When I began my first blogspot, "Torture and Totalitarianism", in January of this year, I was very concerned about the threat to civil liberties posed by the Military Commissions Act of 2006, and with good reason. Its denial of habeas corpus represented a novel and dangerous departure from constitutional law. On June 12 of this year, the Supreme Court's ruling in Boumediene v. Bush struck a blow against this law, although it is unlikely that the executive branch will abide by the court's decision, as the constitution requires. The MCA remains a serious threat to civil liberties. But through my research concerning the ways that psychiatry has been enlisted to help the CIA develop methods of coercing false confessions from detainees (especially as detailed in Colin Ross' book, The CIA Doctors), I have become aware of a still greater threat to civil liberties. It stems from an unholy alliance between government insiders and the psychiatric profession with the pharmaceutical and electronics industries. Under the guise of helping the mentally ill and saving the lives of innocent people who are supposedly threatened by them, it seeks to mandate measures which can only harm the former and place the latter in more danger. And I have come to believe that the accusation of involvement in terrorist activity is not likely to be the way in which the emerging totalitarian government will consolidate itself. After all, only a tiny minority of people can be even remotely associated with such activities. Although law-abiding Muslims will no doubt continue to be harrassed by such spurious accusations and suspicions, for the majority of Americans-- especially dissenters-- the worst threat stems from psychiatry. The leader in this effort is TAC, The Treatment Advocacy Center, founded by E. Torrey Fuller and Mary Zdanowicz in 1998. It advocates above all what it calls "Assisted Outpatient Treatment" or AOT. Nothing is more conducive to both the spread of totalitarianism and violence.
To understand why TAC constitutes such a threat, one must realize first of all that the definition of "mental illness" which applies to the majority of mental patients rests solely upon nonconformism. Thus the American Psychiatric Association defines "personality disorder" as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it." This is obviously not a definition of an illness and one would think that the APA would be embarrassed to put forward a position so much at odds with traditional American respect for individuality. Psychosis is defined much more narrowly as being characterized by delusions and hallucinations, but an influential school of thought holds that those diagnosed with a personality disorder may easily become psychotic-- that for instance, all schizotypal personality "disorders" are stages on a continuum leading to schizophrenia. One can see how in this view, people who have unorthodox political or religious beliefs may first be categorized "schizoid" and ultimately "schizophrenic", simply because they are dissenters. Obviously, opposition to government policies, such as the War on Terror, and prevalent religious beliefs such as monotheism, represent "an enduring pattern of deviant behavior". And when such individuals express their beliefs that, for instance, the threat of foreign terrorism is a fiction invented by our government (enhanced by state-sponsored acts of terrorism such as 9/11), or that the world is not governed by one all-powerful and righteous God but rather an evil one at odds with the true God of Righteousness, opinions which in fact represent merely political and religious dissent can come to be labeled "delusions" and "hallucinations" which prove that their advocates are psychotic. The link between "Assisted Outpatient Treatment" and government repression is made explicit in an interview with Mary Zdanowicz, director of TAC: "Since 9/11, authorities have linked approximately 5,000 murders in the U.S. to people who suffer from the most severe mental illnesses. That's more than have been attributed to our most feared terrorist enemy, Al Qaeda... solving this problem is one of the most urgent Homeland Security policy issues facing the nation today." (http://www.podtech.net/home/search/Treatment+Advocacy+Center). But that these 5,000 deaths were truly committed by people who are mentally ill is even more uncertain than the question of whether 9/11 was really the work of Al Qaeda.
The threat here is not just to civil liberties, as if that is not bad enough. It is to life itself. Consider the fact that the treatments advocated by TAC are harmful and hideous. Every day, groups which act as advocates for the mentally ill, such as Mind Freedom International, receive more and more complaints of court-ordered outpatient treatments with neuroleptic drugs and ECT from people who are perfectly peaceful and law-abiding, and they are quite clear about why they are complaining-- the treatments are horrendous. Neuroleptic drugs cause tardive akathisia, a condition in which the patient cannot sit or lie still and suffers from continual and severe mental torture. ECT causes mental confusion and permanent memory loss-- for one specific group of people, to be discussed later, it may destroy creativity (for more information on this, see the writings of Peter Breggin). No one who is ordered to have such treatments, which do not help and in fact cause immense suffering, is going to do so without protest-- not because they are unable to recognize that they are ill, but because they are perfectly able to recognize that the treatments are making them ill. It is to be assumed that peaceful and law-abiding citizens will pursue their grievance through organizations such as Mind Freedom, which to its credit has organized rescue missions to transport the victims out of the county in which the treatment was mandated. But what about those who are not peaceful and law-abiding? What about that tiny minority who may indeed be psychotic? What does it do to such a person to be threatened with treatments which are horrible while they are still living in the community? An answer may be found in a notorious tragedy which occurred in TAC's home state, The Virginia Tech Massacre.
On April 16, 2007, a 23-year-old student named Seung-Hui Cho murdered 32 people on the campus of Virginia Tech and then turned the gun on himself. In 2005, a Virginia Special Justice had declared Cho mentally ill and ordered him to seek outpatient treatment. Living so close to TAC, Cho no doubt knew what was coming. As he said in his suicide note, "You pushed me into a corner and left me no option". And what if he had been forced to have "Assisted Outpatient Treatment" as TAC advocates? As is well known, there is no form of psychiatric treatment which is guaranteed to work immediately. In the case of neuroleptics, it may be weeks before the incapacitating stupor overcomes one completely to the point that, if one were a student, one would neither be able to commit violent acts nor continue in one's studies. In the case of ECT, it may take several treatments before the deceptive euphoria caused by brain damage "kicks in". That leaves plenty of time for rage to build up. Someone suffering from the immediate effects of such "treatments", especially if they have genuine psychiatric problems to begin with, would not just sit and wait for the next one. If he or she has the slightest inclination toward violence, AOT or the threat of it is likely to be the trigger which unleashes such violence. And perhaps that is exactly what TAC and Homeland Security, with which it is obviously working closely, wants. Anyone examining the events of the Virginia Tech Massacre would have to be psychotic himself not to realize that Cho could not have been allowed to escape from the scene where he murdered the first two victims, change his clothes in the dorm next door, sign on to his computer to erase an e-mail and remove his hard drive, spend two hours in an unknown location, then go to the post office and mail a package to NBC News, before he returned to kill his remaining 30 victims (and himself) without official connivance. Could TAC have been part of this connivance?
Most murders are committed by psychopathic, not psychotic individuals. While often confused in the public mind, the two categories could not be more different. Psychosis is the most severe form of mental illness and is considered treatable. Psychopathy is a state of mind in which the person has no sense of right or wrong and delights in criminal acts-- it could simply be called moral depravity, and is not considered treatable. Being sane, psychopaths are clever and hard to catch-- their killing sprees can continue for years, as is the case with serial killers. By contrast, it is easy to prevent a person who is psychotic from killing and, if one cannot, to apprehend them afterwards. That is because, being completely out of touch with reality, psychotic individuals often give signs of their intentions before they ever commit their crimes, and make no attempt to conceal themselves afterwards. Both of these facts were true of Cho. So what should be done with such people? First let me say that such killing sprees are extremely rare and (unless someone deliberately allows them to continue as at Virginia Tech) inevitably short-lived, so worrying about their incidence is like worrying about an asteroid crashing into planet earth-- it can happen but most likely it won't. In November, 2004, voters in my home state, California (not including myself, of course) approved "Laura's Law", named after a victim of one of these rare killings. They had obviously been persuaded by one of TAC's unscientific but loud media campaigns that a new law was needed to address a problem for which we already have remedies. It says that Assisted Outpatient Treatment may be forced upon someone if they meet certain criteria: the individual must have a history of non-compliance with such treatment that has either "Been a significant factor in his or her being in a hospital, prison or jail at least twice within the last thirty-six months" or "Resulted in one of more acts, attempts or threats of violent behavior toward oneself and others within the past forty-eight months." That means that if a peaceful, law-abiding person were to refuse to have "treatments" for the excellent reason that they are making him worse, and has suffered forced hospitalization for that reason, he would be subjected to still more horrible and dangerous forced treatments. This could implant a desire to kill, in self-defense, even in someone who has no history of mental illness.
Of course if the violence is senseless and real-- even only an attempt-- or accompanied by such obvious indications of seriousness as the accumulation of weapons-- then something must be done. But AOT is not the answer. Faced with "treatments" which are not only genuinely harmful to himself but also extremely unpleasant to undergo, a genuinely psychotic and violent person would almost certainly be driven by this law to precisely the actions it was intended to prevent. I hesitate to advocate forced commitment, because it has so often been abused and because mental hospitals utilize the very "treatments" which as I have said, make a person worse. But if we could only outlaw such treatments, the thing to do would be to place such a person in a hospital. There are sedating drugs which do not have the harmful side-effects of the neuroleptics. Since such commitment must be regarded as a serious infringement of personal liberty, it should be difficult to accomplish legally, as indeed it is. But it has two great advantages over AOT: it does not leave the person at liberty to commit violent acts against innocents, and it does not break down the barrier between freedom and coercion which has heretofore existed in our society. People have long been held without good reason by in CIA prisons and mental institutions. But at least such incarceration left the realm of liberty clear-cut. The old Anglo-Saxon adage says that a man's home is his castle; TAC says that people should not be allowed freedom even in their own homes. This is just one step away from the Orwellian state in which a "telescreen" is installed in every dwelling to make sure that all citizens obey Big Brother. Has not President Bush called for mental health screening of all citizens? One can predict with confidence that President Obama will too. The reason is obvious: not only does it bring more profit to the pharmaceutical and electronics firms in which politicians and increasingly psychiatrists have an interest, but it strengthens the power of government to interfere in people's lives. NOthing could better serve these purposes than to take the focus off of the real threat to the safety of citizens-- the psychopathic killer who can only be dealt with by law enforcement-- and direct it instead at the mentally ill.
One thing is for certain: although the average man and woman in the street might be deceived, no professional who has dealt with the truly psychotic or violent individuals would ever advocate AOT, for the reasons I have enumerated. Anyone who does must be presumed to want such violence to occur, in order to serve ends which have nothing to do with public safety. Someone besides Seung-Hui Cho was responsible for the Virginia Tech Massacre. I accuse TAC of being the agency responsible.
Wednesday, December 10, 2008
Thursday, November 20, 2008
DON'T DARE TELL THEM YOU'RE DEPRESSED! A Review of Pushbutton Psychiatry
Timothy Kneeland and Carol A.B. Warren's Pushbutton Psychiatry: A Cultural History of Electroshock in America, is a useful source whose value is disguised by the ideology they authors impose on their subject. In focusing on patriarchy and sexism they are harping on the irrelevant, for ECT is not a gender issue. That is quite obvious from the fact that the most famous (although hardly the best) negative depiction of ECT, Ken Kesey's One Flew Over the Cuckoo's Nest, is emphatically sexist. And perhaps the most eminent victim of ECT, Ernest Hemingway, was a "macho man" who would not please most feminists. To judge by the CIA's decades of experiments with the procedure, including experiments in the field during the Vietnam War, it is likely that the most pitiable victims of ECT today are terrorist suspects, all of whom are men who adhere to beliefs of which no feminist could approve. Finally, as I know from personal experience, it is perfectly possible for a divorced woman to be the head of a household and to decide of her own volition, without any influence from men, to place her child in a mental hospital where he or she may be forced to endure ECT, drugging with neuroleptics, or other horrors. When women were decidedly second-class citizens, they were more often the victims of ECT because as with any type of abuse, it is the most helpless who are the most victimized. Today, when women have achieved an equal place with men, they are more likely to be victimizers, like for instance Kitty Dukakis whom I wrote about in my last blog, and Joan Prudic, M.D., a co-author of Harold Sackeim's now-famous article promoting unilateral ECT, who teaches a course in that subject at The New York State Psychiatric Institute. This should not surprise us, because there is no fundamental difference between males and females, and no reason why women should not be attracted to power and wealth as much as men-- ECT is an issue upon which some will take a stand from moral courage and others will use to further their own self-interest, regardless of whether they are male or female.
Under the spell of their obsession with gender, the authors waste many pages discussing the quasi-erotic and quackish use of electricity and "animal magnetism" in eighteenth and nineteenth century medical performances (and performances they were, in many cases before an audience) involving male doctors and female patients. Thus they miss the opportunity to discuss a much more relevant use of electricity in so-called "therapy". The practice of aversive conditioning derived from the theories of psychologist B.F. Skinner often makes use of painful electric shocks. Although these are not directed at the brain and therefore do not cause the massive physical damage that ECT does, they can cause psychological trauma when inflicted upon the helpless, such as children at the Judge Rotenberg School for Autistic Children. More importantly, they are similar to ECT in that they are in actuality punishment masquerading as therapy. Indeed, the closest relative of the ECT machine today is the Graduated Electronic Decelerator (GED) developed by Mathew Israel, director of the aforementioned school. The reader would do well to simply skip the first two chapters of this book entirely and read only chapters 3 through 5, which follow ECT from its birth in fascist Italy and enthusiastic reception in the what those countries which we used to call the "Western democracies", through its challenge by the social reform movements of the nineteen-sixties and seventies, to the ultimate and tragic triumph of ECT in the era of incipient totalitarianism, 1981 to the present day.
There are three excellent contributions which the authors make in these chapters. First, they discuss the struggle between the psychodynamic and somatic, or biological approach to mental illness. They establish quite accurately, although it rather undercuts their thesis of ECT as being an expression of patriarchy, that the psychodynamic model is the traditional one, the somatic a brazen usurper of recent vintage. Freud and his followers, whatever their defects (and some, such as Adler and Jung, were relatively free from the sexism which marred Freud's thinking), put the emphasis upon understanding the patient through prolonged discourse. Genuine psychotherapy is a time-consuming and expensive process, which does not appeal to the technocrats of today, obsessed as they are with the search for a "quick fix". But the their substitutes-- whether chemical or electrical-- not only do profound damage to the patient, they do not cure them. Even Kitty Dukakis admits that she has to go back to have more ECT treatments every few months, when her symptoms re-appear. So in a sense, ECT is like an addictive drug, and far more damaging to the user than cocaine or heroin. Similarly, people who are given neuroleptics are subject to the inner tortures of tardive dyskinisea or akathisia (a bit like delirium tremens) when they attempt to withdraw from them, even after a short period of time, with the result that they end up "hooked". The psychodynamic approach to mental illness may or may not cure it-- it is hard to say, for human beings are complex and any approach which takes account of these complexities is not easily subjected to statistical analysis. But the somatic approach is demonstrably a dismal failure. Indeed, psychiatrists who use it do not even claim that they are aiming to cure the patient, generally describing the individual upon whom they have inflicted their techniques as "in remission", implying that they are not and never will be "cured", but will have to come back again and again to pay for ever more expensive and damaging treatments. They are the legal equivalent of drug pushers. And what Kneeland and Warren fail to point out is that the place where the somatic concept of mental illness triumphed first and most completely, to the point of becoming official dogma, is the Soviet Union. Is there not something inherently totalitarian in an approach which had such appeal to the doctors working under Stalin?
The second contribution the authors make is in tracing the history of the legal battles over ECT, especially in California, where they raged most fiercely, probably because the juxtapositioning of some of the most wealthy electronics firms in Silicon Valley next to some of the most enlightened politically progressive communities in the nation in San Francisco and Berkeley. The attempts to restrict ECT in Berkeley and California at large which were made in the nineteen-seventies gave rise to a powerful backlash, led by the Association for Convulsive Therapy (ACT), which has completely eliminated free debate over the issue from the American Psychiatric Association and the psychiatric profession at large. Acceptance of the efficacy of some form of ECT is now required dogma for the aspiring psychiatrist and he or she can no more challenge it than a Soviet doctor could have challenged the questionable tenets which underlay Soviet medicine. But the most important factor in the triumph of ECT seems to have been money. Indeed, greed looms obscenely large in Kneeland and Warren's account. Contrary to Dukakis' assertion that there are only "two small companies manufacturing ECT devices, and they lack the means to do studies of it", there appear to be five major corporations-- Somatics, MECTA, Medcraft, Hittman and Eliot. These companies played a major role in the rehabilitation of ECT after its decline in the seventies, lobbying the FDA not to force them to pre-market test their machines because doing so would increase their costs by more than three million dollars (pp. 88-89). Thus a decision which could adversely affect the lives of millions of potential patients was made purely on the basis of the economic well-being of the corporations which manufactured the devices.
The ties between the "shock doctors" and the companies which make the machines they use and the videos to sell them to the consumer are close: MECTA was the invention of Dr. Paul Blachly, one of the founders of ACT; ECT proponents Drs. Richard Abrams and Conrad Swartz began Somatics in 1985; and Richard Abrams, who wrote the leading text on ECT, derives more than fifty per cent of his income from that company (pp. 91-92). Max Fink, the leading proponent of ECT in America today, shock proponents Harold Sackeim and Richard Weiner all contributed to the making of $350 videos to advertise ECT: Fink received $18,000 for his work and an 8% royalty on the them. One critic of of this overlap of professional and economic interest remarked that the APA Task force on ECT ought to be called "The Manufacturers Task force on ECT" (pp. 91-92). Here one must note the profits to be made from both private and taxpayer supported insurance: one study showed that 65-year-olds receive 360 per cent more shock therapy than 64-year-olds in Texas. The difference? Medicare pays for the latter. (p. 93). Reductions in the length of hospital stays reimbursed by private insurance during the 1980s set time limits on trials of psychoactive drugs (and even more so on traditional psychotherapy, which has always been undersupported by insurance). "Cynical observers noted that the advent of Diagnostic Related Groups (DRGs) for hosptial reimbursement may make ECT more cost-effective than drugs, for it works [sic] 30 to 40 times faster." (p. 93-- of course this means in practice that the patient gets the "high" associated with brain damage much faster than he would if given drugs). Thus insurance companies do not have to pay so much for the procedure, while shock is "very advantageous economically to hospitals". p. 83) Psychiatrists' fees are anywhere from $125 to $250 for the 5- 15 minute procedure; a study published in 1998 found that Medicare paid $97.73 and Medicaid $36 for psychiatrists attending ECT, the anaesthesiologist's fee fanged drom $75 to $160, while the nurse and treatment room added another $500 per treatment." (p. 92) Given the profitability of ECT, it is not surprising that the number of recipients in California doubled between 1994 and 2004, from 2,356 to 4,553.
How then to explain the hypocritical argument, made by many spokesmen for ECT, that it is a "benefit" denied by an unjust society to the poor? (p. 86) To understand this one must recognize that human beings are motivated by the quest for power and prestige as well as profit. And power and prestige can be collective. The struggle to replace the psychodynamic concept of mental illness with a soomatic one emanated from the struggle of psychiatry to gain equality with other medical specialties, and avoid sarcastic comments such as, "We are dissecting a cadaver-- would you be so kind to come and show us the location of the id?" (quoted in Don Gillmor, I Swear by Apollo) To maintain their own self-esteem, psychiatrists had to compete, to come up with results which could be quantified, which presents great difficulty for those who take a humane and compassionate approach to their patients. The increasing public perception of psychiatrists as "scientific" professionals swelled their own pride as it damaged their patients. And of course nothing could compare to the thrill of having the power to destroy a person's identity and rebuild it according to one's own wishes. Faced with the imperatives of modern technological society, traditional psychotherapy was to go the way of the U.S. Constitution and traditional concepts of freedom and dignity, dismissed as a mere relic of an irrelevant past. What was done by government fiat in the Communist countries was done by general agreement in the Western nations. Reading of the tragic acceleration of the rate of administration of ECT, one cannot help but be struck by the harm done by Ken Kesey's One Flew Over the Cuckoo's Nest. The real dangers of ECT are long-term. By emphasizing only the sight of the grand mal convulsion produced by ECT on an unanaesthetized patient, Kesey created a prejudice which was easily overcome by the slick advertising of ECT manufacturers (who were often one and the same as the doctors who administered the treatment). Those of us who formed our opinions of ECT long before we read Kesey's book or saw the film find it maddening to hear people say "Well it's not like that any longer," as if this had any relevance to the debate.
When I think of the ascendancy of the ECT lobby today, I am reminded of a Japanese Noh play, entitled The Valley Rite. I will not go into the entire historical background, which concerns the struggle between the native religion Shintoism and the imported one Buddhism, except to say that the play takes as its starting point an ancient belief that sick people pollute holy places and must not be allowed into them and then exaggerates this in order to make a point. In the play, a young boy, Matsuwaka, accompanies his religious master on a pilgrimage to a holy mountain. On the way, the boy is taken ill. Learning of this, his master says, "Hush! You mustn't say such a thing on this pilgimage. You are only tired because you are not accustomed to traveling. All you need is a good rest." But the leader of the pilgrimage finds out the truth, and says, "The boy is seriously ill. You must inform [his master] that it is our duty to hurl the boy into the valley, as our rule requires." Accordingly the boy is killed (Donald Keene, Editor, 20 Plays of the No Theatre, pp. 323-4). The mentally ill or troubled person is in exactly the same situation today. My advice to them is to find a good friend. If one is agitated, a psychiarist can be of use only if one does not place too much trust in him and knows what to ask for. If one is agitated, demand a minor tranquilizer-- the Benzodiazpepines (such as Valium and Ativan) are the most unjustly maligned of all psychiatric medications and so mild and harmless that in my opinion they should be sold over the counter. If you take an anti-depressant you are getting into heavier stuff-- it may help to pull you out of a depression but it has very bad side effects and should not be taken for long. But the major tranquilizers or neuroleptics will maim you for life and should be avoided. So too, it goes without saying, should ECT. Above all, for God's sake, don't tell anyone that you are severely depressed! Tragically, the "cry for help" does not stimulate compassion any longer but rather the desire to exploit in order to enhance the psychiatrist's own power, prestige and income. I you threaten or attempt to commit suicide, what the psychiatric profession will do to you will make you wish you had.
Under the spell of their obsession with gender, the authors waste many pages discussing the quasi-erotic and quackish use of electricity and "animal magnetism" in eighteenth and nineteenth century medical performances (and performances they were, in many cases before an audience) involving male doctors and female patients. Thus they miss the opportunity to discuss a much more relevant use of electricity in so-called "therapy". The practice of aversive conditioning derived from the theories of psychologist B.F. Skinner often makes use of painful electric shocks. Although these are not directed at the brain and therefore do not cause the massive physical damage that ECT does, they can cause psychological trauma when inflicted upon the helpless, such as children at the Judge Rotenberg School for Autistic Children. More importantly, they are similar to ECT in that they are in actuality punishment masquerading as therapy. Indeed, the closest relative of the ECT machine today is the Graduated Electronic Decelerator (GED) developed by Mathew Israel, director of the aforementioned school. The reader would do well to simply skip the first two chapters of this book entirely and read only chapters 3 through 5, which follow ECT from its birth in fascist Italy and enthusiastic reception in the what those countries which we used to call the "Western democracies", through its challenge by the social reform movements of the nineteen-sixties and seventies, to the ultimate and tragic triumph of ECT in the era of incipient totalitarianism, 1981 to the present day.
There are three excellent contributions which the authors make in these chapters. First, they discuss the struggle between the psychodynamic and somatic, or biological approach to mental illness. They establish quite accurately, although it rather undercuts their thesis of ECT as being an expression of patriarchy, that the psychodynamic model is the traditional one, the somatic a brazen usurper of recent vintage. Freud and his followers, whatever their defects (and some, such as Adler and Jung, were relatively free from the sexism which marred Freud's thinking), put the emphasis upon understanding the patient through prolonged discourse. Genuine psychotherapy is a time-consuming and expensive process, which does not appeal to the technocrats of today, obsessed as they are with the search for a "quick fix". But the their substitutes-- whether chemical or electrical-- not only do profound damage to the patient, they do not cure them. Even Kitty Dukakis admits that she has to go back to have more ECT treatments every few months, when her symptoms re-appear. So in a sense, ECT is like an addictive drug, and far more damaging to the user than cocaine or heroin. Similarly, people who are given neuroleptics are subject to the inner tortures of tardive dyskinisea or akathisia (a bit like delirium tremens) when they attempt to withdraw from them, even after a short period of time, with the result that they end up "hooked". The psychodynamic approach to mental illness may or may not cure it-- it is hard to say, for human beings are complex and any approach which takes account of these complexities is not easily subjected to statistical analysis. But the somatic approach is demonstrably a dismal failure. Indeed, psychiatrists who use it do not even claim that they are aiming to cure the patient, generally describing the individual upon whom they have inflicted their techniques as "in remission", implying that they are not and never will be "cured", but will have to come back again and again to pay for ever more expensive and damaging treatments. They are the legal equivalent of drug pushers. And what Kneeland and Warren fail to point out is that the place where the somatic concept of mental illness triumphed first and most completely, to the point of becoming official dogma, is the Soviet Union. Is there not something inherently totalitarian in an approach which had such appeal to the doctors working under Stalin?
The second contribution the authors make is in tracing the history of the legal battles over ECT, especially in California, where they raged most fiercely, probably because the juxtapositioning of some of the most wealthy electronics firms in Silicon Valley next to some of the most enlightened politically progressive communities in the nation in San Francisco and Berkeley. The attempts to restrict ECT in Berkeley and California at large which were made in the nineteen-seventies gave rise to a powerful backlash, led by the Association for Convulsive Therapy (ACT), which has completely eliminated free debate over the issue from the American Psychiatric Association and the psychiatric profession at large. Acceptance of the efficacy of some form of ECT is now required dogma for the aspiring psychiatrist and he or she can no more challenge it than a Soviet doctor could have challenged the questionable tenets which underlay Soviet medicine. But the most important factor in the triumph of ECT seems to have been money. Indeed, greed looms obscenely large in Kneeland and Warren's account. Contrary to Dukakis' assertion that there are only "two small companies manufacturing ECT devices, and they lack the means to do studies of it", there appear to be five major corporations-- Somatics, MECTA, Medcraft, Hittman and Eliot. These companies played a major role in the rehabilitation of ECT after its decline in the seventies, lobbying the FDA not to force them to pre-market test their machines because doing so would increase their costs by more than three million dollars (pp. 88-89). Thus a decision which could adversely affect the lives of millions of potential patients was made purely on the basis of the economic well-being of the corporations which manufactured the devices.
The ties between the "shock doctors" and the companies which make the machines they use and the videos to sell them to the consumer are close: MECTA was the invention of Dr. Paul Blachly, one of the founders of ACT; ECT proponents Drs. Richard Abrams and Conrad Swartz began Somatics in 1985; and Richard Abrams, who wrote the leading text on ECT, derives more than fifty per cent of his income from that company (pp. 91-92). Max Fink, the leading proponent of ECT in America today, shock proponents Harold Sackeim and Richard Weiner all contributed to the making of $350 videos to advertise ECT: Fink received $18,000 for his work and an 8% royalty on the them. One critic of of this overlap of professional and economic interest remarked that the APA Task force on ECT ought to be called "The Manufacturers Task force on ECT" (pp. 91-92). Here one must note the profits to be made from both private and taxpayer supported insurance: one study showed that 65-year-olds receive 360 per cent more shock therapy than 64-year-olds in Texas. The difference? Medicare pays for the latter. (p. 93). Reductions in the length of hospital stays reimbursed by private insurance during the 1980s set time limits on trials of psychoactive drugs (and even more so on traditional psychotherapy, which has always been undersupported by insurance). "Cynical observers noted that the advent of Diagnostic Related Groups (DRGs) for hosptial reimbursement may make ECT more cost-effective than drugs, for it works [sic] 30 to 40 times faster." (p. 93-- of course this means in practice that the patient gets the "high" associated with brain damage much faster than he would if given drugs). Thus insurance companies do not have to pay so much for the procedure, while shock is "very advantageous economically to hospitals". p. 83) Psychiatrists' fees are anywhere from $125 to $250 for the 5- 15 minute procedure; a study published in 1998 found that Medicare paid $97.73 and Medicaid $36 for psychiatrists attending ECT, the anaesthesiologist's fee fanged drom $75 to $160, while the nurse and treatment room added another $500 per treatment." (p. 92) Given the profitability of ECT, it is not surprising that the number of recipients in California doubled between 1994 and 2004, from 2,356 to 4,553.
How then to explain the hypocritical argument, made by many spokesmen for ECT, that it is a "benefit" denied by an unjust society to the poor? (p. 86) To understand this one must recognize that human beings are motivated by the quest for power and prestige as well as profit. And power and prestige can be collective. The struggle to replace the psychodynamic concept of mental illness with a soomatic one emanated from the struggle of psychiatry to gain equality with other medical specialties, and avoid sarcastic comments such as, "We are dissecting a cadaver-- would you be so kind to come and show us the location of the id?" (quoted in Don Gillmor, I Swear by Apollo) To maintain their own self-esteem, psychiatrists had to compete, to come up with results which could be quantified, which presents great difficulty for those who take a humane and compassionate approach to their patients. The increasing public perception of psychiatrists as "scientific" professionals swelled their own pride as it damaged their patients. And of course nothing could compare to the thrill of having the power to destroy a person's identity and rebuild it according to one's own wishes. Faced with the imperatives of modern technological society, traditional psychotherapy was to go the way of the U.S. Constitution and traditional concepts of freedom and dignity, dismissed as a mere relic of an irrelevant past. What was done by government fiat in the Communist countries was done by general agreement in the Western nations. Reading of the tragic acceleration of the rate of administration of ECT, one cannot help but be struck by the harm done by Ken Kesey's One Flew Over the Cuckoo's Nest. The real dangers of ECT are long-term. By emphasizing only the sight of the grand mal convulsion produced by ECT on an unanaesthetized patient, Kesey created a prejudice which was easily overcome by the slick advertising of ECT manufacturers (who were often one and the same as the doctors who administered the treatment). Those of us who formed our opinions of ECT long before we read Kesey's book or saw the film find it maddening to hear people say "Well it's not like that any longer," as if this had any relevance to the debate.
When I think of the ascendancy of the ECT lobby today, I am reminded of a Japanese Noh play, entitled The Valley Rite. I will not go into the entire historical background, which concerns the struggle between the native religion Shintoism and the imported one Buddhism, except to say that the play takes as its starting point an ancient belief that sick people pollute holy places and must not be allowed into them and then exaggerates this in order to make a point. In the play, a young boy, Matsuwaka, accompanies his religious master on a pilgrimage to a holy mountain. On the way, the boy is taken ill. Learning of this, his master says, "Hush! You mustn't say such a thing on this pilgimage. You are only tired because you are not accustomed to traveling. All you need is a good rest." But the leader of the pilgrimage finds out the truth, and says, "The boy is seriously ill. You must inform [his master] that it is our duty to hurl the boy into the valley, as our rule requires." Accordingly the boy is killed (Donald Keene, Editor, 20 Plays of the No Theatre, pp. 323-4). The mentally ill or troubled person is in exactly the same situation today. My advice to them is to find a good friend. If one is agitated, a psychiarist can be of use only if one does not place too much trust in him and knows what to ask for. If one is agitated, demand a minor tranquilizer-- the Benzodiazpepines (such as Valium and Ativan) are the most unjustly maligned of all psychiatric medications and so mild and harmless that in my opinion they should be sold over the counter. If you take an anti-depressant you are getting into heavier stuff-- it may help to pull you out of a depression but it has very bad side effects and should not be taken for long. But the major tranquilizers or neuroleptics will maim you for life and should be avoided. So too, it goes without saying, should ECT. Above all, for God's sake, don't tell anyone that you are severely depressed! Tragically, the "cry for help" does not stimulate compassion any longer but rather the desire to exploit in order to enhance the psychiatrist's own power, prestige and income. I you threaten or attempt to commit suicide, what the psychiatric profession will do to you will make you wish you had.
Saturday, November 1, 2008
SUICIDE, NOBLE AND IGNOBLE
Voluntary euthanasia or assisted suicide was the first political issue I ever cared deeply about (the right to abortion being the second). I was ten or eleven when I saw the 1962 film The Interns, in which an aspiring doctor, played as I recall by Cliff Robertson, ends the life of a man with a terminal and painful illness, who wants to die. For this he is deprived of his internship. I can still recall turning to my mother and asking, "Mommy, why are they mad at him? He didn't do anything wrong." I could not understand-- it seemed so unjust. Fifty-seven years later, the incomprehension and indignation remain as strong as ever. My rage at the opponents of voluntary euthanasia is increased by the way that proponents of the spiritual murder called ECT or electroconvulsive treatment use the threat of that a patient may commit suicide as an argument. But suicide is not always the rash impulse of a disordered mind. It can be an admirable act of courage. Indeed, such suicides have a long and venerable history throughout the world.
At the beginning of the fourth century BCE, the first prominent individualist in history, Socrates, was accused of "corrupting the morals" of Athenian youth by his argumentative debates, and sentenced to death by drinking hemlock. As he held the honorable status of Athenian citizen, he was however allowed the opportunity to escape into exile. In Plato's Crito, Socrates is depicted giving his reasons for accepting the death sentence-- that someone who has enjoyed the benefits of living under a government of law must abide by it even when the sentence is unjust, because the injustice was the error of men, not the law. This has become the foundation of our own tradition of civil disobedience, or non-violent protest. Althugh civil disobedience only makes sense in a government under law, which our nation is fast ceasing to be, for the person still fortunate enough to live in a democracy, the argument would be unanswerable and Socrates' choice of death was surely a well-considered and noble one.
Similarly, the founding of the Roman Republic was inspired by a suicide, that of Lucretia, who in the sixth century B.C. was raped by the son of the Tarquin king of Rome. According to Livy, Lucius Junius Brutus, her kinsman, grabbed the dagger from her breast and and declared war on the Tarquins. After assassinating the king, he had the Romans swear an oath that they should never again allow themselves to be ruled by kings. His descendent Marcus Junius Brutus, who is immortalized by Shakespeare as the "noblest Roman of them all", was in fact far less noble, because after the assassination he refused to sign a statement declaring Caesar to have been a tyrant in order to keep the office he had been awarded by Caesar as urban praetor. Between this and the servility of the general population, who loved Caesar for providing them with "bread and circuses", the Roman Republic was doomed. But some good men lived on. The letters of Pliny the Younger reveal the high regard in which people who committed suicide for noble reasons were held. While Pliny recognized and regretted that some people committed suicide purely on upon impulse, he praises those take their lives for good reason, as, for instance, and incurable and painful illness. His greatest hero in this regard is Arria, wife of Caecina Paetus.
When Lucius Arruntius Camillus Scribonianus led a rebellion against the Emperor Claudius in 42 CE with the intention of restoring the Republic, Caecina Paetus joined him. Scribonius was killed and Paetus was taken to Rome as a prisoner for conspiring with him. Arria attacked the wife of the leader of the rebellion for giving evidence to the prosecution, crying, "Am I to listen to you, who could go on living after Scribonius died in your arms?" After Paetus was ordered to commit suicide for his rebellion, Arria determined to join him. This should not be viewed as an expression of guilt or shame for their part in the rebellion, as Shakespeare depicts the conspirators in the assassination of Julius Caesar as feeling when they committed suicide-- rather it was an act akin to Socrates decision to drink the hemlock. When Arria's friends and relatives begged her not to take her own life, she said, according to Pliny, "You are wasting your time, for you can ensure me a coward's death, but you cannot prevent me from dying." With these words, she lept up from her chair, and ran into the wall opposite, knocking herself out and illustrating what she would do if her family were to deny her the easier means of killing herself afforded by a dagger. When her husband Paetus showed reluctance to take his own life, she herself unsheathed the dagger, pierced her own breast, and extracting it, handed it to her husband, declaring, "Non dolet, Paete!" ("Paetus, it doesn't hurt!"). These were lauded by Pliny as "immortal, almost godlike words" (Letters, Book III:16, pp. 75-76 of Oxford World Classics).
Outside the West, Japanese tradition also held suicide to be honorable in certain circumstances. Seppuku was the act of a noble samurai, performed if possible in a ritual setting, or if not on the battlefield (it was not so painful as one would think, for as soon as the person slit his belly, a second, or kaishaku, beheaded him. Women were permitted to die by simply slitting their throats). Sometimes Japanese lords or shoguns, such as the cruel Nobunaga and Hideoyoshi, ordered their vassals to commit suicide for no good reason. But on other occasions, seppuku was the route freely and rationally chosen by the samurai. One good reason was when one was faced with the choice of disobeying the lord to which one had pledged loyalty or doing something that one considered dishonorable. Another was defeat at the hands of a cruel enemy, who one knew would not permit one an honorable death. Finally, the Japanese, like Socrates, would commit seppuku if they violated the law, even if it was for a good reason. The famous tale of the Forty-Seven Ronin, or Chushingura, reveals the Japanese attitude both toward the assassination of an evil official and the decision to die. In the eighteenth century, the young Lord Asano of Ako Province was insulted by a Tokugawa bureaucrat, Kira, because he would not bribe him. In response he drew his sword in the shogunal palace, an unpardonable offense, and tried to kill Kira. Although he only succeeded in wounding him, he was sentenced to commit seppuku.
Dozens of Lord Asano's retainers, led by his chief retainer Oishi Kuranosuke, they secretly swore to avenge him and assassinate Kira. For years, they deliberately concealed their intentions in order to throw Kira off-guard. Then one snowy night, by pre-arrangment they descended upon Kira's mansion in Edo and overcame his guards. Finding the cowardly Kira hiding in a closet, Kuranosuke offered him the opportunity to choose an honorable death by seppuku. When he refused, Kuranosuke beheaded him. After offering his head to the gods at the temple of Sengaku-ji, the Forty-Seven turned themselves in in full recognition of what this would mean. Despite their immense popularity among the population of Edo, they were all sentenced to commit seppuku, a sentence which they accepted as calmly as Socrates accepted his. It should be noted that although the Tokugawa Regime was probably the most tyrannical which Japan had ever experienced, it did not torture the Forty-Seven or force them to "confess" that they were wrong, but permitted them an honorable death. In this respect, it showed itself far more civilized than our own present government. It is regrettable to see that Fumon Tanaka, in his otherwise excellent book, Samurai Fighting Arts: The Theory and Practice, has capitulated to Western prejudices to such an extent that he quite nonsensically denies that seppuku is suicide! (p. 48) Similarly, when a petition was circulating in California to permit voluntary euthanasia for the terminally ill, although I signed it, I was highly offended by a clause which denied that the act was suicide, as if suicide were something shameful.
And then, in Europe, the dark ages began. Centuries of domination by Christianity brought suicide into disrepute. The Church wanted people to believe that there was no escape from its tyranny and so it preached that suicide was sin and would condemn the person to hell, itself an invention of tyrannical minds (whether or not the Bible forbids suicide is irrelevant to those who, like myself, are neither Jewish nor Christian, and also to the laws of the United States, whose Constitution enjoins the separation of church and state). In the nineteenth century, psychiatrists replaced priests as buttresses of tyranny and declared suicide to be "sick", a modern variation upon the notion of "sinful". But some progress toward reason began to be made in places such as Switzerland, Scandinavia, and the United States in the late twentieth century. In the nineteen-seventies, the heretical psychiatrist Thomas Szasz wrote: "The individualistic position is that a person's life belongs to himself. Thus he has the right to take his own life, that is, to commit suicide... the medical-psychiatric position on suicide... ends in extolling mental health and survival over every other value, particularly liberty. In regarding the desire to live, but not the desire to die, as a legitimate human aspiration, the suicidologist stands Patrick Henry's famous exclamation, "Give me liberty or give me death!" on its head. In effect, it says, "Give him, commitment, give him electroshock, give him lobotomy, give him lifelong slavery, but do not let him choose death!... The result is a far-reaching infantilization and dehumanization of the suicidal person." ("The Ethics of Suicide, The Antioch Review, Spring 1971; Theology of Medicine; Political and Philosophical Foundations, pp. 75, 79-81).
In 1980 the Hemlock Society was founded by Derek Humphry, who had assisted his wife, diagnosed as terminally ill, to commit suicide. In 1991 it published the classic Final Exit, a manifesto of the right-to-die movement. I admired Humphry and wrote him in the late nineteen-eighties to say that his criteria for assisted suicide was too narrow. The right to die, I argued, should be extended first to mental patients who were suffering from inner torture which seemed incurable, and who should no more be forced to suffer than those diagnosed with a terminal physical illness. Secondly, it should be extended to those diagnosed with an incurable and severe physical illness-- blindness, paralysis and that sort of thing-- which, even if not fatal, reduced the quality of their life to the point where life was no longer living. Thirdly, it should be extended to convicts sentenced to life imprisonment, which I regard as a fate worse than death, which is why I have never supported the movement to abolish the death penalty-- what alternative is there? At the time, still believing that I lived in a democracy, I did not think to add that it should be extended to those threatened by political repression, although this obviously is only an argument for moral acceptance, for any such government would reveal the extent of its despotism precisely by denying the person this right. Humphry wrote me a polite response saying that if I wanted to extend the right to other categories of people I should found my own group, for the Hemlock Society was dedicated only to assisted suicide for those who were diagnosed with a terminal physical illness. Strategically he was right-- if people could not muster sufficient compassion to permit these people to die, how could they be expected to sympathize with mental patients, convicts, and the other categories I mentioned? But events were soon to prove that I was right in my contention that others beyond the terminally ill should be accorded the right to die.
In the nineteen-eighties, physician Jack Kevorkian began to assist terminally ill people to commit suicide in a very public way. Although his quest for publicity was to cut short his career, for which reason he was criticized by Humphry, it brought the issue into high relief among the public. In a sense America needed Kevorkian as much as it needed Humphry. But his attempt to bring the issue to a head backfired. Having helped some 130 terminally ill people to die, naturally he had his license to practice medicine revoked, for where suicide is concerned, the medical profession is still living in the dark ages. On the November, 23, 1998 broadcast of 60 Minutes, Kevorkian allowed the airing of a videotape he had made of the voluntary euthanasia of Thomas Youk. On March 1999, Kevorkian was accordingly charged with first-degree homicide. A Michigan jury found Kevorkian guilty of second-degree homicide (I have this from Wikipedia, and if it is correct, the terminology is chilling. "Homicide" is not a legal definition-- it simply means "the killing of a human being". One category of homicide-- killing in self-defense-- always has been and should be legal. Kevorkian should have been charged with manslaughter or murder, which are by definition crimes). He was sentenced to eight years in prison, which he accordingly accepted. And in prison they broke him--or at least in part. When he was released he told Mike Wallace of 60 Minutes that he would not assist anyone else to commit suicide, "because I gave my word that I would not". But this was merely a face-saving device. In fact, he had been forced to stop, because that was the condition of his release. And Kevorkian was only in an ordinary prison. What about the thousands now being held in Guantanamo and the secret CIA prisons, where fiendish tortures designed by psychiatrists are used to wear down the victim's defenses? Or those who will be sent to such prisons when our government turns openly fascist? Any incarcerated person can be broken. For that reason, in my opinion, Kevorkian himself should have committed suicide rather than allow himself to be incarcerated (oh yes, but he's running for Congress now, you will say-- but what difference can he make in a country which is no longer a democracy, where power resides not in elected officials but "Washington Insiders" and unelected bureaucrats?)
The Right-to-Die Movement has had one success story. In 1994 the governor of Oregon signed into law a "Death with Dignity" act passed by the state legislature. Oregon thus became the only one of the fifty states to be able to call itself truly civilized. Right-to-Die groups live on, although with altered names: The Hemlock Society changed its name to "Death With Dignity", "End-of-Life Choices" changed its name to "Compassion in Dying", then "Compassion in Dying" changed its name to "Compassion And Choices". The Voluntary Euthanasia Society of Australia changed its name to "Dying with Dignity" as did the Voluntary Euthanasia society of Great Britain. It is a sign of moral cowardice and our increasingly repressive times that people must engage in these ridiculous circumlocutions. As Humphry says, "Why not call a spade a spade?"
While there is such a thing as honorable suicide and death with dignity, there is also such a thing as dishonorable suicide. Kitty Dukakis is a prime example of the latter. Not long ago she gave an address to a group of college students on a northeastern campus (see "Addressing a 'Shocking' Issue, http://www.huntingtom-news.com/home/index.cfm?event=displayArticlePrinterFriendly&...) As she said, due to ECT, "I am a different person." To allow one's spirit to be killed and remade by others according to their own wishes is to display a profound lack of self-respect. But her opponents among the movement for the rights of psychiatric patients-- specifically Mind Freedom-- are no better. Having adoped the slogan "Mad Pride", which reinforces the most prevalent myth concerning mental illness-- that all mentally ill people are psychotic-- they have themselves committed a collective and dishonorable suicide. For another, when they had the chance to debate Dukakis they lost every opportunity she provided to defeat the pro-ECT forces. For one thing, they said her book was biased-- but as it is a personal account, not a scientific study, it cannot claim to be anything else. Different people value different things in life-- some value mere existence and animal gratification-- these are the people who seek dishonorable forms of suicide. Others value higher things such as freedom and independence. That Dukakis is of the former variety is evident. But in fact her own testimony can be used against ECT. She has admitted that it changed her personality. She has admitted that it affected her memory. She has admitted that the treatment has to be repeated again and again, so that it becomes in effect like an addictive drug. One could use her own testimony alone to argue against involuntary ECT.
When the issue of how it works came up, Dukakis said that the reason we don't know is because ECT equipment is produced by two small companies who cannot afford to study it. At that point Mind Freedom lost a valuable opportunity to ask if one of those companies is Mecta, and if so, why it is that Harold Sackeim, who is a consultant to that firm, found the support to do a study which finally admits that bilateral ECT causes cognitive defects but implies that unilateral is free of this risk. Clearly what we need are scientific studies aimed at assessing the cognitive effects of uniltateral ECT, but Mind Freedom shies away from this. Indeed, ECT survivor Leonard Frank, who is one of the organization's founders, told me that we already have enough information to ban ECT. But this is obviously not true, or else it would have already been banned, instead of increasing in prevalence and acceptance as it has. Sackeim has scored a spectacular coup against the movement for the rights of mental patients and they don't even recognize this fact. With friends like this, mental patients don't need enemies. There can be little doubt that increasing numbers of people will be forced to endure this spiritual murder in a society which still condemns death which is freely chosen.
For those who recognize what political opposition is ultimately going to mean in a nation headed in the direction ours is, suicide is a rational and even reassuring alternative, infinitely better than the alternatives of grovelling or being crushed in some hospital or prison. If one wonders whether it would be worth it to commit suicide under a totalitarian regime, let me quote George Orwell's villain O'Brien: "It is intolerable to us that an erroneous thought should exist anywhere in the world, however secret and powerless it may be. Even in the instant of death we cannot permit any deviation. In the old days, the heretic walked to the stake still a heretic, proclaiming his heresy, exulting in it. Even the victim of the Russian purges could carry rebellion locked up in his skull as he walked down the corridor waiting for the bullet. But we make the brain perfect before we blow it out." (1984, Signet edition, p. 210. Thus it is easy to see that the decision to die free has political significance, no matter how obscure the person who makes it may be. Let us resolve to blow out our own brains before Big Brother has even the slightest opportunity to go to work on them! But I don't advise suicide until one has exhausted every other option. And I would ask those considering it for political reasons to first ponder the following haiku I have composed on the subject:
And so the sakura
must fall. In our resolve to die lies
infinite freedom.
At the beginning of the fourth century BCE, the first prominent individualist in history, Socrates, was accused of "corrupting the morals" of Athenian youth by his argumentative debates, and sentenced to death by drinking hemlock. As he held the honorable status of Athenian citizen, he was however allowed the opportunity to escape into exile. In Plato's Crito, Socrates is depicted giving his reasons for accepting the death sentence-- that someone who has enjoyed the benefits of living under a government of law must abide by it even when the sentence is unjust, because the injustice was the error of men, not the law. This has become the foundation of our own tradition of civil disobedience, or non-violent protest. Althugh civil disobedience only makes sense in a government under law, which our nation is fast ceasing to be, for the person still fortunate enough to live in a democracy, the argument would be unanswerable and Socrates' choice of death was surely a well-considered and noble one.
Similarly, the founding of the Roman Republic was inspired by a suicide, that of Lucretia, who in the sixth century B.C. was raped by the son of the Tarquin king of Rome. According to Livy, Lucius Junius Brutus, her kinsman, grabbed the dagger from her breast and and declared war on the Tarquins. After assassinating the king, he had the Romans swear an oath that they should never again allow themselves to be ruled by kings. His descendent Marcus Junius Brutus, who is immortalized by Shakespeare as the "noblest Roman of them all", was in fact far less noble, because after the assassination he refused to sign a statement declaring Caesar to have been a tyrant in order to keep the office he had been awarded by Caesar as urban praetor. Between this and the servility of the general population, who loved Caesar for providing them with "bread and circuses", the Roman Republic was doomed. But some good men lived on. The letters of Pliny the Younger reveal the high regard in which people who committed suicide for noble reasons were held. While Pliny recognized and regretted that some people committed suicide purely on upon impulse, he praises those take their lives for good reason, as, for instance, and incurable and painful illness. His greatest hero in this regard is Arria, wife of Caecina Paetus.
When Lucius Arruntius Camillus Scribonianus led a rebellion against the Emperor Claudius in 42 CE with the intention of restoring the Republic, Caecina Paetus joined him. Scribonius was killed and Paetus was taken to Rome as a prisoner for conspiring with him. Arria attacked the wife of the leader of the rebellion for giving evidence to the prosecution, crying, "Am I to listen to you, who could go on living after Scribonius died in your arms?" After Paetus was ordered to commit suicide for his rebellion, Arria determined to join him. This should not be viewed as an expression of guilt or shame for their part in the rebellion, as Shakespeare depicts the conspirators in the assassination of Julius Caesar as feeling when they committed suicide-- rather it was an act akin to Socrates decision to drink the hemlock. When Arria's friends and relatives begged her not to take her own life, she said, according to Pliny, "You are wasting your time, for you can ensure me a coward's death, but you cannot prevent me from dying." With these words, she lept up from her chair, and ran into the wall opposite, knocking herself out and illustrating what she would do if her family were to deny her the easier means of killing herself afforded by a dagger. When her husband Paetus showed reluctance to take his own life, she herself unsheathed the dagger, pierced her own breast, and extracting it, handed it to her husband, declaring, "Non dolet, Paete!" ("Paetus, it doesn't hurt!"). These were lauded by Pliny as "immortal, almost godlike words" (Letters, Book III:16, pp. 75-76 of Oxford World Classics).
Outside the West, Japanese tradition also held suicide to be honorable in certain circumstances. Seppuku was the act of a noble samurai, performed if possible in a ritual setting, or if not on the battlefield (it was not so painful as one would think, for as soon as the person slit his belly, a second, or kaishaku, beheaded him. Women were permitted to die by simply slitting their throats). Sometimes Japanese lords or shoguns, such as the cruel Nobunaga and Hideoyoshi, ordered their vassals to commit suicide for no good reason. But on other occasions, seppuku was the route freely and rationally chosen by the samurai. One good reason was when one was faced with the choice of disobeying the lord to which one had pledged loyalty or doing something that one considered dishonorable. Another was defeat at the hands of a cruel enemy, who one knew would not permit one an honorable death. Finally, the Japanese, like Socrates, would commit seppuku if they violated the law, even if it was for a good reason. The famous tale of the Forty-Seven Ronin, or Chushingura, reveals the Japanese attitude both toward the assassination of an evil official and the decision to die. In the eighteenth century, the young Lord Asano of Ako Province was insulted by a Tokugawa bureaucrat, Kira, because he would not bribe him. In response he drew his sword in the shogunal palace, an unpardonable offense, and tried to kill Kira. Although he only succeeded in wounding him, he was sentenced to commit seppuku.
Dozens of Lord Asano's retainers, led by his chief retainer Oishi Kuranosuke, they secretly swore to avenge him and assassinate Kira. For years, they deliberately concealed their intentions in order to throw Kira off-guard. Then one snowy night, by pre-arrangment they descended upon Kira's mansion in Edo and overcame his guards. Finding the cowardly Kira hiding in a closet, Kuranosuke offered him the opportunity to choose an honorable death by seppuku. When he refused, Kuranosuke beheaded him. After offering his head to the gods at the temple of Sengaku-ji, the Forty-Seven turned themselves in in full recognition of what this would mean. Despite their immense popularity among the population of Edo, they were all sentenced to commit seppuku, a sentence which they accepted as calmly as Socrates accepted his. It should be noted that although the Tokugawa Regime was probably the most tyrannical which Japan had ever experienced, it did not torture the Forty-Seven or force them to "confess" that they were wrong, but permitted them an honorable death. In this respect, it showed itself far more civilized than our own present government. It is regrettable to see that Fumon Tanaka, in his otherwise excellent book, Samurai Fighting Arts: The Theory and Practice, has capitulated to Western prejudices to such an extent that he quite nonsensically denies that seppuku is suicide! (p. 48) Similarly, when a petition was circulating in California to permit voluntary euthanasia for the terminally ill, although I signed it, I was highly offended by a clause which denied that the act was suicide, as if suicide were something shameful.
And then, in Europe, the dark ages began. Centuries of domination by Christianity brought suicide into disrepute. The Church wanted people to believe that there was no escape from its tyranny and so it preached that suicide was sin and would condemn the person to hell, itself an invention of tyrannical minds (whether or not the Bible forbids suicide is irrelevant to those who, like myself, are neither Jewish nor Christian, and also to the laws of the United States, whose Constitution enjoins the separation of church and state). In the nineteenth century, psychiatrists replaced priests as buttresses of tyranny and declared suicide to be "sick", a modern variation upon the notion of "sinful". But some progress toward reason began to be made in places such as Switzerland, Scandinavia, and the United States in the late twentieth century. In the nineteen-seventies, the heretical psychiatrist Thomas Szasz wrote: "The individualistic position is that a person's life belongs to himself. Thus he has the right to take his own life, that is, to commit suicide... the medical-psychiatric position on suicide... ends in extolling mental health and survival over every other value, particularly liberty. In regarding the desire to live, but not the desire to die, as a legitimate human aspiration, the suicidologist stands Patrick Henry's famous exclamation, "Give me liberty or give me death!" on its head. In effect, it says, "Give him, commitment, give him electroshock, give him lobotomy, give him lifelong slavery, but do not let him choose death!... The result is a far-reaching infantilization and dehumanization of the suicidal person." ("The Ethics of Suicide, The Antioch Review, Spring 1971; Theology of Medicine; Political and Philosophical Foundations, pp. 75, 79-81).
In 1980 the Hemlock Society was founded by Derek Humphry, who had assisted his wife, diagnosed as terminally ill, to commit suicide. In 1991 it published the classic Final Exit, a manifesto of the right-to-die movement. I admired Humphry and wrote him in the late nineteen-eighties to say that his criteria for assisted suicide was too narrow. The right to die, I argued, should be extended first to mental patients who were suffering from inner torture which seemed incurable, and who should no more be forced to suffer than those diagnosed with a terminal physical illness. Secondly, it should be extended to those diagnosed with an incurable and severe physical illness-- blindness, paralysis and that sort of thing-- which, even if not fatal, reduced the quality of their life to the point where life was no longer living. Thirdly, it should be extended to convicts sentenced to life imprisonment, which I regard as a fate worse than death, which is why I have never supported the movement to abolish the death penalty-- what alternative is there? At the time, still believing that I lived in a democracy, I did not think to add that it should be extended to those threatened by political repression, although this obviously is only an argument for moral acceptance, for any such government would reveal the extent of its despotism precisely by denying the person this right. Humphry wrote me a polite response saying that if I wanted to extend the right to other categories of people I should found my own group, for the Hemlock Society was dedicated only to assisted suicide for those who were diagnosed with a terminal physical illness. Strategically he was right-- if people could not muster sufficient compassion to permit these people to die, how could they be expected to sympathize with mental patients, convicts, and the other categories I mentioned? But events were soon to prove that I was right in my contention that others beyond the terminally ill should be accorded the right to die.
In the nineteen-eighties, physician Jack Kevorkian began to assist terminally ill people to commit suicide in a very public way. Although his quest for publicity was to cut short his career, for which reason he was criticized by Humphry, it brought the issue into high relief among the public. In a sense America needed Kevorkian as much as it needed Humphry. But his attempt to bring the issue to a head backfired. Having helped some 130 terminally ill people to die, naturally he had his license to practice medicine revoked, for where suicide is concerned, the medical profession is still living in the dark ages. On the November, 23, 1998 broadcast of 60 Minutes, Kevorkian allowed the airing of a videotape he had made of the voluntary euthanasia of Thomas Youk. On March 1999, Kevorkian was accordingly charged with first-degree homicide. A Michigan jury found Kevorkian guilty of second-degree homicide (I have this from Wikipedia, and if it is correct, the terminology is chilling. "Homicide" is not a legal definition-- it simply means "the killing of a human being". One category of homicide-- killing in self-defense-- always has been and should be legal. Kevorkian should have been charged with manslaughter or murder, which are by definition crimes). He was sentenced to eight years in prison, which he accordingly accepted. And in prison they broke him--or at least in part. When he was released he told Mike Wallace of 60 Minutes that he would not assist anyone else to commit suicide, "because I gave my word that I would not". But this was merely a face-saving device. In fact, he had been forced to stop, because that was the condition of his release. And Kevorkian was only in an ordinary prison. What about the thousands now being held in Guantanamo and the secret CIA prisons, where fiendish tortures designed by psychiatrists are used to wear down the victim's defenses? Or those who will be sent to such prisons when our government turns openly fascist? Any incarcerated person can be broken. For that reason, in my opinion, Kevorkian himself should have committed suicide rather than allow himself to be incarcerated (oh yes, but he's running for Congress now, you will say-- but what difference can he make in a country which is no longer a democracy, where power resides not in elected officials but "Washington Insiders" and unelected bureaucrats?)
The Right-to-Die Movement has had one success story. In 1994 the governor of Oregon signed into law a "Death with Dignity" act passed by the state legislature. Oregon thus became the only one of the fifty states to be able to call itself truly civilized. Right-to-Die groups live on, although with altered names: The Hemlock Society changed its name to "Death With Dignity", "End-of-Life Choices" changed its name to "Compassion in Dying", then "Compassion in Dying" changed its name to "Compassion And Choices". The Voluntary Euthanasia Society of Australia changed its name to "Dying with Dignity" as did the Voluntary Euthanasia society of Great Britain. It is a sign of moral cowardice and our increasingly repressive times that people must engage in these ridiculous circumlocutions. As Humphry says, "Why not call a spade a spade?"
While there is such a thing as honorable suicide and death with dignity, there is also such a thing as dishonorable suicide. Kitty Dukakis is a prime example of the latter. Not long ago she gave an address to a group of college students on a northeastern campus (see "Addressing a 'Shocking' Issue, http://www.huntingtom-news.com/home/index.cfm?event=displayArticlePrinterFriendly&...) As she said, due to ECT, "I am a different person." To allow one's spirit to be killed and remade by others according to their own wishes is to display a profound lack of self-respect. But her opponents among the movement for the rights of psychiatric patients-- specifically Mind Freedom-- are no better. Having adoped the slogan "Mad Pride", which reinforces the most prevalent myth concerning mental illness-- that all mentally ill people are psychotic-- they have themselves committed a collective and dishonorable suicide. For another, when they had the chance to debate Dukakis they lost every opportunity she provided to defeat the pro-ECT forces. For one thing, they said her book was biased-- but as it is a personal account, not a scientific study, it cannot claim to be anything else. Different people value different things in life-- some value mere existence and animal gratification-- these are the people who seek dishonorable forms of suicide. Others value higher things such as freedom and independence. That Dukakis is of the former variety is evident. But in fact her own testimony can be used against ECT. She has admitted that it changed her personality. She has admitted that it affected her memory. She has admitted that the treatment has to be repeated again and again, so that it becomes in effect like an addictive drug. One could use her own testimony alone to argue against involuntary ECT.
When the issue of how it works came up, Dukakis said that the reason we don't know is because ECT equipment is produced by two small companies who cannot afford to study it. At that point Mind Freedom lost a valuable opportunity to ask if one of those companies is Mecta, and if so, why it is that Harold Sackeim, who is a consultant to that firm, found the support to do a study which finally admits that bilateral ECT causes cognitive defects but implies that unilateral is free of this risk. Clearly what we need are scientific studies aimed at assessing the cognitive effects of uniltateral ECT, but Mind Freedom shies away from this. Indeed, ECT survivor Leonard Frank, who is one of the organization's founders, told me that we already have enough information to ban ECT. But this is obviously not true, or else it would have already been banned, instead of increasing in prevalence and acceptance as it has. Sackeim has scored a spectacular coup against the movement for the rights of mental patients and they don't even recognize this fact. With friends like this, mental patients don't need enemies. There can be little doubt that increasing numbers of people will be forced to endure this spiritual murder in a society which still condemns death which is freely chosen.
For those who recognize what political opposition is ultimately going to mean in a nation headed in the direction ours is, suicide is a rational and even reassuring alternative, infinitely better than the alternatives of grovelling or being crushed in some hospital or prison. If one wonders whether it would be worth it to commit suicide under a totalitarian regime, let me quote George Orwell's villain O'Brien: "It is intolerable to us that an erroneous thought should exist anywhere in the world, however secret and powerless it may be. Even in the instant of death we cannot permit any deviation. In the old days, the heretic walked to the stake still a heretic, proclaiming his heresy, exulting in it. Even the victim of the Russian purges could carry rebellion locked up in his skull as he walked down the corridor waiting for the bullet. But we make the brain perfect before we blow it out." (1984, Signet edition, p. 210. Thus it is easy to see that the decision to die free has political significance, no matter how obscure the person who makes it may be. Let us resolve to blow out our own brains before Big Brother has even the slightest opportunity to go to work on them! But I don't advise suicide until one has exhausted every other option. And I would ask those considering it for political reasons to first ponder the following haiku I have composed on the subject:
And so the sakura
must fall. In our resolve to die lies
infinite freedom.
Sunday, October 26, 2008
YES, OLD DOGS CAN LEARN NEW TRICKS
In my last blog, I wrote about the threat posed by long-time ECT advocate Harold Sackeim and five colleagues, "The Cognitive Effects of Electroconvulsive Therapy in Community Settings," in the journal Neuropsychopharmacology in January, 2007 (32: 244-254). The most obvious and immediate one, which I have already discussed, is that while showing that bilateral ECT produces adverse cognitive effects, the study still leaves the door open to the administration of right unilateral ECT-- indeed, as I have shown, promoting its use was the authors' intention. But the more I think about it, the more problems I find with this article, which has been so tragically misinterpreted by the movement for the rights of mental patients. For instance, if one analyzes the conclusion, which has given ECT opponents such false optimism, "There seems to be little justification for the continued first-line use of bilateral ECT in the treatment of major depression," one can see that not only does it not rule out the use of right unilateral ECT as a first-line treatment for that illness, it also does not rule out the use of bilateral ECT as a "last resort" if other methods fail. And perhaps even more disturbingly, it says absolutely nothing about the use of ECT to treat other mental illnesses besides major depression.
This presents a danger to a wide range of people because of the way that mental illness is defined. After all, only a minority of people who are diagnosed as mentally ill have ever experienced a psychotic episode. And of those who have-- schizophrenics, manic-depressives (those suffering from what is today called bipolar disorder) and depressives-- many are quite sane most of the time. I recently received the fall, 2008 Journal of Mind Freedom, the leading American organization fighting for the rights of mental patients, and was dismayed as always to find the term "mad pride" all over it. Indeed, the letter from the executive director, David Oaks, entitled "Why Mad Pride?" uses the term throughout with no apparent recognition of the way it discredits everything he says. No one will or should believe someone who is psychotic-- that is to say, irrational-- and organizations like Mind Freedom do not have to persuade the public to do so in order to achieve their goals. For it is unequivocally evident that, whatever he might have experienced in the past, David Oaks has not been having psychotic episodes for the twenty years during which he has headed Mind Freedom, and he was not having one when he wrote this letter. Mind Freedom could not possibly have mounted an effective campaign for anything whatsoever while its members were in the grip of psychosis. There is no evidence of it anywhere on their website or in their publications. Why then do they indulge in the manifestations of self-loathing signified by the term, "Mad Pride"? An article in the New York Times says that "Just as gay rights activists reclaimed the word 'queer' as a badge of honor rather than a slur, these advocates proudly call themselves 'mad'." But this is not true: having lived for much of my life in San Francisco I know that "queer" remains a slur-- what homosexuals did was to find a new word-- "gay"-- to describe themselves. The self-abasement indicated by their adoption of the word "mad" to describe themselves makes members of the movement for the rights of mental patients ill-equiped to fight ECT.
The majority of people diagnosed as mentally ill have what psychiatrists term a "personality disorder". "Personality disorder" is defined by the APA as an "enduring pattern of inner experience and behavior which deviates markedly from the expectations of the culture of the individual who exhibits it." Nothing comes closer to an admission that to psychiatry, people who are simply different are considered for that fact to be mentally ill. Given that this is the official definition (see Wikipedia article on the subject), no psychiatrist could deny that the object of psychiatry is to punish and persecute social deviance and non-conformity. People diagnosed with a personality disorder are not psychotic, but many psychiatrists believe that personality disorders represent milder forms of the psychoses they resemble. In other words, someone with a minor depression could become a major or manic-depressive, and someone with a schizoid or schizotypal personality could become schizophrenic. I recently received an e-mail circular from Rene Talbot, who heads an organization for the rights of mental patients in Germany. He said that his country is on the verge of adopting a provision, fraudulently claiming to be derived from the UN Declaration on the Rights of Persons with Disabilities, which would allow its government to incarcerate an individual diagnosed as mentally ill if he is a danger to himself or others, or under additional circumstances which are not specified. It is easy to see where this provision came from: the equally fraudulent "War on Terror" being waged by the United States government. The aspiring totalitarians in our government have not only the unconstitutional Military Commissions Act to use against dissidents, they also have the category of mental illness, which has long been used to incarcerate people against their will. And of course the worst weapon in their arsenal of repression is ECT.
Although ECT is usually thought of as a treatment for depression, it is in fact also being used against people who are diagnosed-- whether rightly or wrongly-- as schizophrenic (and remember that those diagnosed with a milder personality disorder which resembles schizophrenia can easily be pushed into this category). The website of ect.org has an article based on a number of studies which concludes that "There is some evidence to support the use of ECT for those with schizophrenia for short-term relief of symptoms. Electroconvulsive therapy may be advocated as an adjunct to anti-psychotic medication for those with schizophrenia who show a limited response to medication alone but the evidence for this is not strong... evidence exists to suggest that combining antipsychotic drugs with ECT increases the rate and extent of clinical improvement, in the short term, in one out of every five or six people." (http://www.ect.org/resources/schizophrenia/html) In other words, for the sake of mere short-term improvement, and although the majority of patients show no improvement at all, psychiatrists are willing to take the tremendous risks involved in the administration of ECT, in combination with anti-psychotic drugs which are themselves dangerous. Of course, as I have said before, we need more studies of the effects of unilateral ECT to determine just how dangerous it is, but no form of ECT can be said to be free of risk and to prescribe it under such questionable conditions is truly playing God. Leonard Frank's History of Shock Treatment contains an alarming quotation from English psychiatrist Andrew Wyllie: "The introverted schizophrenic or melancholic may be likened to a walled city which has closed its gates and refuses to trade with the rest of the world. Methods of persuasion having failed to get the citizens to open the gates of 'Mansoul', the artillery of convulsion therapy is brought to bear upon the walls of autism." (p. 14) It seems appropriate that Wyllie was willing to play the role of Satan in the story from which the name 'Mansoul' was taken-- John Bunyan's Holy War.
Is there any circumstance under which the adminstration of ECT may be justified? I was greatly disturbed by another article in the Fall Mind Freedom Journal. It was taken from an address by Mary Van Pelt, entitled "May is Mental Health Awareness Month". In it she speaks of the job discrimination that she, as a highly-placed professional, experienced when it became known that she had been diagnosed with bipolar disorder. This is a legitimate topic for an organization devoted to the rights of mental patients, and would be all the more relevant if she had been falsely diagnosed with a psychotic illness, as many people are. Then she goes off on a very dangerous tangent: "When my career ended so did my need to keep silent about a condition which kills thousands every year... Suicide statistics are difficult to track due to the very nature of suicide. The act is surrounded by stigma. Depending upon the circumstances, suicide can be reported as death from natural causes. The National Strategy for Suicide Prevention estimates that between three and twenty per cent of persons diagnosed with bipolar disorder die each year by suicide. Because of my own experience, I find this statistic very easy to understand." (p.11) How on earth could Mind Freedom have failed to see that this woman is quite obviously working not for patients' rights but rather for organized psychiatry? After all, bipolar disorder and suicide are not political issues, they are personal ones. And a feigned concern over the possibity of suicide is the most common justification for the use of ECT-- one assumes from his conclusion that Sackeim would approve of even bilateral ECT for the suicidal patient. In directing her comments at the danger of suicide rather than psychiatric abuse, Ms. Van Pelt shows very clearly where her sympathy lies-- not with mental patients but with psychiatrists.
Why is her tactic so dangerous and insidious? First of all, because people falsely assume that every suicide is the result of mental illness. Obviously Van Pelt does, and it is people like herself who have stigmatized suicide. Suicide, which was accepted as a legitimate response to many situations by cultures such as the Roman and Japanese, can be a perfectly rational act. It makes good sense for someone diagnosed with an agonizing but incurable illness to want to commit suicide--so too the painter who is told that he is going blind or the pianist who must lose the use of his hands. Above all, one must be ready to die when one is fighting a tyrannical government. By refusing to be taken alive, one spares oneself the pain and indignity of being held captive by people who have no decency or compassion. As for those who are contemplating suicide simply because they are afflicted with a clinical depression, one is certainly justified in stopping them-- at least for awhile-- in the hope that they will change their mind. One may even be justified in forcing anti-depressant medications on them temporarily, in the expectation that their mood will improve. But if they show no improvement, is one justified in using ECT? Some people, being fully informed, prefer the spiritual death involved in ECT to either a continuation of their depression or physical death. Obviously Kitty Dukakis did. And that is their right, just as it is their right to commit suicide. But if a person has been prevented from committing suicide for months, given medication and compassion and is still suicidal, I would present them with the following choice: "There is a treatment which may end your depression, although it will probably have to be repeated again and again all your life. It has worse side-effects than any drug known to man, in that it damages your memory and will, if administered a sufficient number of times, ultimately destroy your sense of identity. Do you wish us to administer this treatment to you or would you still prefer to die?" If they opt for the latter course, it is our moral obligation to provide them with the most humane method available of taking their own lives.
There is in fact no justification for forcing any form of ECT on anyone. Doing so is equivalent to murder. As we have seen, the majority of mental patients are sane and, fully informed, know perfectly well what is good for themselves. Even with those minority who may be having a psychotic episode and are in danger of taking a life they would regret having taken if they were sane, it is not justifiable to force something so dangerous as ECT upon them. Their inability to make a rational decision makes the treatment by definition involuntary. Ironically, the only people who are capable of giving their consent to ECT are those who are sane. Yet ECT continues to be used not only against the insane and incapacitated but also against those who are merely "different". This is the most hideous threat which hangs over anyone who has been diagnosed with a mental illness, however mild, (and perhaps some who have not been, for there is evidence that it may be being used against suspects in the so-called "War on Terror"). Activists for the rights of mental patients are not making things any better by printing articles such as Van Pelt's and speaking of "mad pride." Why not define mental illness in terms which suit the patient rather than the psychiatrist? For instance, a person suffering from bipolar disorder may warn, "Don't kill my spirit in order to save my body." Someone suffering from one of the schizotypal illnesses may declare, "I am a militant loner-- invade my mental space and you'll be sorry!" (in other words, this 'Mansoul' has artillery which can fire back). Above all, we must forever bear in mind the immmortal words of John Stuart Mill:
"Even despotism does not produce its worst effects so long as individuality exists under it, and whatever crushes individuality is despotism, by whatever name it may be called, and whether it professes to be enforcing the will of God or the injunctions of men."
This presents a danger to a wide range of people because of the way that mental illness is defined. After all, only a minority of people who are diagnosed as mentally ill have ever experienced a psychotic episode. And of those who have-- schizophrenics, manic-depressives (those suffering from what is today called bipolar disorder) and depressives-- many are quite sane most of the time. I recently received the fall, 2008 Journal of Mind Freedom, the leading American organization fighting for the rights of mental patients, and was dismayed as always to find the term "mad pride" all over it. Indeed, the letter from the executive director, David Oaks, entitled "Why Mad Pride?" uses the term throughout with no apparent recognition of the way it discredits everything he says. No one will or should believe someone who is psychotic-- that is to say, irrational-- and organizations like Mind Freedom do not have to persuade the public to do so in order to achieve their goals. For it is unequivocally evident that, whatever he might have experienced in the past, David Oaks has not been having psychotic episodes for the twenty years during which he has headed Mind Freedom, and he was not having one when he wrote this letter. Mind Freedom could not possibly have mounted an effective campaign for anything whatsoever while its members were in the grip of psychosis. There is no evidence of it anywhere on their website or in their publications. Why then do they indulge in the manifestations of self-loathing signified by the term, "Mad Pride"? An article in the New York Times says that "Just as gay rights activists reclaimed the word 'queer' as a badge of honor rather than a slur, these advocates proudly call themselves 'mad'." But this is not true: having lived for much of my life in San Francisco I know that "queer" remains a slur-- what homosexuals did was to find a new word-- "gay"-- to describe themselves. The self-abasement indicated by their adoption of the word "mad" to describe themselves makes members of the movement for the rights of mental patients ill-equiped to fight ECT.
The majority of people diagnosed as mentally ill have what psychiatrists term a "personality disorder". "Personality disorder" is defined by the APA as an "enduring pattern of inner experience and behavior which deviates markedly from the expectations of the culture of the individual who exhibits it." Nothing comes closer to an admission that to psychiatry, people who are simply different are considered for that fact to be mentally ill. Given that this is the official definition (see Wikipedia article on the subject), no psychiatrist could deny that the object of psychiatry is to punish and persecute social deviance and non-conformity. People diagnosed with a personality disorder are not psychotic, but many psychiatrists believe that personality disorders represent milder forms of the psychoses they resemble. In other words, someone with a minor depression could become a major or manic-depressive, and someone with a schizoid or schizotypal personality could become schizophrenic. I recently received an e-mail circular from Rene Talbot, who heads an organization for the rights of mental patients in Germany. He said that his country is on the verge of adopting a provision, fraudulently claiming to be derived from the UN Declaration on the Rights of Persons with Disabilities, which would allow its government to incarcerate an individual diagnosed as mentally ill if he is a danger to himself or others, or under additional circumstances which are not specified. It is easy to see where this provision came from: the equally fraudulent "War on Terror" being waged by the United States government. The aspiring totalitarians in our government have not only the unconstitutional Military Commissions Act to use against dissidents, they also have the category of mental illness, which has long been used to incarcerate people against their will. And of course the worst weapon in their arsenal of repression is ECT.
Although ECT is usually thought of as a treatment for depression, it is in fact also being used against people who are diagnosed-- whether rightly or wrongly-- as schizophrenic (and remember that those diagnosed with a milder personality disorder which resembles schizophrenia can easily be pushed into this category). The website of ect.org has an article based on a number of studies which concludes that "There is some evidence to support the use of ECT for those with schizophrenia for short-term relief of symptoms. Electroconvulsive therapy may be advocated as an adjunct to anti-psychotic medication for those with schizophrenia who show a limited response to medication alone but the evidence for this is not strong... evidence exists to suggest that combining antipsychotic drugs with ECT increases the rate and extent of clinical improvement, in the short term, in one out of every five or six people." (http://www.ect.org/resources/schizophrenia/html) In other words, for the sake of mere short-term improvement, and although the majority of patients show no improvement at all, psychiatrists are willing to take the tremendous risks involved in the administration of ECT, in combination with anti-psychotic drugs which are themselves dangerous. Of course, as I have said before, we need more studies of the effects of unilateral ECT to determine just how dangerous it is, but no form of ECT can be said to be free of risk and to prescribe it under such questionable conditions is truly playing God. Leonard Frank's History of Shock Treatment contains an alarming quotation from English psychiatrist Andrew Wyllie: "The introverted schizophrenic or melancholic may be likened to a walled city which has closed its gates and refuses to trade with the rest of the world. Methods of persuasion having failed to get the citizens to open the gates of 'Mansoul', the artillery of convulsion therapy is brought to bear upon the walls of autism." (p. 14) It seems appropriate that Wyllie was willing to play the role of Satan in the story from which the name 'Mansoul' was taken-- John Bunyan's Holy War.
Is there any circumstance under which the adminstration of ECT may be justified? I was greatly disturbed by another article in the Fall Mind Freedom Journal. It was taken from an address by Mary Van Pelt, entitled "May is Mental Health Awareness Month". In it she speaks of the job discrimination that she, as a highly-placed professional, experienced when it became known that she had been diagnosed with bipolar disorder. This is a legitimate topic for an organization devoted to the rights of mental patients, and would be all the more relevant if she had been falsely diagnosed with a psychotic illness, as many people are. Then she goes off on a very dangerous tangent: "When my career ended so did my need to keep silent about a condition which kills thousands every year... Suicide statistics are difficult to track due to the very nature of suicide. The act is surrounded by stigma. Depending upon the circumstances, suicide can be reported as death from natural causes. The National Strategy for Suicide Prevention estimates that between three and twenty per cent of persons diagnosed with bipolar disorder die each year by suicide. Because of my own experience, I find this statistic very easy to understand." (p.11) How on earth could Mind Freedom have failed to see that this woman is quite obviously working not for patients' rights but rather for organized psychiatry? After all, bipolar disorder and suicide are not political issues, they are personal ones. And a feigned concern over the possibity of suicide is the most common justification for the use of ECT-- one assumes from his conclusion that Sackeim would approve of even bilateral ECT for the suicidal patient. In directing her comments at the danger of suicide rather than psychiatric abuse, Ms. Van Pelt shows very clearly where her sympathy lies-- not with mental patients but with psychiatrists.
Why is her tactic so dangerous and insidious? First of all, because people falsely assume that every suicide is the result of mental illness. Obviously Van Pelt does, and it is people like herself who have stigmatized suicide. Suicide, which was accepted as a legitimate response to many situations by cultures such as the Roman and Japanese, can be a perfectly rational act. It makes good sense for someone diagnosed with an agonizing but incurable illness to want to commit suicide--so too the painter who is told that he is going blind or the pianist who must lose the use of his hands. Above all, one must be ready to die when one is fighting a tyrannical government. By refusing to be taken alive, one spares oneself the pain and indignity of being held captive by people who have no decency or compassion. As for those who are contemplating suicide simply because they are afflicted with a clinical depression, one is certainly justified in stopping them-- at least for awhile-- in the hope that they will change their mind. One may even be justified in forcing anti-depressant medications on them temporarily, in the expectation that their mood will improve. But if they show no improvement, is one justified in using ECT? Some people, being fully informed, prefer the spiritual death involved in ECT to either a continuation of their depression or physical death. Obviously Kitty Dukakis did. And that is their right, just as it is their right to commit suicide. But if a person has been prevented from committing suicide for months, given medication and compassion and is still suicidal, I would present them with the following choice: "There is a treatment which may end your depression, although it will probably have to be repeated again and again all your life. It has worse side-effects than any drug known to man, in that it damages your memory and will, if administered a sufficient number of times, ultimately destroy your sense of identity. Do you wish us to administer this treatment to you or would you still prefer to die?" If they opt for the latter course, it is our moral obligation to provide them with the most humane method available of taking their own lives.
There is in fact no justification for forcing any form of ECT on anyone. Doing so is equivalent to murder. As we have seen, the majority of mental patients are sane and, fully informed, know perfectly well what is good for themselves. Even with those minority who may be having a psychotic episode and are in danger of taking a life they would regret having taken if they were sane, it is not justifiable to force something so dangerous as ECT upon them. Their inability to make a rational decision makes the treatment by definition involuntary. Ironically, the only people who are capable of giving their consent to ECT are those who are sane. Yet ECT continues to be used not only against the insane and incapacitated but also against those who are merely "different". This is the most hideous threat which hangs over anyone who has been diagnosed with a mental illness, however mild, (and perhaps some who have not been, for there is evidence that it may be being used against suspects in the so-called "War on Terror"). Activists for the rights of mental patients are not making things any better by printing articles such as Van Pelt's and speaking of "mad pride." Why not define mental illness in terms which suit the patient rather than the psychiatrist? For instance, a person suffering from bipolar disorder may warn, "Don't kill my spirit in order to save my body." Someone suffering from one of the schizotypal illnesses may declare, "I am a militant loner-- invade my mental space and you'll be sorry!" (in other words, this 'Mansoul' has artillery which can fire back). Above all, we must forever bear in mind the immmortal words of John Stuart Mill:
"Even despotism does not produce its worst effects so long as individuality exists under it, and whatever crushes individuality is despotism, by whatever name it may be called, and whether it professes to be enforcing the will of God or the injunctions of men."
Monday, October 6, 2008
BLINDSIDED: The Reality Behind Sackeim's Article
In military strategy, it is axiomatic that one must keep up with the technological sophistication of one's enemy. If he achieves a new breakthrough, then one must be prepared to meet it. The same holds true for political campaigns. If one is ignorant of or misinterprets an advance on the part of the enemy, the results may be disastrous. And that is exactly what has happened in the on-going war over ECT, or electroconvulsive treatment. The pro-ECT forces have recently staged a cunning coup which has caught the anti-ECT forces so off-guard that most are as yet unaware that they have been blindsided.
That coup is best represented by an article authored by long-time ECT proponent Harold Sackeim, along with five colleagues, "The Cognitive Effects of Electroconvulsive Therapy in Community Settings," which appeared in the January, 2007 issue of Neuropsychopharmacology (32, 244-254). Having tested 347 patients who have had ECT, the researchers find that adverse cognitive effects, above all retrograde amnesia, persist for at least six months following an acute treatment course. Since this article's appearance, anti-ECT forces have been crowing over what they interpret as a victory for their cause. The website of ect.org has long been carrying an article entitled "Electroconvulsive Therapy Causes Permanent Amnesia and Cognitive Defects, Prominent Researcher Admits." It quotes Linda Andre, head of the Committee for Truth in Psychiatry, as saying that the study is "a stunning reversal of a 25-year career." Dr. Peter Breggin, the maverick psychiatrist who has long opposed ECT and other questionable psychiatric practices asserts quite falsely that the article proves that "every form of ECT causes lasting memory and mental dysfunction." (http://huffingtonpost.com/dr-peter-breggin/disturbing-news-for-patie-b-44734.html) A recent press release from the Wellbeing Foundation in Ireland continues the praise, calling the article a public recantation of Sackeim's previous views, and concludes that Sackeim "now rejects, at the very least, the widespread use of ECT... This gamekeeper has turned poacher."
Unfortunately, Sackeim's article is exactly the opposite of what the anti-ECT lobby thinks it is. It is an effort to sell ECT-- the new kind of ECT which Sackeim favors-- not discourage its use. The article on the ect.org website asserts that Sackeim is a consultant to the ECT device manufacturer Mecta Corporation-- if this is true, then it should certainly have alerted anti-ECT forces to what is really going on. The electronics industry is progressing at a dizzying and sometimes quite maddening pace. As new technologies become available, corporations try to discredit older technologies so that they may sell the maximum number of new products. This has happened, for instance, in the replacement of LPs by CDs, VHS by DVD, and older types of computers by more sophisticated ones. In these cases the old technology, although perfectly usable, becomes increasingly difficult to obtain, thus forcing the consumer to buy more electronic gadgetry. And in the case of television, the transition is taking place by government fiat, although for reasons I cannot fathom there has been little protest against this blatant violation of free market principles. ECT device manufacturers like Mecta are part of the electronics industry, and as with computers or television manufacturers, they naturally want to push this new, "state-of-the-art" product in place of the old one. With respect to ECT, this means unilateral, in which the current is directed through only one side of the brain, as opposed to bilateral, in which the current is passed through both. The fact that bilateral ECT has been put "on the shelf" does not however mean that it is dead. We may yet witness a craze among psychiatrists for "retro" ECT accompanied by Billie Holiday singing All of Me-- to wit, "You took the best, why not take the rest?"
The explanation for Sackeim's article is not merely economic-- it is also professional-- that is to say, he is defending the professional group with which he identifies. Although Sackeim is a psychologist, his loyalty is to the medical model of mental illness which dominates psychiatry today, and the article in question does not contain the slightest indication that this has changed. Knowing that much of the public fears ECT, a psychotherapist is only too happy to be able to say, "We know that the old kind of ECT had unacceptable side-effects, but the new kind is different," and that is exactly the point of Sackeim's article. It's the same thing that happened when it became common to anaesthetize patients so that they did not appear to have the dramatic and frightening grand mal convulsion portrayed in One Flew Over the Cuckoo's Nest (of course they still had it-- ECT would not be ECT without a convulsion-- but they did not look as if they did). Sackeim wants to win the trust of prospective patients-- if not for himself then for his colleagues-- and he has excellent prospects for doing so, for he has won over his worst enemies. But is this trust warranted? Although his study concludes, "There appears to be little justification for the continued use of BL ECT in the treatment of major depression," with right unilateral ECT (RUL) it is a different matter: "Indeed, recent work suggests that high dosage RUL delivered with an ultrabrief stimulus maintains efficacy and results in minimal retrograde amnesia even in the period immediately following the ECT course." But what does "minimal" mean in practice? That one forgets only the last five years of one's relationship with one's spouse instead of forgetting him or her entirely? Surely it is necessary to do far more tests with RUL ECT before it can be considered safe. Yet Sackeim is not calling for any.
What Sackeim and his colleagues are trying to do was explained in an article in the New York Times,"The Quiet Comeback of Electroshock Therapy," by Daniel Goldman on August 2, 1990. The article quotes Sackeim as saying, "There's been a sea-change in our understanding of ECT in the past decade... Until about 10 years ago, patients were commonly given the maximal charge, with machines set at the upper limit... but patients vary greatly in the level of current at which they will have a seizure. On average, a woman needs about 80 per cent as much current as a man, and the older you are the more you need. You need less current if applied to only one side of the head instead of both." What Sackeim is arguing for is a more fine-tuned version of ECT, instead of the sledgehammer approach which prevailed in the past. It's sort of like first-strike nukes which are accurate enough to take out the enemy's defenses so that one can achieve victory in a single surprise attack rather than the old kind of nuke which destroyed weapons and people indiscriminately. It looks more humane but in fact may be more dangerous for that very reason. Unfortunately, the anti-ECT movement is still using a sledgehammer approach to fight the procedure, and taking no account of the new and more subtle strategy adopted by its opponents. For one thing, it does not keep up with developments in psychiatry-- most of its leaders would not give a psychiatrists the time of day, and seem never to have heard the maxim, "Know your enemy". Furthermore, as one can see from the writings of anti-ECT activists such as Peter Breggin and Leonard Frank, it is calling for a complete and total ban on ECT, voluntary or involuntary. This is bound to doom their cause in an era when people as articulate and intelligent as Kitty Dukakis and Dick Cavett have joined the pro-ECT bandwagon. And it is after all rather hypocritical to oppose ECT on the grounds that it is a violation of civil liberties while denying it to those who really want it.
This support for an all-out ban is associated with another error of monumental proportions, the overestimation of the damage done by ECT, which misses an essential point: ECT is dangerous precisely because it destroys memory while leaving other brain functions relatively intact. Exaggeration such as that found in the work of Breggin, who maintains that it can reduce people to a subhuman level, leaves the anti-ECT people open to the charge that survivors like Leonard Frank, who have become activists against it, are in fact the best advertisements for the procedure (Rael Jean Isaac and Virginia ARmat, Madness in the Streets, p. 209) But the limited and very specific nature of the damage done by ECT in fact makes it easier to sell: shock doctors would have a hard time if Michael now had to bottle-feed and diaper Kitty or Dick's brain had shrunk to the size of a chimpanzee's. Above all, it makes ECT the perfect tool for totalitarianism. The growing number of government officials who want to replace our free republic with a totalitarian state need confessed "traitors" and converts who appear to be of normal intelligence, maturity, and sanity. That is why the CIA showed so much interest in ECT for decades, although it has no conceivable value for the acquisition of intelligence, funding such unethical experiments as those of Ewen Cameron of the Allan Memorial Institute. President Bush's call for national mental health screening shows that psychiatrists are still viewed as the shock troops of the new fascism: capture a dissident, declare him mentally ill, and give him ECT treatments. When he emerges, docile and resigned though to all outward appearances still "normal", he will become a walking advertisement for totalitarianism. The anti-ECT forces do not seem to see how endangered their movement itself is. In 2006, the U.S. Congress and President Bush approved the Animal Enterprise Terrorism Act (AETA), labelling animal rights activists-- most of whom are non-violent to a fault-- as "ecoterrorists". How long will it be before activists opposed to ECT and other psychiatric abuses find themselves branded "psychoterrorists"?
George Orwell, whose 1984 contains what is perhaps the first depiction of ECT in literature, has his villain, O'Brien, say that "He who controls the past controls the future." And it is all too true. That is why the inability of the anti-ECT movment to mount an effective challenge to the pro-ECT lobby is so disheartening. The use of ECT is not on the decline: it is increasing, and is likely to do so to an even greater extent in the future due to articles such as Sackeim's. The organized opponents of ECT, who have deluded themselves into thinking that they are winning, are in fact losing, to a catastrophic extent. And their loss is everyone's loss. For what is at stake here is not just the rights of mental patients, it is political liberty itself.
That coup is best represented by an article authored by long-time ECT proponent Harold Sackeim, along with five colleagues, "The Cognitive Effects of Electroconvulsive Therapy in Community Settings," which appeared in the January, 2007 issue of Neuropsychopharmacology (32, 244-254). Having tested 347 patients who have had ECT, the researchers find that adverse cognitive effects, above all retrograde amnesia, persist for at least six months following an acute treatment course. Since this article's appearance, anti-ECT forces have been crowing over what they interpret as a victory for their cause. The website of ect.org has long been carrying an article entitled "Electroconvulsive Therapy Causes Permanent Amnesia and Cognitive Defects, Prominent Researcher Admits." It quotes Linda Andre, head of the Committee for Truth in Psychiatry, as saying that the study is "a stunning reversal of a 25-year career." Dr. Peter Breggin, the maverick psychiatrist who has long opposed ECT and other questionable psychiatric practices asserts quite falsely that the article proves that "every form of ECT causes lasting memory and mental dysfunction." (http://huffingtonpost.com/dr-peter-breggin/disturbing-news-for-patie-b-44734.html) A recent press release from the Wellbeing Foundation in Ireland continues the praise, calling the article a public recantation of Sackeim's previous views, and concludes that Sackeim "now rejects, at the very least, the widespread use of ECT... This gamekeeper has turned poacher."
Unfortunately, Sackeim's article is exactly the opposite of what the anti-ECT lobby thinks it is. It is an effort to sell ECT-- the new kind of ECT which Sackeim favors-- not discourage its use. The article on the ect.org website asserts that Sackeim is a consultant to the ECT device manufacturer Mecta Corporation-- if this is true, then it should certainly have alerted anti-ECT forces to what is really going on. The electronics industry is progressing at a dizzying and sometimes quite maddening pace. As new technologies become available, corporations try to discredit older technologies so that they may sell the maximum number of new products. This has happened, for instance, in the replacement of LPs by CDs, VHS by DVD, and older types of computers by more sophisticated ones. In these cases the old technology, although perfectly usable, becomes increasingly difficult to obtain, thus forcing the consumer to buy more electronic gadgetry. And in the case of television, the transition is taking place by government fiat, although for reasons I cannot fathom there has been little protest against this blatant violation of free market principles. ECT device manufacturers like Mecta are part of the electronics industry, and as with computers or television manufacturers, they naturally want to push this new, "state-of-the-art" product in place of the old one. With respect to ECT, this means unilateral, in which the current is directed through only one side of the brain, as opposed to bilateral, in which the current is passed through both. The fact that bilateral ECT has been put "on the shelf" does not however mean that it is dead. We may yet witness a craze among psychiatrists for "retro" ECT accompanied by Billie Holiday singing All of Me-- to wit, "You took the best, why not take the rest?"
The explanation for Sackeim's article is not merely economic-- it is also professional-- that is to say, he is defending the professional group with which he identifies. Although Sackeim is a psychologist, his loyalty is to the medical model of mental illness which dominates psychiatry today, and the article in question does not contain the slightest indication that this has changed. Knowing that much of the public fears ECT, a psychotherapist is only too happy to be able to say, "We know that the old kind of ECT had unacceptable side-effects, but the new kind is different," and that is exactly the point of Sackeim's article. It's the same thing that happened when it became common to anaesthetize patients so that they did not appear to have the dramatic and frightening grand mal convulsion portrayed in One Flew Over the Cuckoo's Nest (of course they still had it-- ECT would not be ECT without a convulsion-- but they did not look as if they did). Sackeim wants to win the trust of prospective patients-- if not for himself then for his colleagues-- and he has excellent prospects for doing so, for he has won over his worst enemies. But is this trust warranted? Although his study concludes, "There appears to be little justification for the continued use of BL ECT in the treatment of major depression," with right unilateral ECT (RUL) it is a different matter: "Indeed, recent work suggests that high dosage RUL delivered with an ultrabrief stimulus maintains efficacy and results in minimal retrograde amnesia even in the period immediately following the ECT course." But what does "minimal" mean in practice? That one forgets only the last five years of one's relationship with one's spouse instead of forgetting him or her entirely? Surely it is necessary to do far more tests with RUL ECT before it can be considered safe. Yet Sackeim is not calling for any.
What Sackeim and his colleagues are trying to do was explained in an article in the New York Times,"The Quiet Comeback of Electroshock Therapy," by Daniel Goldman on August 2, 1990. The article quotes Sackeim as saying, "There's been a sea-change in our understanding of ECT in the past decade... Until about 10 years ago, patients were commonly given the maximal charge, with machines set at the upper limit... but patients vary greatly in the level of current at which they will have a seizure. On average, a woman needs about 80 per cent as much current as a man, and the older you are the more you need. You need less current if applied to only one side of the head instead of both." What Sackeim is arguing for is a more fine-tuned version of ECT, instead of the sledgehammer approach which prevailed in the past. It's sort of like first-strike nukes which are accurate enough to take out the enemy's defenses so that one can achieve victory in a single surprise attack rather than the old kind of nuke which destroyed weapons and people indiscriminately. It looks more humane but in fact may be more dangerous for that very reason. Unfortunately, the anti-ECT movement is still using a sledgehammer approach to fight the procedure, and taking no account of the new and more subtle strategy adopted by its opponents. For one thing, it does not keep up with developments in psychiatry-- most of its leaders would not give a psychiatrists the time of day, and seem never to have heard the maxim, "Know your enemy". Furthermore, as one can see from the writings of anti-ECT activists such as Peter Breggin and Leonard Frank, it is calling for a complete and total ban on ECT, voluntary or involuntary. This is bound to doom their cause in an era when people as articulate and intelligent as Kitty Dukakis and Dick Cavett have joined the pro-ECT bandwagon. And it is after all rather hypocritical to oppose ECT on the grounds that it is a violation of civil liberties while denying it to those who really want it.
This support for an all-out ban is associated with another error of monumental proportions, the overestimation of the damage done by ECT, which misses an essential point: ECT is dangerous precisely because it destroys memory while leaving other brain functions relatively intact. Exaggeration such as that found in the work of Breggin, who maintains that it can reduce people to a subhuman level, leaves the anti-ECT people open to the charge that survivors like Leonard Frank, who have become activists against it, are in fact the best advertisements for the procedure (Rael Jean Isaac and Virginia ARmat, Madness in the Streets, p. 209) But the limited and very specific nature of the damage done by ECT in fact makes it easier to sell: shock doctors would have a hard time if Michael now had to bottle-feed and diaper Kitty or Dick's brain had shrunk to the size of a chimpanzee's. Above all, it makes ECT the perfect tool for totalitarianism. The growing number of government officials who want to replace our free republic with a totalitarian state need confessed "traitors" and converts who appear to be of normal intelligence, maturity, and sanity. That is why the CIA showed so much interest in ECT for decades, although it has no conceivable value for the acquisition of intelligence, funding such unethical experiments as those of Ewen Cameron of the Allan Memorial Institute. President Bush's call for national mental health screening shows that psychiatrists are still viewed as the shock troops of the new fascism: capture a dissident, declare him mentally ill, and give him ECT treatments. When he emerges, docile and resigned though to all outward appearances still "normal", he will become a walking advertisement for totalitarianism. The anti-ECT forces do not seem to see how endangered their movement itself is. In 2006, the U.S. Congress and President Bush approved the Animal Enterprise Terrorism Act (AETA), labelling animal rights activists-- most of whom are non-violent to a fault-- as "ecoterrorists". How long will it be before activists opposed to ECT and other psychiatric abuses find themselves branded "psychoterrorists"?
George Orwell, whose 1984 contains what is perhaps the first depiction of ECT in literature, has his villain, O'Brien, say that "He who controls the past controls the future." And it is all too true. That is why the inability of the anti-ECT movment to mount an effective challenge to the pro-ECT lobby is so disheartening. The use of ECT is not on the decline: it is increasing, and is likely to do so to an even greater extent in the future due to articles such as Sackeim's. The organized opponents of ECT, who have deluded themselves into thinking that they are winning, are in fact losing, to a catastrophic extent. And their loss is everyone's loss. For what is at stake here is not just the rights of mental patients, it is political liberty itself.
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