Mental Health Bill: For the Consultation Process
I have been unable to access the area of the official website which contains the Draft Bill law, but my understanding is, the following is set to apply re.
ëElectro-convulsive therapy (ECT) (Draft Bill clauses 118-120)í
"The Bill would allow ECT to be given without consent if it were expressly authorised by the Tribunal, or where it constituted urgent treatment. The Tribunal would be able to authorise ECT irrespective of whether the person had capacity to consent.
"The procedure for urgent treatment
does not require prior approval and it allows two applications of the treatment.
The treatment must be immediately necessary to save the patientís life,
prevent a serious deterioration in his or her condition, alleviate serious
suffering, or prevent violent behaviour or danger to self or others."
I write in order that it cannot be claimed the government is unaware of material implications of the proposals to give ECT to "prevent violent behaviour or danger to self or others." What clauses 118-120 actually indicate is the calculated intent to diminish with ECT a person's mental capacity to perform acts that the person would want to perform otherwise.
Consideration must be given to how ECT subdues the violent or restrains the dangerous. ECT is not direct physical restraint; it acts on the brain. Logically the only way a procedure that works on the brain could control and restrain is by its impact on mental capacity. In truth, no matter the ostensible reason for the prescription of ECT, an inherent capability to subdue exists in a procedure which constricts thinking -- as when it diminishes the ability of recipients to entertain wishes or thoughts of death. (Prudic and Sackeim, 1999) Decreased thinking from ECT is what prevents violence to self.
Although the professionals say they lack knowledge of the mechanisms by which seizures alter mental functions, two prominent psychiatrists have categorically stated that ECT ësaves livesí (sic) by so contracting the ability to think suicidal recipients "are extremely unlikely, at least in the short term, to manifest suicidal ideation or intent." (ëElectroconvulsive Therapy and Suicide Risk,í Prudic and Sackeim, J. Clin. Psychiatry 1999:60 (Suppl 2))
According to Professor Appleby, "The main aim of the proposed legislation is to improve safety for people who are at risk, particularly for patients themselves. Sometimes there are people who feel very suicidal but who in a legal sense still have capacity. We have to make sure that they receive the treatment they need." (http://societytalk.guardian.co.uk/WebXemail@example.comWeayy2ra0.0@.3ba73fb4) In consequence of the "wish to make sure that they receive the treatment they need" patients are to be subjected to a procedure which retards the mind. ECTís ëmind controlí mode of action is decidedly questionable even as therapy, and in implying that people "need" mind control the government takes a less than reputable stance. High-flown rhetoric such as "improve safetyÖfor patients themselves" fails to disguise the fact that a population who will be denied the rights and the effective means to defend themselves are to be cynically exploited.
As for danger to others, restrictions on freedom of expression (Article 10 of the ECHR) are permitted in the interests of public safety, but to slide into law a restriction that is effected through brain regulation is stretching things in relation to the Human Rights Act 1998. ECT contracts all thinking -- and as action cannot occur if thought has been nullified so ECT also contracts the behavioural repertoire, to include aggressive acts. ECT given to subjugate an individualís mind in order that others might benefit is particularly questionable. There can be no recourse to the argument that this is therapy for the person thus treated, as is possible where safeguarding health by limiting someoneís freedom of expression in suicide is concerned.
Psychiatrists are very aware of the importance of assuring the public that ECT is a soundly based treatment. The official (RCP) position on ECT for violent behaviour is that:
"There is no case for prescribing ECT to alleviate violent or offending behaviour per se. For a few patients who are suffering from a psychotic illness which has not quickly responded to antipsychotic medication, and where antisocial acts arise directly from psychosis, ECT may limit the acts by alleviating this." (ëThe ECT Handbook, 1995, p. 30)
Of particular note is the absence of evidence for ECT to "limit the acts" even in psychotic illness, as:
"Only one study seems to have made explicit a possible specific advantage for ECT for those with violent propensities. Smith et al (1967) noted that among people with schizophrenia the problems that responded most significantly and favourably to an ECT / chlorpromazine combinationÖwere hostility (not violence) and ideas of persecution." (p. 30; emphasis added)
Of the Home Office / Department of Health conditions that will govern any decision to apply compulsion, concerning the ëappropriate treatment is availableí condition, no basis for claiming patients would be protected from inappropriate treatment exists in circumstances lacking evidence of appropriateness (or even evidence the procedure is ëmedicalí in the accepted sense). (Para. 2.9) Clearly, anecdotal accounts referring to ECT which subdues, quieten, restrains, etc., drive ill-considered intent.
When it comes to the universally unpopular government diagnosis of DSPD, absence of clinical justification for ECT is glaringly apparent. Although DSPD isnít mentioned in the Draft Bill, violence and danger to others are, along with the proposals for ECT as a preventive measure irrespective of either capacity to consent or ëillness.í
One consequence of the future intentions where ECT is concerned is to throw into doubt the accuracy of the RCP statement that ECT limits antisocial acts due to its effectiveness in treating diseases that are characterised by aggression or violence as symptoms of mental illness. The mode of action of ECT that is going to count by far the greatest is its impact on mental capacity and not its impact on psychosis (or whichever illnesses allegedly have aggression, violence and dangerousness as symptoms). Under the single definition of mental disorder, people with personality disorders will assuredly end up being treated exactly the same as those with any and every conceivable mental, neurological -- or social -- disorder, meaning diagnosis becomes flagrantly the means to effect a ëmind controlí objective.
According to Louis Appleby, "As now, powers of compulsion will only be used for those who present a serious risk to themselves or others." (http://society.guardian.co.uk/societyguardian) But is it entirely correct to describe the proposals as in no way more draconian than the 1983 act? It seems one test of the appetite in Whitehall for more draconian powers resides in what is being said about ECT to "limit the acts," compared with present usage. In the light of denial by psychiatrists that they currently use ECT for purposes other than to treat illness, any use of ECT for non-medical purposes would be more draconian.
The youth of this country are understandably wary of what the new laws could mean for them. According to the findings, revealed on 13.9.02, from a relevant MIND survey of 1,000 people, "concerns about the measures were even higher amongst the young, where 52% said they would not seek medical help for a mental health problem." (http://news.bbc.co.uk/1/hi/health/2253358.stm) Plainly, in relation to danger to self or others, it is widely believed that there exists the potential for increased use of compulsory treatments in the under 20 age group. I must therefore point out that:
a) The WHO draft legislative manual
opposes ECT for young people -- even as treatment -- and the law in at
least two US states restricts use of ECT with minors (see Appendix).
b) Absence of evidence the treatment is appropriate is compellingly relevant to ECT for young minds.
In response to Consultation Point 3.10: The Government would welcome your views on these proposals to extend legal protections to children while respecting parentsí rights to make decisions about their childrenís treatment, I stress the lack of knowledge of ECTís long term adverse effects on the personality of the young recipient. It is especially noteworthy that pro-ECT researchers Walter, Rey and Mitchell have stated,
"There is no published data about the experience and attitudes of adolescent recipients of ECT, or their parents, regarding their treatment. However, in a recent survey of 26 patients who received ECT in adolescence, and 28 parents, we found that overall ECT was viewed favourably." (ëPractitioner Review: Electroconvulsive Therapy in Adolescents, J. Child Psychol. Psychiat 40:3, 1999)
ECT was indeed viewed favourably, but the survey Walter et al.. mention reported of adolescent recipients three years on from the ECT experience that they were socially inadequate, living on welfare benefits, "chronically ill [and] functionally impairedÖ." (ëElectroconvulsive therapy in adolescents: experience, knowledge and attitudes of recipients,í Walter, Koster and Rey, J. Amer. Acad. Child and Adolescent Psychiatry, 38, 1999).
Lasting functional impairment following treatment and all that this implies is conveniently dismissed as ëcontinuing mental illness,í but interpretation by pro-ECT psychiatrists does not constitute proof of cause of functional impairment or that ECT ought to be being viewed favourably. Besides, ëcontinuing mental illnessí is actually an admission that the treatment hasnít worked -- and effectiveness in the age group in question is undemonstrated, for:
"No scientific evidence based on controlled evaluations supports the use of ECT with children and adolescents. No data exist to support the use of ECT in preference to other less invasive treatments." (ëShock Story,í Nursing Times, Barker and Baldwin, February 21, Vol. 86, No. 8, 1990
In the matter of adolescent ECT, legal protection as envisaged would not be adequate. To repeat, there is no backing from controlled studies, reliably applied criteria or valid assessment scales -- in short, no body of scientific knowledge. Therefore, parents should not be able to use the law to force ECT onto anyone whose brain and personality are still developing, and no government should countenance mind control ëtreatmentí where immaturity further compounds the dubious suppositions surrounding such a measure.
In the absence of medical evidence generally, although the expertise of the experts of experience is treated with contempt, ECT survivors are the only ones in a position to counsel the government on the ways in which ECT that subdues and controls actually works. As noted, important questions being avoided include the question of what ECT really does to personality and functioning.
As for the ethics of the proposals, to ignore the ethical dimension is folly. In a Sunday Times article which appeared on 24.1.1999 (ëPsychiatrists accused of serial rapesí) Lois Rogers reported, "One alleged victim, a 41-year old interpreter with two teenage children, claimed that Haslam ensured her compliance with repeated sex attacks by subjecting her to excessive amounts of electroconvulsive therapyÖ." (The reference is to retired a psychiatrist Michael Haslam, who is still being investigated for sexual assaults on female patients.)
The reasons ECT has the potential to facilitate rape is because:
a) ECT concusses and head trauma
often leaves recipients with such poor judgement (Breggin, 1998 -- see
Appendix) they place themselves in dangerous situations.
b) The ECT impact on brainwaves increases suggestibility and can result in pathological ductility.
Concerning impact on brainwaves, Grey Walter reported:
"The only characteristic of behaviour which was significantly correlated with the presence of delta activity wasÖa relatively promising attitudeÖ. Ö ConsiderationÖhas suggested that the common factor related statistically to delta rhythms is a comparatively docile attitude to suggestions from others. The terms ëmalleableí, ëeasily helpedí, ëeasily ledí were used, and the word that seems most apt and free from irrelevant or misleading associations is ëductile.í (ëThe Living Brain,í Penguin Books, 1961, p. 182)
Psychiatrists have observed yielding, agreeable, easier patients after ECT, and they acknowledge that ECT induces increased delta activity. The ëHandbook of ECTí (Kellner et al., American Psychiatric Press, 1997) reports that "Increased predominance of delta activity on interictal EEG is seen as a function of the number of ECT treatments given in a course of ECT and their rate of administration. (Fink 1979)."
In reality, what the nature of interictal EEG changes is a function of is interpretation. It should not be assumed that a large number of treatments is essential to effect extensive EEG changes. According to Professor Robert Kendell:
"If bilateral electrodes are used paroxysmal delta activity starts to appear in the frontal leads after the first two or three treatments and becomes steadily more prominent and extensive thereafter." (ëThe Present Status of Electroconvulsive Therapy,í Brit. J. Psychiat. (1981), 139)
Nor should it be assumed that increased delta activity is therapeutic, as this hasnít been demonstrated and such activity is by no means universally accepted as therapeutic. In fact, Laverne Johnson et al. pointed out that:
"With the exception of Fink and his co-workers, there has been almost complete unanimity in the finding that clinical improvement was not related to post-ECT changes in the EEG or to pre-ECT patterns." (ëElectroconvulsive Therapy (With and Without Atropine),í Arch Gen. Psychiat., Vol. 2., 1960)
ëClinical improvementí is a value judgement according to Professor Fink (see Appendix). Nevertheless, this leader in the field maintains that EEG changes are an index of efficacy, and he advocates the obtaining of an appropriate EEG sequence. By rights, the fact that ECT induces EEG changes with the potential to create victims vulnerable to assault -- a potential one unscrupulous psychiatrist is accused of turning to advantage -- should have led to the conclusion the risks vastly outweigh benefits.
A key area of interpretation concerns durability of brainwave changes, which are said to be "transient." Therefore, I would add my own personal statement to that of the interpreter who claims ECT was employed to ensure her compliance with rape. Whether or not ECT is actively employed for this purpose, I will say that it facilitates all types of victimisation, from scapegoating to rape.
I am a woman who stood there unable to say "No!" when faced with rape eight years after ECT was used. I had been a fighter as a child, yet I let a little man with a little penknife have things all his own way. I wasnít frightened of him, rather permanent ECT-inflicted ductility prevented appropriate action in word or deed. My mental capacity to resist rape having been diminished, it transpired my behavioural repertoire was lastingly contracted. (I received compensation from the Criminal Injuries Compensation Board, i.e. the fact of rape may not be discounted.)
The point I am making is that although it is true ECT renders people docile and suggestible, those proposing to give ECT to prevent violent behaviour or danger to others cannot afford to ignore the various ramifications of their stated intention. Does the proposed removal of "the problem in the current Act that people with mental impairment or psychopathic disorder need to fulfil a requirement that ëtreatment is likely to alleviate or prevent a deterioration of this conditioní" (para. 2.11) mean the pretence ECT is of therapeutic benefit to the recipient disappears in tandem?
This being how things appear, and how they would in any case operate in practice given that the requirement for treatment to be of therapeutic benefit to the recipient will vanish, naturally the question arises as to whether treatment is envisaged, or punishment. According to Abse, "the very nature of the treatment itself can produce the attitudes described. The success of EST principally in depressions is thus associated with hostile or punishing attitudes on the part of the therapistÖ." (ëTransference and Countertransference in Somatic Therapies,í Journal of Nervous and Mental Diseases, 1956)
Is the underlying justification actually meant to be of the eye-for-an-eye variety, with perpetrators to be turned into victims, themselves at risk of assault from others? As for would-be perpetrators, is it to be a matter of the authorities getting in a pre-emptive strike via doctors who swear to do no harm but who are nevertheless rendered hostile and punishing by ECTís very nature? In short, does the State intend health care which is more oppressive than legal sanctions and punishment? That being where the logic of the ECT proposals points, I doubt anyone has thought the matter through at all carefully or considered reasonableness.
Government-sanctioned intent to subdue and make docile with ECT those deemed to require this type of ëmanagementí implies the will to gross violations of Article 3. It is obvious psychiatrists (and now officials in Whitehall with a duty to promote public health) are fully aware that ECT is a system not of health but of control, compulsion, restraint and punishment. I find it remarkable that the government should need to be reminded of Article 3 of the ECHR:
No one shall be subjected to torture or to inhuman or degrading treatment or punishment.
* According to Dr. Peter Breggin (a psychiatrist who wishes to see ECT banned),
"Head-injury victims, including post-ECT patients, frequently develop an organic personality syndrome with shallow affect, poor judgment, irritability, and impulsivity. They seem "changed" or "different" to people around them, much as lobotomy patients often seem to their families. Sometimes they become slightly clumsy, moving awkwardly or dropping things. Often they have "lapses" where they cannot think or cannot voice their thoughts. Sometimes their handwriting deteriorates. Headaches frequently begin with the traumatic treatment and may recur indefinitely.
"Many post-ECT patients suffer from irreversible generalized mental dysfunction with apathy, deterioration of social skills, trouble focusing attention, and difficulties in remembering new things.. I have evaluated a number who have suffered from dementia, confirmed by neuropsychological testing. Several have developed partial complex seizures or psychomotor epilepsy, permanently abnormal EEGs, and atrophy as measured by brain scans. Many have been deprived of the experience of years of their lives, their professional careers, and their mental ability following ECT."
(ëElectroshock: scientific, ethical,
and political issues,í Peter R. Breggin, International Journal of Risk
& Safety in Medicine 11 (1998) 5-40, IOS Press)
* Professor Kendell (1981) has pointed out that, "A course of ECT almost invariably produces extensive EEG changes" and Dr. Breggin mentions permanently abnormal EEGs following head trauma. If ECT is head trauma how likely is it that the inevitable ECT-induced EEG changes are transient in an overwhelming majority of cases, given:
"Williams (1941) has shown that the E.E.G. may remain abnormal for many years after a head injury and has demonstrated a relationship between E.E.G. abnormalities and the severity of the injury, as judged by the length of post-traumatic amnesia."
of Psychopathic Personalities,í Denis Hill and Donald Watterson, J.
Neurol. and Psychiat., 5-6, 1942-3)
* Professor Max Fink, writing on ECT to ëimproveí behaviour, has provided indication that so-called ëtherapeuticí EEG changes are a matter of opinion.
"Behavioral change is a consistent accompaniment of alteration in cerebral function. Changes in mood, language, attitude, judgment, thought process, perception, and insight attend changes in cerebral function, from whatever causeÖ.
"In this study, electroshock has been shown consistently to alter the electroencephalogram in a fashion which we have come to associate with states of altered cerebral function. The studies of Davis and Davis (1939), Ostow and Strauss (1953), Ostow and Ostow (1946), and Jung (1954) have affirmed the significance of diffuse delta activity as an index of altered brain function.. Symmetric dysrhythmic delta activity has been interpreted as evidence of dysfunction of midline hypothalamic centres -- the centrencephalic system (Ostow and Strauss, 1953). Such activity is also indicative of an alteration in the state of consciousness, more marked alteration being directly related to the duration, amplitude, and frequency of the slow-wave activity. The demonstrated relationship between induced delta activity and behavioral response after electroshock, therefore, permits the conclusion that changes to the centrencephalic system with attendant alteration in consciousness are the physiologic basis of the electroshock process. Ö
"These studies of the electroshock process have demonstrated that alteration in brain function is induced early and is sustained in patients in whom the greatest degree of behavioral change is noted. Ö
"We have been impressed that the ratings of improvement are value judgments of the behavioral response. All patients in whom cerebral changes are induced by electroshock manifest changes in behavior. The range of behavioral patterns induced under these conditions is wide. Ö "Improvement" is a special case of behavioral response, being a subjective evaluation on the part of the observer that the patient is "better." Electroshock does not induce "improvement"; it induces a milieu of cerebral activity in which behavior is different than before electroshock.
To the extent that the induced behavior in depressed patients is perceived as less complaining, or anxious, or in schizophrenic patients as less delusional, hallucinatory, or excited, the patient is evaluated as "improved." When behavior, however, is perceived as anxious, agitated, paranoid, complaining, or withdrawn, it is evaluated as "unimproved." The particular type of behavioral pattern induced by electroshock is dependent on a number of factors, such as personality.
"Another aspect of the rating of improvement is the environmental response to the induced behavior. The modification of mutism, withdrawal, and negativism to excitement, overactivity, and irritability may be considered a positive movement by the therapist but a disorganization by the ward physician or family."
(ëRelation of EEG delta activity
to behavioral response in electroshock: Quantitative serial studies,í
Fink and Kahn, Arch. Neurol. Psychiatry, 1957, 78:516-525)
* Restrictions on use of ECT with minors: Texas law stipulates:
§ 578.002. Use of Electroconvulsive
(a) Electroconvulsive therapy may not be used on a person who is younger than 16 years of age.
(b) Unless the person consents to the use of the therapy in accordance with Section 578.003, electroconvulsive therapy may not be used on:
(1) a person who is 16 years of age or older and who is voluntarily receiving mental health services; or
(2) an involuntary patient who is 16 years of age or older and who has not been adjudicated by an appropriate court of law as incompetent to manage the patient's personal affairs.
(c) Electroconvulsive therapy may not be used on an involuntary patient who is 16 years of age or older and who has been adjudicated incompetent to manage the patient's personal affairs unless the patient's guardian of the person consents to the treatment in accordance with Section 578.003. The decision of the guardian must be based on knowledge of what the patient would desire, if known.
Added by Acts 1993, 73rd Leg., ch.
705, § 5.01.
* Respecting medication employed to "limit the acts," as with ECT, there is no established indication for any substance to control aggression -- even aggression as a mental illness symptom.
"Most clinical information on treating
aggression has been collected for atypical neuroleptics, particularly for
clozapine. Ö At the moment, clozapine seems to be the first choice in aggression
treatment. Within the last few years, about 10 articles were published
showing that this is the most effective antiaggressive agent in the treatment
of aggression and agitation in psychiatric patients, independent of psychiatric
diagnosis. However, clozapine, like all the other substances used,
does not have an established indication for the treatment of aggressive
symptoms. Ö Ethical, juridical and methodological problems prevent controlled
studies from establishing a reference in the treatment of aggression in
mentally ill patients."
(ëPsychopharmacological Treatment of Aggression in Schizophrenic Patients,í T. Brieden, M. Ujeyl and D. Naber, Pharmacopsychiatry 35, 2002)