She talked about the testimony of Dr. Azemar, the psychiatrist assigned by Pilgrim Psychiatric Center to Mr. Thomas. She noted that Dr. Azemar is on Mr. Thomas' ward five days a week, and that Mr. Thomas attends a group which Mr. Azemar holds every week. She said that Dr. Azemar's opinion is that Mr. Thomas lacks capacity and denies his mental illness, in part because of illness induced thought disorder, in part because of how mental illness is viewed in Haitian culture, and in part because of the type of treatment which is being recommended. Dr. Azemar also found that Mr. Thomas couldn't understand the consequences of his behavior, and doesn't understand the risks and benefits of treatment.

Ms. Gatto made reference to Mr. Thomas' decision to stop taking psychiatric medication in the middle of the hearing, giving this as further reason to question his competence. She submitted that the evidence was overwhelming that he lacks capacity.

Ms. Gatto argued that ECT is the most narrowly tailored treatment available. She said that Dr. Kalani and Dr. Azemar, both staff psychiatrists at Pilgrim, had testified that every time treatment was stopped or spaced out to greater than 10 days, this was followed by a decompensation. She said that there is ample evidence suggesting that when Mr. Thomas is not given ECT, he stops taking medication. She claimed that he needs both treatments. She said that he has stopped taking medication at two crucial points in his life, first when he was about to be discharged, and second in the middle of this hearing. She asserted that there is no way to treat psychotic features other than with neuroleptic medication or with ECT, and that with Mr. Thomas' sensitivity to tardive diskenesia and liver damage, neuroleptics can not be used. She said that Dr. Lynch not only recommended ECT, but that he said that 40 treatments may not be enough. She asked, is there an end in sight? She said that we don't know, but that every time treatment is interrupted, his condition becomes acute and then he needs two to three ECT treatments per week. She said that everyone agrees that Mr. Thomas hates ECT, and that no one likes ECT or chemotherapy. She said that Dr. Azemar sympathizes, but that at this time no other way to treat Mr. Thomas is available. Without treatment, he loses insight, wears three to four layers of pants and a hooded jacket, walks around with rotten sandwiches in his pocket and a newspaper rolled up in his mouth, yells, screams, and eventually is playing with his feces. She claimed that this was not a choice or about a messy room. She drew attention to the fact that Mr. Darrow had earlier said that he might be calling Mr. Thomas to testify at the end of the hearing, and questioned why Mr. Thomas had not been called. She then said that he may be back to delusional thoughts, and that last week he had been sitting on the floor saying don't worry about me, this is treatment for me. She said that ECT may not be what Mr. Thomas wants, but that it is what he needs.

Justice Hall announced that he reserved decision, which means that his decision will be announced at a later time.

Now that the hearing has concluded, and I have resigned from my position as Long Island Recipient Affairs Specialist for the New York State Office of Mental Health, I feel freer to be candid in my own comments. I hope to comment more fully at a later date, but would like to take this opportunity to make a few observations.

First, although there were several outbursts on the part of other people present at the hearing and emotions were running high, Mr. Thomas conducted himself throughout like a perfect gentleman, even shaking Laurie Gatto's hand on more than one occasion. All of us who have faithfully attended the hearings have had the opportunity to observe Mr. Thomas' behavior for many stressful hours. I find that it stretches credibility to describe his behavior as hypomanic, and stretches credibility even further to describe his behavior as acutely manic, at any point during the proceedings.

Second, if a restatement of the clinical judgment of an institution's staff members is taken as being adequate to demonstrate "clear and convincing" evidence, the court process is doomed never to be anything more than a rubber stamp for the decision of that institution. If it is sufficient to demonstrate that a person "lacks insight" (in other words, to demonstrate that a person disagrees with the institution's treating professionals over diagnosis and treatment) in order to declare that person incapable of making treatment decisions, disagreement becomes equivalent to incompetence, and the Rivers decision has lost all meaning. I submit that the State failed to show any clear or convincing evidence that Mr. Thomas' judgment was, at any time during this proceeding, clouded by psychotic thought process, impaired by manic symptoms, or that he was otherwise impaired by psychiatric symptoms in a way that rendered him incompetent to make his own treatment decisions. Third, even Dr. Lynch was willing to admit that for Mr. Thomas, certain hospitals would believe in psychotherapy alone, without ECT. Dr. Lynch discounted such treatment as impractical, however, due to the fact that Mr. Thomas is receiving treatment in the public mental health system, but said that if he had the freedom to do that (i.e., be treated privately), such treatment may be appropriate. I would comment, though, that the monthly cost of psychotherapy as practiced by a psychotherapist experienced in using psychotherapy to treat psychotic disorders is roughly equivalent to the monthly cost of atypical neuroleptics. These expensive medications are routinely covered by the public system. The contrasting lack of coverage for psychotherapy designed specifically to treat psychotic disorders is evidence of a bias in the public mental health system against this form of treatment. The denial of this option to people is not based exclusively on cost factors.

Fourth, I considered that Laurie Gatto's remark predicting that, if not given electroshock, Mr. Thomas would deteriorate to the point that he would be playing with his feces was particularly offensive. Mr. Thomas has himself testified that he has no memory of this particular behavior. If this behavior occurred at all, it occurred on one occasion under extraordinary circumstances, and certainly could not be considered typical of his "untreated" behavior. Considering that Mr. Thomas has been given approximately 60 electroshock treatments since it allegedly took place, I believe his testimony that he has no memory of this behavior. Although Ms. Gatto seemed to disparage Mr. Thomas' ability to take responsibility for his behavior and the consequences of that behavior, she neatly sidestepped the question of how being given a memory-disrupting treatment such as electroshock might impact on his ability to improve in this area. My memory of the testimony early in the trial is that this particularly bizarre behavior allegedly occurred roughly two years ago at South Nassau Communities Hospital, where Mr. Thomas was abruptly withdrawn from both Clozaril and Zyprexa. There was evidence that these drugs were damaging his liver. Discontinuation psychosis is a phenomena well documented in the mainstream psychiatric literature. It can be particularly severe when a patient is withdrawn abruptly from an atypical neuroleptic, such as Clozaril or Zyprexa. It was not Mr. Thomas' decision at this time to stop these medications, but rather it was his doctor's decision. This behavior may very well have been evidence of a severe withdrawal reaction rather than a sign of underlying mental illness. To use this behavior as an example of what Mr. Thomas is like when he is "untreated" seems to me to be gratuitously cruel.

Note: Anne Krauss recently resigned from the New York Office of Mental Health, saying "Given the choice between continuing to work for an agency which so discounts recipients' voices that it will repeatedly force electroshock on someone who has clearly said that he experiences it as torture or advocating for this person's right to make his own decision about whether electricity should be run through his brain, I am choosing to advocate. For this reason, I am resigning from my position as Recipient Affairs Specialist for Long Island effective immediately."

Anne held the position since 1995. There is no question that she will be missed by those she helped over the years, but her determination, spirit and willingness to stand up against the tyranny of the New York OMH should inspire us all.

next: How Do Psychiatrists Decide To Use Forced Electroshock?