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."