Dear Minister a letter from Delete59b Campaign

Dear Minister,

Re: Section 59(B) of the Mental Health Act 2001

We hope this finds you well.

We are writing to enquire about developments in relation to the above.

When Senator Dan Boyle proposed the deletion of Section 59(B) in the Senate last year, there was an agreement that the heads of a bill to do this would be brought before the Dail by the summer session. Senator Boyle, in the company of John McCarthy, agreed to postpone debate in the Senate on the day. As we understand it, the amendment to delete 59(b) was to stand alone as a proposal in the Dail, as it was worded in the Senate amendment.

We would respectfully ask if there are plans to progress this matter.

At the hearing in Leinster House, the College of Psychiatry’s position was that there should be minimal amendments to the current regulations governing the use of ECT in Irish hospitals. Their proposal was that 1) the word ‘unwilling’ should be removed, 2) that the second opinion consultant should be nominated from a panel held by the Mental Health Commission (MHC) and that this consultant should ‘consult’ with another member of the Multi Disciplinary Team (MDT), 3) that the College itself should, in conjunction with the MHC, collect information about the use of ECT.

We believe that these changes are far from what is needed and what is being demanded by many service users in Ireland. In reality, they will lead to no significant change in the status quo. Doctors will still be able to order ECT for patients without their consent and with minimal consultation with anyone else. There will be no redress for those who feel that they were treated wrongly. The safeguards for patients will continue to be inadequate. We believe that many people working in mental health share these concerns.

We acknowledge that many patients feel that they have benefited from ECT. This is not disputed. However, a very large number do not benefit and many are significantly harmed by the procedure. When you organized the two presentations to parliamentarians earlier this year, you indicated that you thought there was merit in both sides of the debate. We hope that you will not now renege on this by putting forward the College’s proposal as your answer to the debate. To do this would be to turn away from the many service users, relatives and professionals who have grave concerns about ECT and particularly its use with patients who cannot give consent.

Our proposal to delete Section 59(B) will not affect the provision of ECT on a voluntary basis. However, we believe that the regulations governing voluntary ECT need to be amended as there is evidence that up to 50% of people who have this treatment do not feel that it was properly explained to them. It is questionable how ‘voluntary’ their consent is in these circumstances.

What is really at stake in this debate is an effort to open up the field of mental health so that different voices can be heard. For too long, the voice of the medical profession has dominated. Only service users who agreed with the medical model and who presented no real challenge to the status quo were heard. Times have changed. This culture of medical paternalism is no longer acceptable and is completely out of keeping with the values of A Vision for Change (VfC). This makes the case that: ‘service users and carers should be involved in a meaningful way with the planning and delivery of care. A partnership approach should be taken to the planning, development, delivery, evaluation and monitoring of mental health services, with the inclusion of all stakeholders. It is through partnership that trust is built for all involved’ (VfC, p 15). Many service users in Ireland and internationally do not experience the medical framing of their problems as helpful. In fact, many feel that they have been harmed by the overly forceful use of the medical approach. Some feel that they have been abused. We believe that such individuals, and the groups that represent them, have a right to be ‘stakeholders’ in the partnership approach advocated by VfC. To exclude them, to ignore them when they challenge the current power structures in the mental health field would be a travesty and an insult to those who worked to produce VfC.

However, we believe that if the voices of ‘critical’ service users are to be heard and given the same respect afforded to those who are happy with the traditional medical approach, the powers invested in mental health professionals, especially psychiatrists, will have to be lessened.

ECT is a controversial intervention. In their presentation at Leinster House, the College of Psychiatry presented a very positive version of the empirical evidence about the efficacy, safety and mode of action of this treatment. The obvious enthusiasm for ECT displayed by those who presented is out of keeping with the practice of most psychiatrists in Britain and Ireland over the past 20 years. ECT is being used less and less across these islands. Most psychiatrists seem increasingly slow to prescribe this treatment. However, the wide variation in usage of ECT across the state demonstrates that while the majority of psychiatrists are using this treatment less often, there are a minority who are ‘ECT enthusiasts’. This fact, particularly when combined with the catchment area system of mental health care (in which service users have no control over which psychiatrist will be involved in their care) is a very strong argument against the status quo.

At present, Ireland is undergoing a major cultural change. Deference to traditional sources of authority has been substantially eroded by scandals involving the clergy, politicians, bankers, financiers and the medical profession. We believe that it is time to seriously interrogate the power structures involved in the mental health system. This system, which has been dominated by the psychiatric profession since its origins in the asylums of the 19th century, has failed many of the people who were placed in its care. This debate about ECT has drawn public attention to the fact that massive powers continue to be placed in the hands of psychiatrists. Our argument is not anti-psychiatry. But we do seek a psychiatry that is more humble and more willing (and able) to engage respectfully with those who critique the medical model.

We urge you not to endorse the proposal presented by the College of Psychiatry. We urge you to consider removing Section 59(B) of the Mental Health Act, thereby placing ECT alongside all the other treatments that can be prescribed by doctors, and giving psychiatric patients the right to legal redress when they feel they have been treated badly.

Yours etc,

Pat Bracken
Harry Gijbels
John McCarthy
Paddy McGowan

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School of Applied Social Studies, University College Cork

The Case of Involuntary ECT

Tuesday 27 April 2-4 pm

Boole 2, UCC

Presentations by: Dr. Pat Bracken (Consultant Psychiatrist, West Cork Mental Health Services), John McCarthy (Mental Health Campaigner, Founder MadPride Irelan……d) &
Paddy McGowan (Expert by Experience Lecturer, Dublin City University)

Followed by open debate and questions

All Welcome!

log on to http://www.delete59b.com and sign the petition

We live in interesting times

Change is on the way.

 www. Delete 59b.com, of the mental health act 2001 of Ireland (to stop the use of involuntary ECT) is gaining significant ground, already compromise is on offer, section 59b states if the patient is “unable or unwilling” then two psychiatrists can sign a form and force you take ECT against your will.

 We have been to Lienster House over the last few weeks, debating.

 The college of psychiatry agreed yesterday that it is time to remove “unwilling”.

 There were calls for a full independent review of the whole mental health act.

 Calls, for the new capacity legislation to come into place!

 To ratify the UN Convention on the rights of the Disabled!

 Advanced directives( a type of living will)

 All necessary.

 All sounds great, but they just do not get the point, it is not enough.

 We are told we should be grateful for progress; but this is about human rights not some treatment or other.

 This is about equality, our right as members  of the mad community to stand tall as equal citizens. The common law is there to protect us, but rather then protect us we are excluded from that same common law.

 They offer crumbs we want to share the meal.

 Stigma and abuse will always exist as long as we empower one section of our community to force treatment of any kind on another.

 The recent Murphy and Ryan reports confirm this.

 The college of Psychiatry tried to divert the debate yesterday and they focused in on the benefits of ECT.

 Delete 59b will not affect anybody’s right, to choose with free and informed consent to have ECT.

 It is so important that you understand this fact.

 We believe in choice, that is your right, we do not believe that you should be forced to take ECT by force, and on the signature of two psychiatrists and that alone. No need to consult with family, or anybody else, and its legal.

 Fear again set the tone of the opposition, irrational fear of us, in the public arena, as justification for the abuse.

 It was interesting yesterday to see some facts begin to emerge in this debate. You are very un-lightly to have ECT on offer in public hospitals, yet it seems to be big business in the private sector of psychiatry.

 That factor alone surely deserves an independent investigation, the private sector of psychiatry in so much more enthusiastic in its use of ECT, as against those psychiatrists who work in the public sector. Why? You guess, I won’t speculate here.

 I will state that when I was a patient in a private hospital I was offered ECT as a last resort, as my psychiatrist explained,

“ you are going home next week John, the pills are not working and your VHI is running out, I would like to try a few doses of ECT”.

  My wife put a stop to that thank God, I had no idea at that time of what had just been proposed I was so drugged up!

 When the Neary case came before the courts, the judge reached a guilty verdict, because Dr Neary’s threshold of use of his surgical procedure was too high in comparison to his colleagues.

 This pattern is emerging now in psychiatry, across the country. We need to know the truth here, and not some peer review.

 It was both sad and upsetting to hear myself as a person who lives with the normality of madness in my life, who now recognises the great gifts that deep emotional feelings bring to my life, being referred to over and over again by those who should know better, those who purport to speak for us, as VUNERABLE members of the community.

 How can we expect to hold our heads high as equal citizens when those who “support” us believe we are not capable of walking with dignity and equality in our own communities?

 I would call for a complete ban on the use of that overwhelming, paternalistic, insulting description of my community, those gifted with deep feelings, open to insult, we who give society art, poetry, literature, beauty:

 “as those VUNERABLE people who live among us, and society has a DUTY to protect THEM”, they are insulting me to my face, when they our supporters speak thus to my position in reference to the  law. Where I am defined in article 3 of the 2001 mental health act as follows….

“3 (1) in this Act “mental disorder” means mental illness, severe dementia, or significant intellectual disability where…”

How can I as someone, a successful business man, who had a breakdown and on a temporary basis, simply lost control of my emotional feelings, expect equal treatment under the law when my capacity under that same law is accessed on the basis I exist in the same legal space as a person with intellectual disability!

It is time to talk of mental health not “mental illness”.

Those same spokespeople “supporters” will stand on another platform next week and rail on at the need to reduce stigma, in policy!!

Society has a duty to protect all its citizens equally, we ask for no more than that.

Either that or those who in their hearts do not believe we are capable of standing with pride in our own place should walk a    way from this debate.

It is most encouraging speaking on an ongoing basis to the college of psychiatry at least we both know where we stand.

There is certain honesty to their arrogance, simply put; we need to dismantle their power, granted under the law, we need to do it in cooperation with them, together, for the good and benefit of psychiatry, and all our lives.

 It is as simple, and as complicated as that.

Sometimes you can be more damaged by your supporters then those opposed in this type of debate.

There were representatives for all parties in the house in attendance; interesting questions were raised.

Finally it would be most remiss of me not tell you of the vital role being played in this debate by Senator Dan Boyle.

But more importantly Minister John Moloney, it is vital in the non political sense that this man, (not politician) stay in his position for the next two years.

 We are grateful to you minister and we thank you from our hearts.

MDAC hails compensation “milestone for global human rights”

11 March 2010, Budapest (Hungary), St. Petersburg (Russia) and Strasbourg (France). MDAC welcomes last week’s judgment of the European Court of Human Rights which ordered the Russian government to pay 25,000 EUR compensation to a man with mental health disabilities who was unlawfully deprived of legal capacity and arbitrarily detained in a psychiatric hospital for more than six months. This is the largest amount of compensation the Court has ever awarded in a disability rights case.

The Mental Disability Advocacy Center today welcomes the 4 March 2010 European Court of Human Rights judgment which ordered the Russian government to pay 25,000 EUR damages to MDAC’s client Pavel Shtukaturov. The judgment follows a judgment on the merits issued by the same court in March 2008, which found that Russia was in violation of several provisions of the European Convention on Human Rights. The client has been represented in proceedings by MDAC’s Legal Monitor in Russia, attorney Dmitri Bartenev.

Welcoming the judgment, MDAC’s Executive Director Oliver Lewis said,
“This judgment is a milestone for global human rights as 25,000 euro is the largest amount of compensation the European Court of Human Rights has ever awarded to an applicant in a disability rights case. This sum reflects the gravity of human rights violations faced by people with disabilities the world over and the seriousness with which the mainstream human rights community now views these violations. The judgment sends a clear message to governments that it will be expensive if they fail to take legislative and policy action to effectively implement international human rights law for people with disabilities.”

In its judgment last week the Court reiterated that the amount of compensation for non-pecuniary damage (meaning compensation for pain and suffering) is assessed with a view to providing “reparation for the anxiety, inconvenience and uncertainty caused by the violation” and that the respondent State is under a legal obligation to “restore as far as possible the situation existing before the breach.”

In awarding compensation the Court noted that the Russian judicial system had failed to remedy the past wrongs which had in fact persisted for Mr Shtukaturov over the previous four years. In doing so, the Russian system continued to infringe on some of his most fundamental rights. As the Court noted in its March 2008 judgment Mr Shtukaturov was deprived of his legal capacity to act independently in almost all areas of life. He was unlawfully detained in a psychiatric hospital for more than six months, not taking into account his subsequent periods of detention. Mr Shtukaturov’s suffering was, the Court held last week, “undoubtedly aggravated by the State’s failure to respect his [fair trial] rights and the authorities’ interference with his right of individual petition [to the European Court of Human Rights]”.

The Court’s scathing comments refer to the extraordinary way in which Mr Shtukaturov’s legal capacity was eventually restored in May 2009 by a St. Petersburg district court. No steps were taken by any authority following the March 2008 judgment of the European Court of Human Rights. Nor were any steps taken by any authority following the February 2009 judgment of the Russian Constitutional Court, a case concerning Mr Shtukaturov and also initiated by MDAC. In this case the constitutional court struck down as unconstitutional provisions of the Psychiatric Care Act and the Code of Civil Procedure which had been applied in his case. Despite these judgments it was an unrelated application by the State guardianship authority in light of an perceived improvement in Mr Shtukaturov’s mental health condition which eventually led to the restoration of his legal capacity. The district court’s ruling did not cast doubt upon the validity of the original decision of the court, a remarkable oversight given the damning critique of the original decision both by Europe’s human rights court and Russia’s constitutional court. Now that he is no longer under guardianship, Mr Shtukaturov is at liberty to spend his compensation as he pleases.

In its March 2008 judgment the European Court of Human rights found Russia in violation of several provisions of the European Convention Human Rights. It said that:
Deprivation of legal capacity constitutes a “very serious” interference of a person’s private life, it is applied indefinitely, and cannot be challenged by the person under guardianship (Article 8 of the Convention)
A mental illness cannot be the sole reason to justify stripping someone of legal capacity and Russian law is disproportionate in allowing this to happen without making provision for a tailor-made response (Article 8 of the Convention)
The guardianship proceedings were unfair because they wholly excluded Mr Shtukaturov (Article 6 of the Convention)
Deprivation of legal capacity is not a ground to deprive a person of their liberty (Article 5(1) of the Convention)
Every person who is detained – including those who have been deprived of their legal capacity – should have the right to pursue independently a legal review to challenge their detention (Article 5(4) of the Convention)
The Russian Government failed to comply with an “interim measure” of the European Court ordering it to allow Mr Shtukaturov’s lawyer to have access to him (Article 34 of the Convention)
For more information on this case call Oliver Lewis, MDAC Executive Director +36 1 413 2730 or Dmitri Bartenev, attorney and MDAC Legal Monitor in Russia + 7 905 222 8915. Click here to read the March 2008 judgment on merits, here to read MDAC’s related information bulletin, and here to read the March 2010 judgment on just satisfaction.

We live in interesting times

Change is on the way. The campaign http://www.delete 59b.com, who’s aim is to delete section 59b of the mental health act 2001 of Ireland (to stop the use of involuntary ECT) is gaining significant ground, already compromise is on offer, the section states if the patient is “unable or unwilling” then two psychiatrists can sign a form and force you take ECT against your will.

We have been to Lienster House over the last few weeks, debating.  The college of psychiatry agreed yesterday that it is time to remove “unwilling”.  There were calls for a full independent review of the whole mental health act.  Calls, for the new capacity legislation to come into place!  To ratify the UN Convention on the rights of the Disabled!  Advanced directives, a type of living will, all necessary.  All sounds great, but they just do not get the point, it is not enough.  We are told we should be grateful for progress; but this is about human rights not some treatment or other.

 This is about equality, our right as members of the mad community to stand tall as equal citizens. The common law is there to protect us, but rather then protect us we are excluded from that same common law.

They offer crumbs we want to share the meal.

 Stigma and abuse will always exist as long as we empower one section of our community to force treatment of any kind on another.  The recent Murphy and Ryan reports confirm this.  The college of Psychiatry tried to divert the debate yesterday and they focused in on the benefits of ECT.  Delete 59b will not affect anybody’s right, to choose with free and informed consent to have ECT.  It is so important that you understand this fact.

 We believe in choice, that is your right, we do not believe that you should be forced to take ECT by force, and on the signature of two psychiatrists and that alone. No need to consult with family, or anybody else, and its legal.  Fear again set the tone of the opposition, irrational fear of us, in the public arena, as justification for the abuse.  It was interesting yesterday to see some facts begin to emerge in this debate. You are very un-lightly to have ECT on offer in public hospitals, yet it seems to be big business in the private sector of psychiatry.  That fact alone surely deserves an independent investigation, the private sector of psychiatry in so much more enthusiastic in its use of ECT, as against those psychiatrists who work in the public sector.

Why? You guess, I won’t speculate here.

I will state that when I was a patient in a private hospital I was offered ECT as a last resort, as my psychiatrist explained, “You are going home next week John the tablets are not working and your VHI is running out, I would like to try a few doses of ECT”.   My wife put a stop to that thank God, I had no idea at that time of what had just been proposed I was so drugged up!

When the Neary case came before the courts, the judge reached a guilty verdict, because Dr Neary’s threshold of use of his surgical procedure was too high in comparison to his colleagues.  This pattern is emerging now in psychiatry, across the country. We need to know the truth here, and not some peer review.

 It was both sad and upsetting to hear myself as a person who lives with the normality of madness in my life, who now recognises the great gifts that deep emotional feelings bring to my life, being referred to over and over again by those who should know better, those who purport to speak for us, as VUNERABLE members of the community.

 How can we expect to hold our heads high as equal citizens when those who “support” us believe we are not capable of walking with dignity and equality in our own communities?  I would call for a complete ban on the use of that overwhelming, paternalistic, insulting description of my community, those gifted with deep feelings, open to insult, we who give society art, poetry, literature, beauty: “As those VUNERABLE people who live among us, and society has a DUTY to protect THEM”, they are insulting me to my face, when they our supporters speak thus to my position in reference to the law. Where I am defined in article 3 of the 2001 mental health act as follows….

“3 (1) in this Act “mental disorder” means mental illness, severe dementia, or significant intellectual disability where…”

How can I as someone who had a breakdown and on a temporary basis, simply lost control of my emotional feelings, expect equal treatment under the law when my capacity under that same law is accessed on the basis I exist in the same legal space as a person with intellectual disability!  It is time to talk of mental health not “mental illness”.  Those same spokespeople “supporters” will stand on another platform next week and rail on at the need to reduce stigma, in policy!!

 Society has a duty to protect all its citizens equally, we ask for no more than that.

 Either that or those who in their hearts do not believe we are capable of standing with pride in our own place should walk away from this debate.  It is most encouraging speaking on an ongoing basis to the college of psychiatry at least we both know where we stand.  There is certain honesty to their arrogance, simply put; we need to dismantle their power, granted under the law, we need to do it in cooperation with them, together, for the good and benefit of psychiatry, and all our lives.

  It is as simple, and as complicated as that.

 Sometimes you can be more damaged by your supporters then those opposed in this type of debate.  There were representatives for all parties in the house in attendance; interesting questions were raised.  Finally it would be most remiss of me not tell you of the vital role being played in this debate by Senator Dan Boyle.  But more importantly Minister John Moloney, it is vital in the non political sense that this man, (not politician) stay in his position for the next two years.

 We are grateful to you minister and we thank you from our hearts.

Presentation to Leinster House 23rd February 2010 – Paddy Mc Gowan

Delete Section 59b 2001/06 Mental Health Act.

Good afternoon I would like to thank you for giving me the opportunity to speak to you today. My name is Paddy McGowan; I am a psychiatric survivor and activist. I have been an activist for nearly 25 years. I spent over ten years within psychiatry many of those years in the hospital and the community, I have had ECT carried out on me both voluntarily and forced. In my case, I was told that ECT was my last chance. They had tried all other medicines and treatments on me, but the only treatment I was offered was medicine and ECT. After the first treatment when I was taken back to the ward I lay on my bed, my head felt that it had been driven over by a steam roller, the pain was excruciating, I had problems with my memory, and I was confused. I was informed a few days later that I was going for another ECT treatment I immediately refused and was told that it would be easier for me to have the shock voluntarily, because if I was to refuse that my status could be changed to involuntarily. I was left to think over whether I would consent or not. I was advised by some of the staff and other patients that it would be better for me not to put up a fight. I received a number of other treatments over the years. I cannot honestly say that it did not help me but it has left me with long term memory problems. I would never allow myself to have it carried out on me ever again. If in the future I found myself in a posisition of being detained under the Mental Health Act I would honestly consider suicide. I have recovered from my time of severe distress, largely with the help of fellow survivors and friends, without the use of medication and ECT. I was told for years that I had a disease that I could not recover from; my family were left with absolutely no hope and almost given me up for dead.

I think we have to question what is wrong with our Mental Health Service provision, when we have to force people to use our services and have to use force to treat them. We don’t have to force people with mental health difficulties to use our general health services. We are often told that people who have to be forced with ECT treatment or indeed any other forced treatment within Psychiatry, have no insight, this argument is very often bandied about without any clear research being produced. The reality, is more likely that people have had bad experiences, subjected to these forms of treatments, the side effects are toxic to say the very least. My own experience of ECT is that I suffered from both long and short term memory loss. I have in the last 25 years advocated for people within psychiatric services, and my experience tells me that the majority of people who are deemed to be service users are very much opposed to forced treatments and more so around, ECT. The Irish Advocacy Network as a peer led organisation that provides advocacy to people in hospitals and the community are also opposed to forced ECT they are in favour of deleting section 59b, they are not opposed to ECT per say. People should have a choice around their treatment, and it is not the duty of the Network to make those choices for people. The Irish Advocacy Network is the longest service user group on the island of Ireland working with people for ten years in various states of distress.

The well known and respected Psychiatrist Peter Breggin has spoken in one of his books (Toxic Psychiatry) relating ECT to being the same as a (closed Brain Injury). Indeed other Psychiatrists of standing within the profession are of the same opinion. The Royal College of Psychiatry has also within their own code of practice declared   ECT is unlikely to help those with mild to moderate depression or most other psychiatric conditions. It has no role in the general treatment of schizophrenia. We know from the inspector of mental health services report for 2008 that 73% of people given ECT had a diagnosis of a Depressive Disorder, 27% had other conditions and 24 people given ECT had a diagnosis of Schizophrenia. The fear that most people have with the ECT is that there is no clear consensus from within Psychiatry around the efficacy and safety of the procedure. We are often told that ECT has saved people lives, yet we have never seen any research to prove or discount this statement, on the other hand, some people could claim that ECT has damaged people, and taken people lives. We know from some people that they claim they became suicidal after undergoing the procedure. How many people have died during the procedure? Some would say that deaths during the treatment were recorded as cardiac deaths or natural causes. We just simply don’t know, neither of the two groups either for ECT or against have any clear research or science to base an informed opinion. I would call on the Government to commission independent research on ECT preferably from outside the country. I think we as a country will find ourselves under investigation, similar to the last few reports that have been published we have questions as a country to answer. The institutional abuse scandals that have come to light have close linkages to our past Psychiatric Service Provision and practices.

There is another group that is not being taken into account here, they are a group I call the Service Refuser community. Over the years, I have come into contact with a large number of people who live and work in our communities who encounter mental health distress. When you speak with them, they clearly tell you that they have no faith in Psychiatry, because of fear and the treatments they could or have experienced at the hands of practitioners. People have found alternative ways of managing and living with their distress, they quite often tell me that they would love to be able to have contact with professionals, but don’t believe that they would find people who could understand their belief systems, I remember one individual I met, I asked him why he refused to use the services, his answer to me was I might be mad, but I am certainly not stupid. He believed that he would have no rights in Psychiatric Hospitals he had absolutely no faith in the Mental Health Act. His argument and that of others, coming from refuser community, also indeed from within the service user community was that the second opinion Psychiatrist provided for within the legislation is just a rubber stamping exercise. They would say that they come from the same professional group and in some instances, are friends or colleagues. The argument being that they are not fully independent, and do not provide a sense of security for the user. Fundamentally they come from a pro medical model view point which quite often is at variance with the user’s beliefs.

I would like to point out again that we are not saying that ECT should be abandoned; we are just simply saying that people should have choices. We as a society need to protect the human rights of all our citizens. We have come to a place now that we are starting to listen and respect service user points of view, can we afford to go back to the days of paternalism. I would like to thank Minister Maloney for arranging this meeting. However, I would like to point out that I find it difficult to understand why our meeting was held first and separate from the second meeting, in my opinion, both sides should have given their evidence on the same day to allow the senators and deputies the chance to ask questions of both sides, it begs the question why?. It seems that the opposing side has the opportunity of listening to our presentation, and we have no chance of contributing when they present. Both sides need to be able to contribute in the debate and challenge.  

We have also an online petition Delete Section 59b; the poll has just been alive for around a month or so. To date, we have received 522 signatures given that we had no resources nor did we publicise widely, and a short time span. I think it gives you a flavour of the feeling in society. When we close the poll, I think you will find that we will have obtained a large constituency from across the country who agrees with our position.

I urge you to protect the rights of people and value them as equal citizens in this land of ours, after all this country and ancestors fought for our independence and equality.

Thank You.

Presentation on Proposal to Delete Section 59(B) of the MHA 2001

Dr Pat Bracken

Consultant Psychiatrist and Clinical Director, West Cork Mental Health Service, Bantry, Co Cork

Pat.Bracken@hse.ie

I am a consultant psychiatrist and Clinical Director of the West Cork Mental Health Service. I have worked as a doctor in the field of mental health for nearly 27 years. I trained in psychiatry in Ireland and in the UK. I have worked as a psychiatrist for many years in difficult inner-city settings, in post-conflict situations in Africa and more laterally in a rural part of Ireland. I have publicly challenged my own profession to listen more attentively to the voices of patients and their carers, including those who are critical of psychiatry and I am known and (I hope) respected for promoting the active involvement of patients and carers in the development of services .

I am here today to explain why I believe that Section 59B of the Mental Health Act should be amended and, moreover, why I think that this should be the first step in an overhaul of the 2001 Mental Health Act which, in my opinion, puts far too much power in the hands of psychiatrists.

My essential argument is that Section 59B serves to safeguard the doctor who administers ECT, rather that the patient receiving it.

59(B) allows for ECT to be given to a non-consenting patient simply on the order of a consultant psychiatrist if that decision is supported by any colleague. Under the Act, the consultant is not obliged to consult with non-medical colleagues or the nearest relative, nor is he or she obliged to honour the patient’s wishes if these are written in an advance directive. When treatment is given under the MHA, there is no legal comeback for a patient who subsequently feels they were harmed, or for a relative to intervene if they feel the treatment is wrong. In any other branch of medicine it would be unconscionable to allow a procedure to go ahead, except in the most dire emergency, without procuring consent, if not from the patient, then from a next-of-kin. If Section 59(B) was removed, ECT could still be given to patients without consent, but it would be given under common law . This is the situation pertaining in the rest of medicine when procedures are carried out on patients who cannot give consent. In this situation, the psychiatrist would have to proceed more carefully as he/she would not have the protection of the MHA 2001.

And let us be very clear what this procedure involves. It requires a general anaesthetic and then the passage of an electric current via electorodes attached to the head to the level that will induce a Grand Mal convulsion. It is the most invasive procedure currently used by general psychiatrists. It is now generally accepted that at least a third of recipients suffer substantial memory loss after the treatment . Some people lose large chunks – up to twenty years in some cases – of their remembered lives, including memories of their children’s births, wedding days etc. The writer, Ernest Hemingway, famously blamed ECT for his suicide. In his suicide note he said that the treatment put him ‘out of business’ by destroying his memory.

ECT is a treatment that is gradually disappearing world-wide. It is now used much less frequently across Europe, including the UK and Ireland. In Italy, it is effectively banned, in Germany and Belgium it can only be administered in special centres and in the UK the rules governing ECT without consent have been substantially tightened in the past decade . The WHO now argues that ECT should never be given without consent . I believe that more and more psychiatrists are becoming very wary about it’s use. We are now nearly 10 years on from the date when the current MHA act was passed in Ireland, and the scientific evidence about the benefits and side-effects of ECT has moved on substantially.

As a psychiatrist, I maintain that we have to learn from the mistakes of the past, otherwise we are doomed to repeat them. In many ways, the history of psychiatry is not a happy read. In our enthusiasm to do things to the patients put into our care, we have inflicted terrible damage on many of them. Take, for example, the recipients of interventions such as lobotomy and insulin-coma treatment. For many years, these interventions were hailed as dramatically successful by doctors, families and even patients. For some they appeared as ‘life-saving’. Patients who were catatonic got up and talked and left hospital. If they had not been successful in some way or another they would not have been performed over such lengthy periods of time. At least 40,000 lobotomies were performed in the US, 17,000 in the UK. I don’t know how many were performed in Ireland. In many cases it was only later that dreadful deficits were noticed and eventually lobotomy went out of fashion. Not all doctors recommended lobotomy, but some were enthusiasts and if you came under their care, there was a good chance that you would be given that intervention . The point is that psychiatrists differed greatly in the value they saw in the treatment and most importantly in how much they were open to see its negative effects.

I believe that this is the same with ECT.

There is a large variation in the use of ECT across the State, which suggests that some psychiatrists have much more faith in it than others. The Mental Health Commission figures for this variation of use in Ireland give substantial cause for concern . In 2008, out of 64 approved centres across the country, ECT was used in only 24 (37.5%). Even allowing for some movement of patients between hospitals specifically to receive this treatment, this is a remarkable variance. But if we look further, we find that only 2 programmes of ECT were delivered in the whole of County Cork (with a population of approx 480,000) while in Galway (with a population of approx 230,000, half that of Co Cork) 69 programmes were used. If my calculations are right, this means that, per head of population, ECT was used approximately 70 times more often in Galway than in Cork! This is an extraordinary degree of divergence.

What the figures on ECT demonstrate, I think, is that some Irish psychiatrists are ‘ECT enthusiasts’. The probability of these doctors seeing a patient (whether voluntary or involuntary) as being in need of ECT is going to be much greater than many of their colleagues. Furthermore, it is likely that they will be very aware of colleagues who also use ECT enthusiastically. In these circumstances, Section 59(B) offers no protection whatsoever for the patient. In fact, as I have already argued, the protection offered is in the other direction. This is no longer acceptable.

It brings to mind the enquiry into the practice of the obstetric services in Our Lady of Lourdes Hospital in Drogheda in recent times, where the discrepancy in the rates of Caesarean hysterectomy as compared with the rest of the country led eventually to the exposure of a scandalous situation for the women involved. Dr Michael Neary performed 129 peripartum hysterectomies during his career over 25 years in this hospital. According to Judge Harding-Clarke’s report, the average consultant obstetrician can expect to carry out 4 of these procedures in his or her career, in extreme circumstances. The divergence of Dr Neary’s practice from the average (an excess rate of approx 32 times) was deemed so problematic that he was eventually struck off the medical register. When it comes to ECT usage in Ireland we are talking about a divergence in medical practice that is twice this level.

I believe that we could be looking at a similar situation several more years down the line, when the already well-documented and damaging side-effects of ECT become more widely recognised.

Moreover, the recent television Prime Time investigation about the practice of symphysiotomy has added to public outrage about the way in which certain medical practices can be allowed to continue in the face of well-documented and serious side-effects. One of the most troubling aspects of these questionable obstetric practices, is that is has become clear that we cannot rely on medical colleagues to be the ones to investigate them.

In Ireland, we are struggling to get beyond the culture of medical paternalism that reigned in our health service until recently: the belief that doctors always know best and will act accordingly. The present government health strategy, A Vision for Change, aims to do just that. We need protections for patients that are substantially more transparent, more democratic, and more multi-disciplinary. The MHA 2001 puts enormous power and responsibility into the hands of consultant psychiatrists. It is now out of date.

-I believe that we need to do 4 things:

First, we need to move quickly to remove Section 59(B). This will at least offer detained patients the protection of common law, something that the MHA 2001 currently denies them.

Secondly, we need to develop very clear guidelines for how decisions are made when patients cannot give consent.
Thirdly, we need an external audit of ECT practice in Ireland. This audit should seek to examine the reasons behind the extraordinary level of variance in ECT use. It should also seek to explore, in some depth, the experiences of patients (both positive and negative) of this treatment. This review should not be led by a psychiatrist .

Fourth, we need to rethink our mental health legislation more generally. The current MHA, which essentially serves to endorse the culture of medical paternalism, needs to be replaced by a framework more in line with our mental health policy A Vision for Change.
Pat Bracken MA MD MRCPsych DPM PhD