Electroconvulsive Therapy (ECT) Involuntary Treatment

NOTE TO: Interested Parties
SUBJECT: Electroconvulsive Therapy (ECT), Involuntary Treatment, and Related Issues

Recently, there has been a great deal of discussion about electroconvulsive therapy (ECT) and, in particular, the involuntary administration of ECT to mental health services consumers/survivors. (People who have received mental health services refer to themselves as "consumers," "survivors," "ex- patients," and other terms. This correspondence will use "consumers/survivors" to encompass the various nomenclature used.)

The Center for Mental Health Services (CMHS) recognizes the controversy regarding the ECT treatment alternative and its involuntary application. We also recognize that research from the National Institute for Mental Health (NIMH) stresses the value of ECT under some circumstances. Moreover, we have heard from individuals and organizations about the importance of maintaining the availability of ECT for those who desire it. I would like to share our perspective and our initial action steps regarding these concerns.

I sincerely appreciate the views shared with staff of CMHS on ECT, involuntary treatment, and related issues. Obtaining this type of input is invaluable for CMHS in working to develop and improve responsive, accessible, and appropriate mental health services. We are committed to seeking broad-based constituent involvement and participation in our activities--especially from consumers/survivors and their families.

Issues surrounding ECT and involuntary treatment are especially complex. The administration and policies of treatment are generally governed by State laws enacted by elected officials through our democratic process. The CMHS does not have the authority to endorse or prohibit such procedures, practices, and policies. Nevertheless, we are dedicated to working with consumers/survivors, family members, providers, and State and Federal agencies, including the Food and Drug Administration (FDA), National Institutes of Health (NIH)/NIMH, and Agency for Health Care Policy and Research (AHCPR), to develop solutions that will promote alternatives and respect consumer/survivor choice.

Interested Parties

I welcome this opportunity for CMHS to facilitate ongoing dialogue on these matters. The CMHS has begun this process through the following:

1. Meetings and Roundtable Discussions on Involuntary Interventions

CMHS has encouraged discussion on topics surrounding the use of involuntary treatment including providing support for the National Symposium on Involuntary Interventions sponsored by the University of Texas-Houston Science Center, the National Council of Juvenile and Family Court Judges, and the Texas Department of Mental Health on May 5- 7, 1994. This gathering included consumers/survivors, family members, practioners, advocates, and public officials. The Symposium succeeded in fostering communication among the participants and in bringing needed attention to concerns that beset involuntary interventions.

During 1990-1992, the CMHS Community Support Program (then part of NIMH) sponsored three roundtable discussions on involuntary interventions which also included consumers/survivors, family members, mental health service practioners, attorneys, and policymakers. These meetings underscored the need for greater sensitivity to the psychological impact of involuntary interventions, the need to distinguish between treatment and behavior control, and the need to employ a greater variety of noncoercive approaches. Furthermore, significant conclusions from the meeting indicated that:

"...the major stakeholders in fact have much in common...that the current system of involuntary treatment is not working well for some individuals in some places, and that overall use of involuntary treatment in the system can and should be reduced."

A monograph based on these meetings is available from the Boston University Center for Psychiatric Rehabilitation at (617) 353-3549.

2. Research and Demonstration Projects

A number of research and demonstration projects have been supported to examine crisis intervention options and alternatives to hospitalization including:

a consumer/survivor-operated crisis hostel in Tompkins County, New York, where individuals who define themselves in crisis and at risk for hospitalization can be supported through a psychiatric emergency;

a psychosocial alternative in Montgomery County, Maryland, where nonhospital group or foster home care is combined with other services to help people through crisis episodes;

a crisis residential facility with a mixed staff (consumer/survivor and nonconsumer/survivor) in Sacramento County, California, that is an alternative to involuntary hospitalization.

Please contact the CMHS Office of External Liaison at (301) 443-2792 if you would like further information on these efforts.

3. Advance Directives

CMHS is undertaking a nationwide review of the use of advance directives for involuntary psychiatric care. Recently, many States have passed legislation to give persons the right to specify, in advance, choices about treatment in the event of a mental health crisis. We are working directly with the Protection and Advocacy (P&A) Systems in each State, and beginning to collaborate with the National Association of State Mental Health Program Directors, to examine the utility of advance directives.

4. Protection and Advocacy Program

The P&A Program, administered by CMHS, is operational in 56 States and territories to protect the rights and investigate complaints of abuse and neglect of persons with mental illness in residential facilities and other settings. The P&A Program, in addition to examining the use of advance directives, is constantly pursuing new approaches to promote consumer/survivor choice and empowerment during times of psychiatric crisis.

5. Informed Consent

CMHS intends to work with NIMH, FDA, and other groups to investigate methods for improving informed consent procedures for services as well as research. We also intend to assist in providing education on this topic to consumers/survivors, family members, providers, researchers, policymakers, and others.

6. Review of ECT and Involuntary Treatment Issues

Over the next several months, CMHS will be undertaking a review of the issues relating to ECT, involuntary treatment, and related issues. This will include further analyses of the 1985 NIMH Consensus Development Conference on ECT which indicated the efficacy of ECT for some patients, findings of the 1990-1992 NIMH/CMHS Reports of Three Roundtable Discussions on Involuntary Interventions, proceedings of the 1994 National Symposium on Involuntary Interventions, and other activities and materials. This will include the active participation of and consultation with consumers/survivors, family members, providers, advocates, and others.

We also intend to work with the FDA, NIH, AHCPR, and other relevant agencies to review current policies and materials dealing with ECT and involuntary treatment and to promote guidelines to ensure consumer/survivor involvement and choice while maintaining the widest range of treatment options. Through this process, we hope to develop a broad statement on ECT, involuntary treatment, and related issues to be disseminated to States, territories, local communities, mental health service providers, consumers/survivors, family members, and other constituents.

There are no easy answers to the issues surrounding ECT, involuntary treatment, and related matters. It will take significant effort, time, and energy to explore these matters fully. Together, however, I believe that we can effectively advance the dialogue to crystalize workable and appropriate solutions.

To facilitate this dialogue, I have asked the Office of External Liaison, CHMS, to coordinate the above activities. For further information, please contact Mr. Harlan Zinn, Knowledge Exchange Manager, at (301) 443-2792. He will work in conjunction with other CMHS staff, including Mr. Paolo del Vecchio, the newly-designated Consumer Affairs Specialist.

Please share this information with others who may also be interested. I look forward to continuing to work with you to improve and enhance the quality of life for all consumers/survivors of mental health services.

Bernard S. Arons, M.D. Director
Center for Mental Health Services

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