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 why?

These questions were publicly answered by the two psychiatrists who signed the papers seeking a court order for involuntary shock of Paul Henri Thomas.

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 her will.

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 2001.

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 Azemar.

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 illness.

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 treating psychiatrist.

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.