The Mental Health Act is vulnerable to ageist and misogynistic application, argue Dr Anna Duxbury and Dr Stephen Weatherhead.
For most people, the thought of administering electric shocks to the brain just feels wrong. Rightly so, you may say, as our brains are highly vulnerable to disturbance and injury. However, ECT is a contentious subject. It is one which divides opinion. A majority, including professionals, tend to either be advocates for ECT as an approach in specific circumstances, or completely against it under any circumstances. There are very few who ‘sit on the fence’ when it comes to ECT.
"We need much greater emphasis on shared decision-making models."
Mental health service providers will say interventions should be decided upon according to the evidence base. But it’s not that simple. The evidence-base is a murky area often without the clarity we would hope for when making decisions as huge as whether or not to give ECT. Indeed, “the cost benefit analysis for ECT is so poor that its use cannot be scientifically justified” (Read & Bentall, 2010). Yet according to one source, 1,800 individual treatments were administered in 2017. [Editor's note, NHS Digital say their own figures on ECT use over the last three years are meaningless in their current form due to the development of a flawed reporting system. The Information Commissioner's Office has upheld a complaint from MHT under Freedom of Information law.]
Some people seem to be over-represented in the statistics of people who receive ECT. For example, more than half of those who receive ECT as an ‘acute’ treatment are over 60 and 74 percent of the people who receive ‘maintenance’ ECT are female. This could be because these groups suffer more from the mental health difficulties which ECT is shown to have most benefit for [depression; catatonia], or it could be for more concerning reasons such as the misogynistic, ageist nature of our mental health systems and structures. Perhaps we will never have a clear answer to these debates, but we can find out more about how decisions are made and if necessary adjust our processes to make sure we eliminate biases such as ECT being delivered based on the preferences of the person in charge. Yes we have safeguards in place to reduce such issues, but we still have a very paternalistic mental health system which is hierarchical and risk averse.
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We recently undertook some research to better understand the processes by which decisions to administer ECT - or not - are made. This research (Duxbury et al, 2018) found that personal and professional identities were the foundation upon which decisions are made. These identities and the consequences of them are based on a mix of subjective and objective information. Guidelines and clinical instinct play their part, but ultimately the Consultant/s hold the professional consequences of clinical decisions. This means that the experiences of the Consultant often have the biggest role to play when deciding whether or not a person should have ECT. This most certainly should not be the case, particularly as the voice of the ‘patient’ and often their significant others get lost in discussion.
It is the Consultant who holds the legal role of Responsible Clinician and their own experiences lead to biases, for example a participant in our research said “I think the problem that we have got is that our consultant had a few like serious incidents where people have gone and killed themselves so his anxieties is, it’s awful when you are standing in front of a coroner…but the way that he sees it is that [they] have to do everything that [they] can in order so that if someone does then they have tried everything”.
Inevitably a lot of this is linked to our cultural understanding of issues such as ‘expertise’, recovery, right to die, ethics and responsibility. We need much greater emphasis on shared decision-making models, and we really need to deal with the legislative loophole that holds an interaction between the Mental Capacity Act and the Mental Health Act when it comes to ECT. Either, advanced directives as set out by the MCA should be upheld regardless of doctors’ opinion, or we should not have advanced directives in ECT. The former certainly seems much more empowering, even if it means some people will choose to die rather than have ECT.
As it stands,ECT is the only mental health treatment a person can refuse if they hold the capacity to make that decision. However, we end where we started, with the knowledge that when it comes to psychological distress we always have the potential to deteriorate to the point where our life may be in danger. At this point, it is the medical professionals, not the individual, who hold the decision-making power. This power will always be used to keep a person alive, and if ECT is seen as the only way to do that, then regardless of our opinion, at the point where we lack capacity, we will receive ECT.
Dr Stephen Weatherhead is a Consultant Clinical Psychologist specialising in brain injury. He is a Senior Academic and Clinical Tutor with the Liverpool University Clinical Psychology Programme. He is a Co-Director of NeuroTriage (www.neurotriage.com), and has a special interest the impact of socio-economic oppression, mental health, and effective service design. Twitter @SteWeatherhead
Dr Anna Duxbury is a Clinical Psychologist working in child and family services. She is a Clinical Tutor with the Lancaster University Doctorate in Clinical Psychology programme. Twitter @clinpsy_anna