Madam, – In our current cultural context, where the experience of many vulnerable and voiceless people has been revealed as consisting of shocking assaults on their personhood and subjective experience, it is important to give full space to discussion of the treatment of mentally ill people. The experience of many such traumatised individuals has remained unheard for decades, perhaps even lost to their own everyday recall.
The continuing media discussions on electroconvulsive therapy (ECT) administered without consent illustrates another instance where individual subjectivity may be overridden for the sake of expediency.
Is our “time-poor” and “quick-fix” society biased in favour of treatments that do not make the time and relational continuity available for persons whose experience is beyond our comprehension?
Subjectivity is already severely compromised in persons suffering emotional/mental distress. It seems a barbaric act to further rob them of this, along with the remnants of whatever autonomy remains to them, by administering, against their will, a shocking sledgehammer to the brain which may leave them bereft of some of their autobiographical history.
Research shows many patients experience ongoing memory loss or personality effects. Does their experience not count? Might one not hope that, long before a person reaches the desperate state that psychiatrists describe, someone might have noticed something emotionally amiss with them and tried to engage them in a non-judging, non-fixing, listening kind of relationship while it might still have been possible to do so?
Undoubtedly some persons may welcome a treatment that rids them of painful memories and emotions that they find intolerable. Research shows that some men in our society choose suicide rather than express themselves emotionally. However, others may wish for the time and relational continuity where their subjective experience can be heard and validated; it is not a “one size fits all” situation. But this is distinct from the forced imposition of ECT on a person whose understanding of the process is impossible, or who refuses consent, and where the ethical guidelines seem far removed from those in most healthcare disciplines (S Barry, Letters, December 14th, 2009).
The treatment by biological methods of disturbed social relations (and, by extension, one’s relationship to oneself) as if these were disease entities has been consistently questioned in psychosocial approaches to psychiatry.
The use of ECT has always been controversial. Disagreement exists within psychiatry about the appropriateness of administering it to patients against their will, as well as what constitutes mental capacity to consent or refuse. Differences in the understanding of a patient's "best interests" are widespread ( Journal of Mental Health, June 2008).
Dr Dermot Walsh's call for the retention of compulsory ECT (Opinion, December 28th) omitted an important point from the British Medical Journalarticle on which he based his argument. In the journal article, it was clear that psychotherapy was an option that had been considered for the patient under discussion, but was not made available to her despite her being on a waiting list.
The associated Medscapearticle asserts: "ECT is recommended for consideration only after an adequate trial of other treatment options has proved ineffective."
For a treatment to be considered ineffective, it needs to have been actually offered on a trial basis. The fact a treatment is not available in the health service concerned should not preclude its discussion as part of fully informing the individual of options, both within and without a particular service. Withholding such information could be unethical.
Underlying these attitudes is another difficulty. Carers, both relatives and professionals, faced with a person who seemingly chooses to die, face a dreadful dilemma. They need a safe and supportive forum in which to discuss the stress and sense of responsibility they feel, to enable a sense of some distance from the powerful and painful emotions in which they are caught up. In some cases their predicament may lead to “therapeutic omnipotence”, a trap into which any professional may fall: a necessary belief in the power to cure/prevent any and all misfortunes.
Implementing professional support structures for all those who care for and work with the seriously emotionally disturbed could bring us nearer a mental healthcare system where ECT might no longer need to be a tool in the treatment box. – Yours, etc,