns, who for twenty years “argued ardently” for Community Treatment Orders (CTO’s), which are described as the British version of California’s newly passed AOT laws.”
    You must give credit where credit is due. Seems like one guy who may have principles and actually care about science and evidence and is willing to change his position based on it.

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