How do psychiatrists decide to use forced
by Linda Andre
Director of CTIP
Have you ever wondered how psychiatrists make a decision to shock a
person against his or her will? Who's a candidate for forced shock, and
These questions were publicly answered by the two psychiatrists who
signed the papers seeking a court order for involuntary shock of Paul
In some but not all states---New York is one of them---a person must be
found to be legally incompetent before he or she can be shocked against
The general public, upon hearing this, sighs in relief: of course;
that's as it should be; that could never happen to me; of course there
must be safeguards in place, and standards as to what constitutes
competence; a person must have to be really bad off, really crazy like
catatonic, to be ruled incompetent.
Treating psychiatrist Andre Azemar and supervising psychiatrist Bob
Kalani of Pilgrim State Psychiatrist Hospital both testified against
their patient Paul Henri Thomas in hearings held in March and April
They were asked how they decided that Paul lacked the capacity to make
this own treatment decisions.
They made it clear.
Having a diagnosis of mental illness helps you get ruled incompetent,
but it's not enough by itself. And you sure don't need to be catatonic
or psychotic. Here are the rules:
Rule # 1: You're incompetent if you think you're not crazy.
"Lack of insight" was cited an overwhelming number of times by witnesses
against Paul as justification for forced treatment. Both doctors said,
in essence, that any person who says that he is not mentally ill when a
doctor says he is lacks "insight into his illness", and that this means
he lacks the capacity to make his own treatment decisions.
Paul's lawyer Kim Darrow was thorough in his questioning, trying to
elicit from the doctors any other factors they might have weighed in
making their decision that Paul lacked capacity and therefore qualified
for forced shock.
There were none. On further questioning, Dr. Azemar was asked why Paul
doesn't think he is mentally ill. His answer: "Because mental illness
clouds his judgment." It was clear to everyone who watched this trial
(except the judge) that this was a Catch-22, no-win situation. As long
as you say you're not crazy, you're considered crazy.
The audience waited in vain for further justification of the claim that
Paul was mentally ill. He was said to have various diagnoses, including
schizoaffective disorder (also the diagnosis of this reporter), bipolar
disorder, and mania. Neither doctor had enough evidence against Paul to
justify these diagnoses by DSM criteria. Paul was said to be "loud",
"noncompliant", "threatening", to have worn inappropriate clothing on
the ward and to have hoarded food (which would have been entirely
appropriate for someone looking to escape from the hospital, former
patients concurred later). His hygiene was said to be poor; he was
accused of cluttering his hospital room with books and dirty
clothes---"dirty clothes on top of clean clothes!" in the words of
The other shrink, Kalani, conceded that on the day he testified---as
well as on the day he signed the petition for forced shock---his patient
had no symptoms of mental illness other than denying he had a mental
An independent, unpaid psychologist who examined Paul in the hospital at
the end of March, interviewing him as well as performing some
psychological testing, testified that he found no evidence of psychosis,
mania, or mental illness. He testified that Paul is competent to make
his own decision regarding ECT.
Rule #2: When you say yes, you're competent; when you say no, you're
incompetent. Either way you get shocked.
"The staff would ask him, are you going to consent or are we going to
have to go back to court?" ---Bob Kalani
If Paul was really incompetent, he was incompetent not only to reject
treatment, but to accept it. His yes would not have been legal. Yet both
shrinks testified about attempts to talk the legally incompetent Paul
into saying yes to shock.
"Did you try to get Mr. Thomas to consent to ECT in January? If he had
consented, would you have sought a court order?" asked Darrow of the
The judge objected.
"If Paul had said yes, would you have tested his competency?" Azemar
looked baffled and answered, "If they say no, we have to do it."
At this point the judge interrupted, saying, "I don't understand the
question". No one else in the courtroom seemed to have any difficulty
understanding the question or the point that had been made.
"If he accepts the illness then he can make his own decisions and we
don't have to force him," Dr. Kalani had testified. Sure Paul can make
his own decisions----as long as he consents.
Rule #3: If you disagree with what your doctors say about treatment
in general or your treatment in particular, you're incompetent.
When asked: What constitutes capacity? Azemar replied as follows:
---Capacity depends on the person understanding what the treatment is
---Capacity means he understands the consequences of the treatment, and
has the ability to assess benefits and risks.
Paul has had over 60 ECTs, but no one thinks this makes him qualified to
understand what the treatment is about, or to understand its
consequences. Only a psychiatrist can know these things.
Both doctors said Paul was incompetent because he refused to acknowledge
that previous ECT had been beneficial for him. Azemar said, "Even when
we tell him he is improved, he never accepted the fact that he had any
benefit from it."
Both doctors said that Paul was incompetent because he "is unable to
assess the risks and benefits of ECT."
Further questioning from Darrow clarified the situation. Did Paul have
the mental capacity to understand that his doctors thought he had
improved with ECT? Yes. He understood this. "Did he understand what you
thought were the benefits and risks?" Yes, the doctors said. Paul was
perfectly capable of hearing and understanding what his doctors were
He just didn't agree with them.
As long as patients and doctors disagree about the nature, risks and
benefits of ECT, and as long as doctors get to define the "right"
answers to these questions, everyone is at risk of forced ECT. Persons
who have previously had ECT, know about it from personal experience, and
will not deny what they know to be true, are most at risk.
Dr. Kalani testified that he "knew" about ECT from reading a book. All
books about ECT for professionals are written by financially compromised
ECT proponents like Richard
Abrams, shock machine company owner. Kalani couldn't remember which
book he had read...Fink's, Kellner's, Coffey's? He went on to make
further blatantly false statements about what he "knew". He knew the FDA
had approved shock machines. (Never
happened.) He knew the FDA had conducted animal
trials of shock. (Not
only has it never conducted animal trials, neither the FDA nor anyone
else has ever conducted human trials.) Kalani's source was revealed when
he claimed that the FDA had studied baboons. The baboon line comesfrom
HaroldSackeim, prolific ECT advocate and shock machine company
consultant. Even Sackeim, famous for his lies, did not say that FDA
studied baboons; his claim was that epilepsy researchers had studied
baboons and concluded that seizures didn't damage their brains. Kalani
got his misinformation garbled. The Pilgrim shock doctor went on to
testify that there have been "lots of" before-and-after MRI studies
showing that ECT doesn't cause brain damage. Wrong again. There
have been less than a handful, and they don't show that.
Dr. Azemar wasn't any more knowledgeable. He claimed that his own
facility did not do "bipolar" ECT (the correct term is bilateral), that
this was the "old fashioned way" of doing ECT that's still done in Haiti
but not here. In fact, Paul has been getting bilateral ECT at Pilgrim.
If capacity is determined by what you know about ECT's risks and
benefits, then both Kalani and Azemar flunked the test, and can now be
legally forcibly shocked.
Unfortunately Darrow did not challenge Dr. Kalani's false statements.
The judge was left with the impression that ECT has been proven safe
because no one contradicted it.
If Darrow had been able to raise doubt about ECT's efficacy and
safety---by invoking the FDA
classification of ECT devices, for instance---a logical further
question would have been: "If it were true that Paul did not benefit
from ECT, would he be incompetent? What if Paul is right that the risks
of ECT outweigh its benefits? Is he still incompetent?"
The judge got very upset once Darrow made the point that Paul understood
but did not agree with his doctors, yelling at him to move on. This was
one of three outbursts on the part of the judge that day, each one
louder than the last. The judge was very, very loud.
Forced treatment and biological psychiatry go hand in glove.
If biological psychiatry is a kind of law---if we as a society have
decided it is the only acceptable or permissible way to think about and
treat problems---then it must have its police force for those who don't
find it helpful or agree to abide by it. It must have the doctors and
judges who force treatment on these people.
Both shrinks testified that drugs and ECT were the only treatments
available for Paul. When challenged, however, they claimed to be doing
psychotherapy. They were questioned further about what that meant. It
turns out that psychotherapy doesn't mean what it used to mean.
"Psychotherapy consists of making him understand his mental illness and
accept therapy and understand the impact of medication and ECT.
Noncompliance is the issue," said Bob Kalani. He also explained that
there had been family psychotherapy, consisting of trying to talk Paul
into consenting to ECT.
Dr. Azemar called his brand of psychotherapy "insight psychotherapy".
"Insight psychotherapy" consisted of trying to get Paul to accept that
"It's all chemicals. There are all these chemicals in the brain---for
anxiety, for appetite, for sleep. It's getting him to understand what
these chemicals do and what drugs he needs to take."
The drugs he has been taking have caused liver damage and tardive
dyskinesia. Dr. Azemar testified that Paul wanted to take a computer
class, but his hands now shake so badly that he is unable to type. He
characterized TD as a "disorder of the fingers"---it's actually
permanent brain damage.
It was nearing the end of the last day of the trial when the topic of
drug-induced brain damage came up. Darrow began a dramatic summing-up
type question. "They've damaged his liver, they've damaged---" he might
have been beginning to say "His brain".
He didn't get to say it because he could not longer be heard over the
judge. Judge Hall pounded on his desk, stood up, and yelled at the top
of his lungs: "You should be ashamed at yourself!" He said it twice. It
was far from clear to anyone in the courtroom what, exactly, he was
referring to. Should Darrow be ashamed because he was bringing up
tardive dyskinesia in a case that was just supposed to be about ECT? Was
Darrow being reprimanded because he was only allowed to talk about ECT
brain damage, not drug brain damage? Was the judge himself, who is known
for signing forced drugging orders, actually ashamed of himself and
simply projecting those unmanageable feelings onto Darrow? Why the
It was a better ending to the case than the State's lawyer, Laurie Gatto,
could have hoped for. She's clearly clueless on shock, and her idiotic
questions had her much more educated audience laughing----like when she
claimed that the MiniMental
Status Exam (which you
can hardly do poorly on unless you're in a coma) could measure memory
loss from ECT, or when she tried to disparage Paul's good performance on
an IQ test by saying that math doesn't involve problem solving. But even
she could sense that she didn't need to add a single word.
Had anyone wandered into the courtroom at 4:20 p.m. on April 2nd,
observed the behavior and demeanor of both Paul Henri Thomas and Judge
Hall, and been asked to pick out which man was suffering from mania,
there would not have been any doubt that it was the one in the black
If you think you can protect yourself against forced ECT with an advance
directive, think again.
Paul had an advance directive. He had signed it on October 19th, the day
before his doctor signed the petition for forced shock. Paul couldn't
have executed a legal document like an advance directive if he were
considered incompetent. Dr. Azemar clearly found him competent on the
19th; in fact, he even signed the advance directive as a witness.
Azemar's position at trial was that Paul became incompetent the very
But wait---even if that were the case, wouldn't the advance directive
have been valid? After all, this is exactly the situation an advance
directive anticipates. It specifies what should be done should a person
become incompetent. Paul's directive said that his brother would act as
his proxy to make his health care decisions. He should have been
consulted, and his yes or no would have been the final decision on shock
for Paul. But the hospital disregarded the advance directive and went
ahead with its forced shock petition.
In the words of Judge Hall: "What that document said at that time, it
doesn't say now."
FOR RIGHTS PROTECTION AND ADVOCACY