ECT and “unwilling” in Ireland: the principle and practice

On 8th December, the word “unwilling” was deleted from section 59 of Ireland’s Mental Health Act.

Section 59 of the Act deals with administration of electro-convulsive therapy ECT without informed consent to involuntary patients in approved centres (psychiatric units). The amendments mandating this change and an analogous change to section 60, which governs the administration of medication without consent to involuntary patients, are here.

The Mental Health Act up to 8th December allowed for administration of ECT to people who were “unable” or “unwilling” to consent, or both. The decision as to who whether a patient was “unable” or “unwilling” was formally the decision of the treating consultant psychiatrist along with one other independent consultant psychiatrist. (“Unwilling” is now gone, but the decision around inability to consent remains with two consultants.)

The removal of “unwilling” from the Act was long-flagged. The College of Psychiatrists of Ireland have been advocating for the change since 2010. (The College has only existed since 2009).

The change to section 59 is an important change, in principle. In practice, I would argue, it will make very little difference.

To be “unwilling” to consent, under the Act, implied that the person had capacity to give informed consent – which means that he or she was able to refuse informed consent. A person who received ECT or medication without consent but was documented to be “unwilling” to consent rather than “unable” was therefore considered capable of giving or refusing consent. It never made sense that this provision would be in the Act and I find it hard to imagine a set of circumstances in which I would give a treatment to a patient who refused it, if they were able to weigh up the pros and cons of that treatment.

To be “unable” to consent to a treatment – ECT, medication, or any other – means to lack capacity, which is “the ability to use and understand information to make a decision, and communicate any decision made.”

Capacity is judged on a decision by decision basis so that one might have capacity to consent to one treatment and not another. Ireland’s capacity legislation dates from 1871, but is almost updated – a Capacity Bill from 2013 is nearing the end of its legislative journey.

A person who is “unable” to consent to ECT – “unable” has stayed in the Act, by necessity – is, generally, too sick to make treatment decisions. I’ve written about illness depriving people of capacity here.

The only way that the loss of the word “unwilling” in Section 59 would make a substantial difference in practice is if, in recent years, the number of apparently capacitous people being treated with ECT without consent was large. It was small. (It was not zero.)

The most recent figures on ECT from the Mental Health Commission, which has oversight of all activity in approved centres, are from 2013. They were published on November 12th 2015 and widely reported.

The MHC report records each course of ECT without consent and the assessment of each psychiatrist, documented in a tick box on the MHC’s Form 16, as to whether the patient was unable or unwilling to consent. (The forms are yet to be updated.)

In 2013, 46 people received ECT without consent. In 39 cases, both psychiatrists ticked “unwilling”. In six cases, one psychiatrist ticked “unable” and another ticked “unwilling”. In one case in 2013, both psychiatrists ticked “unwilling”. The analogous numbers for 2012 were 26, 3, and 1; for 2011 20, 4, and 3; for 2010 29, 6, and 5; and for 2009 38, 5, and 11. (I hadn’t gone back as far as the 2009 figure before now and it’s higher than I would have thought it would be.)

What these figures show is that the number of people receiving ECT without consent went down, then back up, in the five cited years, and the number of people receiving ECT under “unwilling” – i.e. those who the Form 16s would indicated had preserved capacity, but had ECT without consent anyway – dramatically reduced, from 11 in a year to one in a year; we don’t have figures for 2014 or 2015 so we don’t yet have a baseline to judge any potential change in the figures to ensue from the legislative change last night.

There is a question here: why did anyone receive this treatment without consent when they were deemed, one would infer, to have capacity to decline the treatment? I just don’t know. It’s a basic principle not just of psychiatry but of all medicine that if you have capacity, and you say no, your no is respected. It’s how we work day in day out. There’s no reason to insist on a treatment that a capacitous person is refusing – not just in principle, but in practice. Psychiatrists are used to thinking that a treatment might help, and to being told no.

I have my suspicion, which is that psychiatrists ticked “unwilling” to mean both unable and unwilling – as in, we wouldn’t even be looking at this form if the patient were “able” to consent. I doubt anyone who received ECT without consent in Ireland in the last several years had capacity to consent. But I don’t know for sure, and I’m not sure we’ll ever know. From now on, we’ll know.

People are going to need treatment with ECT without consent as long as severe depression exists. Those people will receive that treatment without consent because they are unable to consent – they may think all hope is lost when it’s not; they may think we are trying to kill them; they may think they are already dead. Small numbers of people will need this treatment. It is a very good thing that “unwilling” is gone. The number of people receiving treatment with ECT under “unwilling” is now, as it should be, zero. The number of people we have to treat who are too sick to consent will never be.


To Be A Psychiatrist Is To Be Uncertain: Cognitive Error and Kindness

“Hello babies. Welcome to Earth. It’s hot in the summer and cold in the winter. It’s round and wet and crowded. On the outside, babies, you’ve got a hundred years here. There’s only one rule that I know of, babies: God damn it, you’ve got to be kind.” ― Kurt Vonnegut

Jerome Groopman wrote a piece in 2007 in The New Yorker called “What’s The Trouble“, which is one of the more influential texts in my life, and which I’m often sorry I ever read. If you want to remain free of anxiety about your potential failings as a doctor, or about the potential failings of your doctor, maybe don’t read ‘What’s The Trouble’. Read this! Or this.

Groopman, who is a haematologist, Harvard professor, and author of more than two hundred scientific papers as well as a New Yorker staffer, because he has more hours in his day than I have, introduced me in “What’s The Trouble?” to the field of cognitive error in medicine.

This is the study of medical mistakes we make by the very act of thinking.

As Daniel Kahneman, cognitive psychology pioneer, put it, people think fast and slow.

Slow thinking in medical decision-making involves accumulation of all necessary evidence, painstaking appraisal of that evidence, and demonstrably disinterested decision-making. This is what college trains us to do. Adherence to this model demands essentially unlimited time and resources and a degree of objectivity that no-one possesses.

Fast thinking is making decisions based on pattern recognition and gut instinct; this is what, as we mature clinically, we mostly do. Fast thinking is good. Efficiency is important; speed is not laziness.

Whenever we have limited time (which is always) and insufficient or ambiguous information (close to always) we rely, said Kahneman, on cognitive shortcuts, rules of thumb, called heuristics.

We are right to rely on heuristics, said Groopman. “Heuristics are indispensable in medicine; physicians, particularly in emergency rooms, must often make quick judgments about how to treat a patient, on the basis of a few, potentially serious symptoms.” And they are fine, until they’re not.

When cognitive shortcuts let us down cognitive error happens, and we risk mistakes. The list of cognitive errors, outlined by Dr Pat Croskerry in The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them, is long. Most cognitive errors are intuitive, if, by their very nature, irrational.

Anchoring is the tendency to rely too much on information obtained early in the decision-making process, even when it’s not the most pertinent piece of information, or when it’s later shown to be irrelevant. If in a phone call about a paranoid patient a colleague mentions a history of cocaine use, it’s going to be hard not to rank cocaine-induced psychosis high up the list of likely diagnoses, even if the patient insists he hasn’t had any cocaine in a year.

(There’s a great example of anchoring involving Mahatma Gandhi, not involving cocaine, here.)

Confirmation bias is the tendency to seek out information that confirms your initial provisional diagnosis and to dismiss information that challenges that diagnosis. You should seek out information that challenges your initial diagnosis; if you’re right, you won’t be able to prove yourself wrong. In the previous example, one might if biased doubt the history of abstinence more than the diagnosis of drug-induced psychosis; a negative drug test would be read to mean the patient used cocaine long enough ago that it’s out of his system, not, as he insists, that he’s clean.

Commission bias is the decision to act (e.g. to treat with an antipsychotic) because you are a doctor and you are supposed to help, even if your actions are not all that helpful (e.g. you might not know exactly what you are treating, and antipsychotics are serious drugs). “Don’t just stand there – Do something!” applies here.

The sunk cost fallacy is the failure to back out of an initial diagnosis because of the feeling that you have that you have committed to this diagnosis – regardless of whether it is right. This must be bipolar II disorder because I said it was in a letter to a GP a few weeks ago.

I have honest to God caught myself thinking this way.

It looks so stupid when you write it down like that.

And there are cognitive errors that doctors make because we are influenced by our emotions much more than we like to admit – influenced, often, by the way we feel about our patients. We make bad decisions because we care about our patients too much (the affective error) and because, less comfortably, we care too little.

Making the affective error, we may act as if a clinical situation was how we wish it to be rather than how it is. If a patient looks like he has a psychosis, but we’re not 100% sure, and if receiving that diagnosis may have adverse consequences for the patient, we may hold off on making the diagnosis for longer than we should, because we don’t want to upset our patient. (Magical thinking is common in cognitive error.)

Conversely, if a patient is difficult or self-destructive, or engaging in behaviour that is not helping us to help him, we are prone to the fundamental attribution error: “the tendency to be judgmental and blame patients for their illnesses rather than examine the circumstances that might have been responsible”. Then, we need to be careful that we don’t let ourselves off the hook of helping that patient – he’s not helping himself, why should I?

In ‘What’s the Trouble’ and The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them, Jerome Groopman and Pat Croskerry gave some great advice.

They said, primarily, to use the patient. Don’t just trust yourself. Ask for hard questions from your patients and their families. Insist, politely, that they test you. Ask that they ask you why you’re doing what you’re doing – how do you know you’re making the right decision?

Put yourself through the effort of considering three or four diagnoses even when you are sure you know what the diagnosis is – you can be sure and still be wrong. Routinely ask the question: What else might this be?

On commission bias: Don’t just do something – stand there!

Croskerry also advised clinicians to develop insight into their own thinking style and be aware of the potential for error. I did this – I internalised Croskerry and wrote about cognitive error in psychiatry, and worried myself, and taught it to freaked-out trainees.

I figured the likelihood in psychiatry of error related to complexity and ambiguity was high; to be a psychiatrist is to be uncertain. Psychiatric diagnostic systems depend on subjective assessments of ambiguous information about inner experience. How much anhedonia is enough anhedonia to count towards a diagnosis of depression? How bad should concentration be to be “poor concentration”? How firmly held must a belief be to count as a delusion, and so to justify consideration of an antipsychotic? The potential for bias is huge, as is, accordingly, the potential to be wrong.

So I’ve always found cognitive error compelling and deeply unnerving.

I’m a busy clinician. I have the guts of 300 patients on my books at any one time. I make a lot of decisions; some without much time to make them; some with potentially serious consequences. All you have in your clinical practice is your ability to think through a decision. If you can’t trust your thinking, where are you? Knowing how wrong you can be is unmooring. You can easily run into crises of confidence when you are hyper-aware of your fallibility.

So how do we know we are making the right decisions?

We have to trust ourselves, up to a point, and trust those around us. We have to ask our teams how we are doing, and I do this to a degree that I worry might annoy my team. (“Oh Jesus get on with it.”) The occupational therapists, social worker, psychologist, and nurses on my team are well able to tell me when they think I’m wrong. I rely hugely on that.

I ask my trainees to tell me what they think of the plan I just put together. Some look perplexed – why are you asking me? – and some get it. Consultants have the final call – we are the people on the team who need to be OK with every decision anyone makes – but we need help. In avoiding overconfidence you have to have the confidence to ask for honest feedback, and hope that it is forthcoming.

And you rely on your patients as much as you rely on your colleagues. You have to trust your patients and their families to tell you what they really think and to co-design their care with you. My favourite words to write in a chart (after “Mood subjectively ‘grand'”) are “We agreed the following”. There’s something so reassuring about that.

The more I go on the more I’ve realised that external assurances aren’t enough. You need a solid underlying principle if you want to be confident that you are doing the right thing by your patients. You need bedrock. This probably seems obvious. But I don’t remember being trained to have such a principle in college, or in basic or senior training.

And it’s back to Kurt Vonnegut, and I think it’s kindness.

Kindness is not talked about too much in medicine or psychiatry right now. It’s a little paternalistic and probably embarrassing. But kindness, I think, anchors you. How far wrong can you really go? If you are a clinician focused on being kind you are not focused on your own ego. You won’t make the mistakes we make for not allowing ourselves to be wrong. You were wrong. So what? Get over yourself. As Neal Maskrey wrote in the BMJ in 2013 in a beautiful blog postThe Importance of Kindness, “it isn’t about you… it’s about them”.

Aspring to kindness also sounds self-righteous. But you can aspire to be kind and know that you won’t, obviously, manage it. Maskrey quoted the late American novelist David Foster Wallace: “It’s hard, it takes will and mental effort, and if you’re like me some days you won’t be able to do it, or you just flat-out won’t want to.”

A practical approach could work as follows. If you’re practising medicine, or psychiatry, and you feel like being kind or compassionate, go for it. It’s easy when you’re feeling it. And if you’re practising medicine, or psychiatry, and you don’t feel compassionate – do it anyway. Behave as if you were feeling compassionate. Make the effort. You know what you’d do if you were feeling compassionate – so do it.

David Foster Wallace knew that kindness doesn’t always come easy, but, still, he said, “Most days, if you give yourself a choice, you can choose to look differently”. Maskrey replied: “I’m trying David, every day I’m trying”.

Pockets of Light

Responses to my piece on The Stone Roses last week got me thinking about ageing and about the ever-evolving role of music in our lives.

Why do any of us love the music we love? How does our relationship with music change as we age? Is it possible, ever, to fall for a song the way you did when you were fourteen and everything was up for grabs?

I am not the first person to wonder about this.

I think, for the record, that the answer to the last of those is Yes – though I’d be surprised if a song ever transformed things again like ‘Tame’ did in April 1989. When you’re 41, the days of songs inducing seismic upheavals in your sense of self are over, you’d hope.

So, I had great intentions on Saturday night of posting on this subject.

What ended up happening, though, in a pattern that I’ve been repeating for 25 years and more, is that rather than complete the task I’d set myself, I listened to loads of music.

Not too constructive, but it felt constructive on Saturday, as it did throughout college, when I would sit up to 3AM with textbooks sprawled, ostensibly cramming but, in fact, devoting all my attention to AMC’s Engine.

(Quick aside: how great a track one side one is ‘Big Night’? The day I don’t get a shiver from its steadfast forlorn devotion – “When time peels off your statue skin, I’ll still be fooled by what remains / Yeah, whatever’s left of you will be my dream” – is a day I will have a stern word with myself.)

In an attempt at salvaging something from Saturday, I made a playlist, which I called Pockets of Light, after Lubomyr Melnyk and Peter Broderick’s beautiful 2015 piece on the wonderful Erased Tapes label.


I started on this playlist because it occurred to me that if the pieces I love right now have anything in common, it is a transcendent quality.

I don’t mean sacred as such – though the oft-religious output of the Louth Contemporary Music Society has heavily influenced my taste in the last half-decade, and there is Russian choral music on the playlist, which would have nonplussed the 1989 version of me.

What I mean is something in the music operating at a level I don’t understand, that’s visceral, usually involving sheer beauty, and makes me happy and sad and yearning and centred at the same time.

It’s something about the quality of emotional focus the piece induces and it has an addictive feel. How I know this is happening is that when the song ends, I miss the feeling, and I have to put it on again, like Dave Fanning used to compulsively replay MBV’s ‘Sometimes‘.

There’s a neurobiology of musical emotion here, possibly involving delta waves, that a more biological psychiatrist than I could explain. There are certainly enough fMRI studies.

I’m not sure how much these transcendent songs have in common.

I think the description applies to Nick Drake’s ‘Place to Be‘. I think it applies  to Jon Hopkins’ and Natasha Khan’s ‘Garden’s Heart‘ and Ergodos Musicians’ ‘Ladrang mugirahayu‘; to Squarepusher’s ‘Tommib‘, John Cage’s ‘In A Landscape‘ and Sufjan’s ‘The Owl And The Tanager‘; to Ghost Culture’s ‘Glaciers‘, Guided By Voices’ ‘Chicken Blows‘ and Arvo Part’s ‘Da Pacem Domine‘. The compulsive thing alluded to earlier means that as I type those names in rapid succession I want to hear them all, like now, and all together if necessary. At times like this paragraph I feel a rush of gratitude to these people.

If one way you recognise transcendence in music is the profundity and inexplicability of the effects it induces – in your stomach, in your suddenly dry throat, in a fluttering of your heart that you weren’t expecting – then ‘Os’ by Slow Moving Clouds is transcendent.

This band is completely new to me. I came across them just on Saturday night, through Fractured Air, though I know Seti The First, the wonderful band belonging to Slow Moving Clouds’ Kevin Murphy.

Slow Moving Clouds are Finnish and Irish and I have to assume that ‘Os‘ is sung in Finnish. It’s one of those songs that you don’t understand and you completely understand. The confluence of Aki’s strong, brittle baritone, the restraint replete with emotion, Danny Diamond’s keening fiddle and Kevin Murphy’s sweeping cello, and what I read and hope may be a nyckelharpa – it’s quite something.

I’ve listened to ‘Os’ twenty-five times in a weekend. I’ve played it five times writing this piece. I need to stop, and I will, but not now.

NC 30/11/15

The Stone Roses in 2016: Remember When Is The Lowest Form of Conversation

Tickets for a show next July by The Stone Roses in Marlay Park went on sale last Friday at €75 a pop.

Marlay Park fits 30,000-odd people. The Roses have also announced three dates in the Etihad in Manchester, which means they are expecting 150,000 punters through the door. They will get them: in 2012, 220,000 tickets for their reunion shows in Heaton Park sold out in an hour, making these the fastest-selling shows in UK history.

The Stone Roses most recently released new material on December 5th 1994. A child born on the same day as Second Coming can, next month, legally fly a plane, or buy booze in the United States, though not simultaneously.

The Stone Roses’ first album, the one that inspires the perpetual pilgrimage, was released 26.5 years ago. That’s slightly older than the median age of the world’s population.

It’s quite the album! But still.

Pop music is the only art form in which record-breaking success is achieved by resting on laurels that are older than half of the people currently alive in the world.

I get nostalgia. When I was small we’d go to Westport all summer, and when, in late August, we would turn around the corner of my Granny’s lane to take the road back to Dublin, I would pine for late June. Why is it not June any more? I was a religious child and I wondered why, if faith can get a mustard tree to pull up its roots and walk into the sea, faith so insistently failed to make it June again.

In 1993, I read an interview with the Frank & Walters in the NME in which Paul Linehan, and I’m paraphrasing, but only slightly, said: “I’m not just nostalgic for the past. I’m nostalgic for now. I’m already nostalgic for this interview”. I read this at 18, and Paul had read my mind. What business has an 18 year old being nostalgic?

I still often have that feeling. Regularly, usually with my family, I love a moment so much that I already miss it; so the joy is tempered with, and sometimes bested by, sorrow. This feels daft, and I kick myself, which makes it worse, but it’s real.

It’s not just me. Zen tells us this is a universal experience. What a relief!

Sogyal Rinpoche wrote in the Tibetan Book of Living and Dying:

Grasping is the source of all our problems.

Since impermanence to us spells anguish, we grasp on to things desperately, even though all things change. We are terrified of letting go, terrified, in fact, of living at all, since learning to live is learning to let go.

And this is the tragedy and the irony of our struggle to hold on: Not only is it impossible, but it brings us the very pain we are seeking to avoid.

Hence, as I understand it, anyway, the “-algia” in “nostalgia”.

So: we attach ourselves to musical moments from a past that we fancy was purer or freer or less burdened than now is.

I do this with The Divine Comedy, or American Music Club, or REM, or Pixies, or Tindersticks. My love for those bands is bound up so much with the intense emotions and daily revelations of that time in my teens in the late Eighties and early Nineties that I honestly couldn’t tell you how good Promenade actually is. It is part of me.

I wrote in 1999 that you could “pick holes in the songs of the Divine Comedy in the same way as you can pick holes in the personalities of your parents: it doesn’t mean you love them any less”. That’s how close we get to the music that ingrains itself in us when we’re young.

Those times, those deep early hard-wired connections, are also, later on, safer. They’re past; they don’t have any unpleasant surprises for us.

Nostalgia is not, though, on balance, OK in music.

Getting stuck in the music of lost decades is un-rock’n’roll.

You have to let go. Trust that the next thing will be better, and it will be.

And lose the belief that what has gone before is better, while what is ahead can’t live up to it. Art has to be alive; present or future tense.

Reunion tours are founded on a fundamental untruth, which is that there is something inherently better about the old stuff than the new stuff; the new stuff being produced every single day right now by artists right around the world in their rooms and going up on Soundcloud and Spotify and Bandcamp. This seems wrong for a few reasons.

The old stuff was once the new stuff, for a start. The Stone Roses wouldn’t have happened if everyone in 1989 was crowding into yet another Kinks reunion; the space The Stone Roses occupied in the NME culture of the time might never have opened up if The Smiths hadn’t honoured their art by splitting when the moment, when their Muses, demanded it.

It’s also not a fair fight: The old stuff benefits from recall bias.

Decades of mass produced music are neatly sorted – half a dozen bands per decade are essentially untouchable and no-one mentions the oceans of dross we spent so many years and millions of words sorting through. Real time is more confusing; we don’t know yet who the great ones are. (If it matters – art doesn’t have to be a hierarchy.) It’s more exhilarating too.

Thirdly, so many classics are actually pretty poor. The Sixties were just not that great. The Eighties are the subject of such adoration and imitation in the 2010s that you have to catch yourself and think – hang on; I lived through that. The 80s were awful!

So many classic hits or legendary albums don’t have the beauty or smarts or emotional heft of the better stuff from our time.

By definition (unfair in the opposite direction), songs from the Sixties or Eighties don’t have the relevance to the 2010s that they had to fifty years ago. How could they? But timeliness is a cornerstone of pop music; not everything is ageless, nor should it be.

‘Someone Great’ By LCD is completely of its late 2000s moment and emotionally completely right: “The coffee isn’t even bitter / Because, what’s the difference?” East India Youth’s ‘Carousel’ hits me somewhere no Sixties tune does. Taylor Swift’s ‘Blank Space’ is as good a song in its class as has existed, and I’m delighted it has had a billion views. Sufjan Stevens’ Carrie And Lowell is unmatched, by anyone, in all time. It’s just perfect. I can’t wait to hear what he does next, and it could be anything.

Musicians deserve reverence, as far as I’m concerned. Like artists in all disciplines, and at the risk of over-generalising, musicians are incredible, inspiring people. Musicians put themselves out there, making beauty from nothing but experience and craft and courage and obsessionality and vibrating air. They compulsively create new work that exposes them deeply without the slightest notion how anyone will respond to it; you can’t know, and how wounding if your labour of love is unloved?

Musicians are to be admired, and encouraged, and supported. We need them. The message should not get out there, though it already has, that endlessly replaying the dozen songs you know we like is the way to go.

NC 23/11/15


Addendum: The Stone Roses were never the be-all and end-all for me but The Pixies were. And in October 2009 I wrote this in the Irish Independent about their (to me) ill-conceived 20th anniversary Doolittle tour.

Why I would not cross the road to see the band that changed my life.

Niall Crumlish. 1st October 2009.

For the last three nights, the legendary Pixies used the Olympia as the launching pad for their keenly awaited Doolittle tour. The tour commemorates the twentieth anniversary of Doolittle, their magnum opus, the album that led music website Pitchfork to acclaim the Pixies as “the most influential alternative rock band of all time”.

At the time of writing, the shows haven’t happened, but rapture will abound. Like a handful of records of its era (Murmur, The Queen is Dead, The Stone Roses) Doolittle has acquired sacred text status. This is the first time it has been played in its entirety on stage. The Olympia is a great venue. Rock fans of a certain age are pretty excited.

And why not? Doolittle was a landmark moment, for rock and for this writer. In any list of key moments in my life, reading the Hot Press review by Graham Linehan that sent me scurrying into town for a scratched vinyl copy of the album in April 1989 is right up there.

At the time I read Graham’s piece I was just feeling my way into pop via REM, U2 and the Beatles. Doolittle completely exploded my concept of what rock music could do: the ideas a writer could address; how a singer could sound; the language that qualified as lyrics; the distance artists could and must go beyond what is considered acceptable. (‘Dead’ is barbarous.)

Right from the urgent opening bass notes of ‘Debaser’, Doolittle was an epiphany. Anyone who has obsessed about music can cite two or three records that were life-changing; I have even been known, after a couple of pints, to trace back to ‘Monkey Gone to Heaven’ the evolution of my entire adult personality. This is not an entirely comfortable notion.

So why not wait till after the Pixies have actually played to write about the Doolittle tour? Because I didn’t go. I couldn’t go. I love Doolittle too much to watch it being mummified.

It’s not just that the Doolittle tour is such a nakedly commercial venture. (A box set, Minotaur, is being released to coincide with the tour; that is, the Pixies’ discography is being sold to us again, but with shinier packaging and a book. A book! How lovely.)

It’s not just that there is no creative reason for the tour, although Black Francis has mentioned new material. Ever since reforming to support the Chilli Peppers in 2004, they have promised new material, as if they were a going artistic concern. None has arrived, and none will.

In fact, the Doolittle tour is part of a wider and disturbing trend in rock, particularly in independent music, which has long-laughable pretensions to being adventurous.

The last few years have seen ever more bands reforming to play shows at which they perform single classic albums years after the event. As the Pixies are doing with Doolittle, so Echo & the Bunnymen did with Ocean Rain, and even Iggy and the Stooges with Raw Power.

At the last true Stooges show in 1974, recorded on Metallic KO, Iggy roared abuse at bikers while beer bottles smashed against the amps either side of him; he ended the night in hospital. Now, he sells insurance while playing ‘Gimme Danger’, dissonance unnoticed or ignored.

There’s more to my antipathy to these reformations than disappointment with former renegades pandering to the phoney nostalgia of a now-moneyed audience that, tired of the present and wary of the future, wants to pay to relive a mythical past – though there is that.

There is the principle that bands should know when to break up. Bands should be Fawlty Towers, not Friends. They should then stay broken up. Other than ABBA and The Smiths, it’s hard to think of a band of consequence that refuses on principle to reform. That Agnetha Fältskog could have more artistic integrity than Iggy Pop would once have been shocking.

There is the stifling notion that albums should be commemorated. They are just songs, and unless they live and breathe in the present, they’re nothing. Pixies, the Bunnymen and Iggy Pop are making museum pieces of their music. It is rock’n’roll as taxidermy.

And with the best will in the world, the Doolittle shows can only provide a faint, sad echo of the Pixies at their peak; high-class karaoke, but karaoke all the same. Pixies Rock Band.

Doolittle can’t be revived in this way – how could it? It was a moment.

It was a glorious confluence when four people in one room channelled something mysterious. It was like flames descending on the heads of the apostles on Pentecost Sunday, or lightning hitting the DeLorean in Back to the Future. It would only happen once.

The Pixies couldn’t tell you how they did it; Black Francis was often asked. It happened, and the moment passed, and it was gone. You can’t ask the Pixies, twenty years on, to reproduce the unearthly unwilled wonder of Doolittle. You may as well ask them to speak in tongues.

In 2015, I stand over all of this, except what I said about Iggy.

Dismissing artists who used to have bottles thrown at them on stage and now do insurance ads is what happens when Bill Hicks indoctrinates you as a teenager with ‘Artistic Roll Call’ (“You do a commercial… Everything you say is suspect”).

But a little consistency: fortysomethings should be capable of moving on from their teenage ethics just as we should be able to move on from the bands that defined those years; Bill would have moved on by now. It’s not, as it can feel, a betrayal of our younger selves to move on; it’s just letting go. Just as those bands that we gave ourselves entirely to should be able to move on from us.

And seriously – where did I get off? Iggy doesn’t owe anyone anything.

All hail Iggy.

ECT in the Irish media: A failure of understanding


November 16 2015.

The Sunday Independent published on 15th November an article with the headline “Mentally ill still forced to endure shock treatment”. The article, by Allison Bray, commented on a report by the Mental Health Commission (MHC) published on Thursday 12th November regarding the use of electro-convulsive therapy (ECT) in Ireland. The MHC reported a “worrying” rise in the administration of ECT without consent between 2012 and 2013, from 27 courses of treatment to 46 nationally in a year.

The lurid headline, which will have been written by a sub-editor rather than by the author of the piece, begs to be picked apart. Every word in the headline is problematic.

“[The] Mentally ill”, referring to people with mental illness, is a terrible phrase, as is the word “epileptics” used elsewhere in the article to describe people who have epilepsy. People with mental illness, who form a large proportion of any population, are not “the mentally ill”. Mental illness does not define these people, as epilepsy does not define people, like me, who have a diagnosis of epilepsy. It is not their essence. It is not us and them, as that phrase implies. Language is important.

The word “still” is intended to imply that ECT is some archaic throwback. (“I can’t believe they still do that!”) “Forced” implies a degree of physical coercion that is not there. “Endure” we will come back to – as if the worst a severely depressed person had to endure was an effective treatment. And “shock treatment” is thrown in purely to sensationalise. No one calls it that, except headline writers.

The article itself, like articles dealing with the MHC report in the Irish Examiner and the Irish Times, had serious issues. It did not respect its subject enough to know its subject.

Each of these articles discussed ECT without consent. None of them read as if its author understood the fragility of capacity to consent to treatment. Each article cited the Mental Health Act concepts of “unable” and “unwilling” with respect to consent for ECT without appearing to know the difference. (Section 59(b) of the Mental Health Act, 2001, deals with the administration of ECT to people who are “unwilling” and/or “unable” to consent. Most people who receive ECT under section 59(b) are both unwilling and unable; They can’t consent, and they don’t assent.)

None of the articles read as if the authors had any knowledge of severe depression.

Nowhere in the articles was there a recognition that a person with severe mental illness might lose the capacity to consent to treatment by virtue of the severity of their illness, and so become “unable” to consent to treatment, such as ECT.

There was much discussion of the wish of the MHC and the Government to ban ECT without consent for people who were “unwilling” to consent, but who were not deemed “unable”.

This does not translate, as one relying on these articles for information would think, to a ban on treatment without consent. Consent is not saying yes. Consent and assent are different. A person who loses capacity but still says yes to treatment – unable but willing – still has to receive the treatment under section 59(b).

A ban on “unwilling” means a ban on treatment without consent for people who retain capacity to make decisions about treatment but who refuse ECT. This is an obvious and necessary move.

No one thinks people with capacity to decide who say no to this treatment, or to any other treatment, should have the treatment. Capacity means the ability to make decisions about treatment. Most people who receive treatment for mental illness retain capacity at all times to make their own decisions. The College of Psychiatrists of Ireland stated as long ago as March 2010 that the provision to treat people who are “unwilling” to accept treatment but able to refuse should come out of the Act.

The College also stated that Section 59(b) needed to stay in the legislation. People will still need ECT without consent when “unwilling” comes out – when their illness is severe enough that they lose the capacity to make decisions about their own treatment, and they are “unable” to consent; when other treatments have failed, or their lives are endangered by their depression, and ECT is likely to help.

It is a daily reality that people with mental illness of various kinds – usually severe depression or mania or schizophrenia and related disorders – temporarily lose capacity because of their symptoms.

A person with severe mania admitted after driving at 100 miles an hour thinking himself incapable of coming to or causing harm, who believes he’s in hospital to heal all around him by laying on of hands, and who angrily refuses treatment for mania, does not have capacity to refuse that treatment.

A person with severe psychotic depression who believes it is better for the world if he dies because he is certain that his inherent evil kills children does not have the capacity to refuse treatment for that depression.

Back, with this context, to the headline: “Mentally ill still forced to endure shock treatment”.

ECT is a safe and effective treatment for a number of serious psychiatric conditions. It is not perfect. No treatment is. It has adverse effects, some of which are severe. All treatments do. It is used rarely. The most common use for ECT is in the treatment of severe depression, for which it is the most effective treatment.

That word “endure” is gnawing at me, and it has angered me. Its use diminishes the suffering of people with severe depression of the kind that makes psychiatrists like me gingerly suggest ECT.

No one could write that headline if they knew how low ECT comes on the list – the long, long list – of horrors that people with severe depression endure.

William Styron wrote “The pain of severe depression is quite unimaginable to those who have not suffered it, and it kills in many instances because its anguish can no longer be borne. The prevention of many suicides will continue to be hindered until there is a general awareness of the nature of this pain.”

Styron is a starting point. But we can be more specific.

People with severe depression endure the certain knowledge, every day, all day, that they are worthless. That they are pointless, and that the world would be better off without them.

People with severe depression are often more agitated than they are depressed or sad. They cannot rest. They cannot have peace. “Depression” is often the wrong word; Lewis Wolpert coined “malignant sadness”.

Severe depression is often a painful absence of feeling; it’s a sickening numbness, a hollowness, that brings with it a shocking loneliness.

Severe depression is often anguished hopelessness. Styron, again: “The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come – not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul.”

People with severe depression endure psychic pain that people without severe depression can’t understand; that goes almost beyond our capacity for empathy. They may endure the constant, pressing, urgent wish to die. They may wish they had never been born. They sometimes say that they would kill themselves if they weren’t so tired; but they are bone-tired.

They feel guilt that they are alive, guilt that they are sick, guilt that they are a burden, though they’re not. People with severe depression feel guilt that they can’t, as they see it, even kill themselves properly. They may feel depressive guilt to such an extent that they believe they deserve their torment.

People with severe psychotic depression endure auditory hallucinations telling them they are scum, they are hated, they should die; these voices scream at them.

They endure delusions that you wouldn’t believe if you hadn’t heard them first hand. That they are evil and sinful; that they have caused wars, that they are responsible for murders, that they are physically hurting other people just by being in their physical presence. I would bet anything that there is a depressed person in Dublin right now who believes he is responsible for the Paris attacks. It’s impossible but he knows.

People with severe psychotic depression believe these things, that are physically impossible, with utter conviction. They know these things, that are wrong and terrifying, as surely as they know their own names.

People with severe depression endure the belief that their organs are rotten, or that they have already died (the “nihilistic delusion”). Sometimes, when they believe these things, they stop eating and drinking. What’s the point of eating if your insides are rotten, or if you’re already dead? Then, they endure starvation and kidney failure and they can easily die, untreated.

There is no talk therapy that works here. People who are severely depressed are too tired and hopeless and agitated and they are incapable of adequately listening and concentrating.

There is sometimes no drug that works, or works quickly enough. And supportive care alone is not enough.

So sometimes other options are needed.

I’ve sat with these people and I have reached out to them and failed to reach them; they’re too far away, across a gap that depression has rendered unbridgeable. I’ve sat with their families in solemn rooms and joined them in tough decisions, and it’s gone either way; not every time has my opinion that ECT is needed held sway.

I’ve hardly ever reached for ECT. But I have used it. And it has worked. And it has been transformative. Looking back I wonder if I’ve used it too little; if I’ve let suffering go on too long, unnecessarily, because of a stigma imposed on ECT by commentators who are not in the room when those decisions are made, but who I still hear in my head.

It belittles the suffering of people with severe depression and their families when broadsheet newspapers publish articles about mental illness that don’t understand their subject. When they publish ill-informed, poorly thought through and provocatively headlined pieces about depression, and the treatments that we reach for when nothing else has worked.

It belittles the suffering of these people when authors casually throw in the words “inhumane” and “barbaric”, as the author of the Sunday Independent piece did. (“Some [psychiatrists] have denounced it as inhumane and barbaric” – in fact, I would challenge the author to find one consultant psychiatrist who would use these words.)

Let’s say we took these commentators seriously, and looked at what happens when we refuse to consider treatment with ECT for a person who lacked the capacity to consent.

So a person with severe depression has suffered for weeks or months. Nothing is working. Every hour of every day for that person is torment. They are starting to refuse food, and slowly shutting down.

They are so sick that they believe they are evil and they deserve their unremitting anguish. I have a treatment that works – an unpopular, ‘barbaric’, effective treatment – available to me.

I have a choice here.

Because my patient, delusionally, says no, because he can’t envision his recovery, and because I’ve listened to the authors of articles in the national newspapers decrying ECT without consent, I let the anguish go on. It goes on. I don’t know, then, if this person lives – the hypotheticals have stopped now, and in real life I’m treating this patient.

In real life, I recognise that people who are so severely depressed as to be utterly lacking in hope and delusional need help with decisions that they can’t make, and need steps taken that they can’t consent to, to bring them back for themselves and their families.

As long as I am practicing medicine, I will believe that barbarism is permitting suffering that you could have ended or death that you could have prevented. I want to be on the side of William Styron and to prevent those deaths that ensue because people fail to grasp the calamitous seriousness of severe depression. I want to be on the side of life, of patients and their families; I want to understand.