In a world where rapid advances in medical and psychological interventions continually shape our understanding of human behavior, ethical considerations often lag behind. In a recent development, the top court in Massachusetts sanctioned the use of shock devices on institutionalized patients on September 7, setting off a wave of ethical debates surrounding psychological treatment methods (Weiss, 2023). This paper delves into the complex interplay between the legal decision and the psychological concept of dyscontrol, examining how our evolving comprehension of this phenomenon influences, and is influenced by, such legal decisions.
The Massachusetts Supreme Judicial Court recently ruled in favor of the Judge Rotenberg Educational Center, an institution for the developmentally disabled, allowing the facility to continue the use of the graduated electronic decelerator. This device administers electric shocks to deter residents from self-destructive and violent behaviors. The court's decision was based on a 1987 consent decree and specified that more substantial evidence would be needed to terminate this form of treatment. The ruling also outlines that electric shock can only be used following the least intrusive, most appropriate treatment protocols. Such a plan must be physician-approved and, if the resident is unable to give consent, permission must be obtained from a probate court.
While the court's decision provides a legal framework for the continued use of electric shock therapy, it's essential to recognize that this issue does not exist in a vacuum; there is a history of compelling arguments and substantial opposition that add further layers of complexity to this already fraught topic. In 2021, a federal appeals court reversed the FDA's prohibition on electric shock therapy devices at the same school, ruling that such a ban exceeded the FDA's authority and encroached on the practice of medicine. Many parents and guardians who challenged the regulation viewed the judgment as a win (Pierson, 2021). An association of parents stated, “We have and will continue to fight to keep our loved ones safe and alive and to retain access to this life-saving treatment of last resort” (2021). While strong support for electric shock therapy exists among some parents and guardians, the practice has faced long-standing scrutiny and is increasingly considered outdated by experts in the field. As early as 2007, William Pelham, a behavioral specialist and director of the Center for Children and Families at the State University of New York at Buffalo, emphasized that electric shock is no longer the standard of care and pointed out that alternative, non-aversive behavioral treatments are available (Kaufman, 2007).
Having explored the legal and ethical dimensions surrounding the use of electric shock therapy in treatment settings, it becomes imperative to delve into the psychological underpinnings that might rationalize or challenge such interventions. One such concept that stands out in this debate is dyscontrol—a phenomenon that has implications both for the individuals undergoing such treatments and for the ethical parameters of the therapies themselves.
Dyscontrol is fundamentally described as an involuntary impairment in psychological functioning and is considered one of the primary features of mental disorders (Kirmayer & Young, 1999; Klein, 1999; Widiger & Sankis, 2000, as cited in Widiger, 2016). As Klein (1999) succinctly put it, "Involuntary impairment remains the key inference" (as cited in Widiger, 2016). This concept is emphasized in various definitions of mental disorder, such as Bergner's (1997) notion of "significant restriction" and Widiger and Sankis' (2000) term "dyscontrolled maladaptivity" (all as cited in Widiger, 2016).
Importantly, the introduction of dyscontrol as a defining characteristic of mental disorders distinguishes it from physical disorders, in which dyscontrol is generally not a consideration (Kirmayer & Young, 1999; Klein, 1999; Widiger & Sankis, 2000, as cited in Widiger, 2016). This distinction serves not just as an explanation for certain behaviors but also as an ethical fulcrum when debating the appropriateness of interventions like electric shock therapy.
Indeed, this becomes quite clear the exact moment dyscontrol enters into the mental health professional’s understanding of mental disorders because the “involuntary” dimension of dyscontrol suggests that individuals with this complex experience have an inability to control behaviors or feelings and therefore an impairment in their psychological functioning, which casts doubt on the extent to which free will plays a role (Klein, 1999, as cited in Widiger, 2016). In this light, the question of free will becomes problematic, as it is a difficult concept to verify either scientifically or empirically (Bargh & Ferguson, 2000; Howard & Conway, 1986, as cited in Widiger, 2016).
These complexities prompt us to question what solutions are available for those who, in their experiences of dyscontrol, may pose risks to themselves or others. This leads us into a critical examination of electric shock therapy as a means of navigating the intricate terrain of involuntary behavior and free will.
Now, before fully commencing this exploration, it is important to address the range of experiences that comprise dyscontrol not solely for what they are, but for what they are not. Dyscontrol does indeed encompass a range of subjective experiences, each with its own "what-is-it-like" essence of being out of control. However, dyscontrol is not equivalent to unconscious behavior, such as sleepwalking. Despite the involuntary aspect, it appears to exist in a different phenomenological and perhaps neurological substrate, further complicating our understanding of what it means to lack control. Given the complex nature of dyscontrol, electric shock therapy emerges as a contentious method aimed at exerting control over those deemed to be lacking it through actions that harm themselves or others, a practice that unsurprisingly has its staunch proponents as well as vehement critics.
At Rotenberg, for instance, children are subjected to electric shocks as a form of behavior control. Rotenberg students wear backpacks with a device that can deliver shocks to electrodes on their body for prohibited behaviors, with parental and court consent (Kaufman, 2007). Rotenberg houses children with severe behavioral issues, including self-harm and aggression, often stemming from conditions like autism (2007). Most are placed there as a last resort when other institutions find them unmanageable.
While Rotenberg claims to be the only institution in the U.S. that uses electric shock as a treatment method, it has faced numerous critical investigations by both the media and state officials. Given this context of controversy, it raises two crucial questions: Is there evidence to support the efficacy of electric shock therapy in treating severe behavioral issues? Further, how does electric shock therapy interact with the concept of dyscontrol in individuals undergoing such treatments?
Parents and administrators at Rotenberg who support electric shock therapy note that undesired behavior is controlled but whether or not that indicates treatment might depend on the psychological framework one explores the matter with. From a behavioral psychology perspective, electric shock therapy can be understood as a form of operant conditioning. According to Skinner's seminal work from 1953, the electric shocks serve as aversive stimuli, encouraging the individual wearing the backpack device to actively avoid behaviors that would trigger the punishment (Skinner, 1953, as cited in Ollendick et al., 2001). In this perspective, the stopping or prevention of undesired behavior occurs; therefore, a treatment has occurred. A psychoanalytic perspective might argue that such an approach only addresses the surface-level symptoms of dyscontrol without delving into its underlying causes. From this view, while the behavior may be halted temporarily, the root issues—whether they be psychological, emotional, or neurobiological—are not treated. This could potentially lead to a recurrence of the dyscontrolled behavior or the emergence of other, perhaps more problematic, behaviors as the individual's underlying struggles remain unaddressed. Therefore, the efficacy of electric shock therapy in genuinely "treating" dyscontrol remains an open question.
Naguy (2017) suggests an alternative solution as she showed that sertindole was shown to be an effective and well-tolerated treatment for a pediatric case of autism spectrum disorder (ASD) with severe behavioral dyscontrol, after other psychotropic drugs had failed. The drug not only improved symptoms but also reversed metabolic and neurohormonal side effects, suggesting it could be a promising alternative for treating complex cases of ASD (2017). This advancement highlights the growing arsenal of treatments that could serve as viable alternatives to more controversial methods like electric shock therapy.
The issue of using electric shock therapy as a form of treatment for individuals with severe behavioral issues sits at the intersection of law, ethics, and psychology. Legally, the Massachusetts Supreme Judicial Court has set a precedent for its continued use, albeit with restrictions. Ethically, the practice is fraught with challenges, particularly concerning the involuntary nature of the conditions being treated, which brings the concept of free will under scrutiny. Psychologically, the efficacy of electric shock therapy is still a matter of debate. Depending on the framework one uses, it can either be seen as a form of behavior modification or a symptomatic treatment that doesn't address underlying issues.
Importantly, the psychological construct of dyscontrol adds another layer to the ethical and practical considerations of using electric shock therapy. It forces mental health professionals to question whether they can or should impose external control mechanisms on individuals who, due to involuntary impairments, may not have the level of self-control deemed acceptable by societal norms. When does intervention become infringement? And who gets to decide?
While alternatives like medication have shown promise, they are not without their own sets of challenges and limitations. Ultimately, the question boils down to what comprises effective and ethical treatment and how those goals align with or contradict legal guidelines. As science and medicine continue to evolve, it is crucial that legal frameworks and ethical considerations evolve in tandem. A multi-disciplinary approach, involving legal experts, psychologists, ethicists, and other stakeholders, may be necessary for reaching a more holistic understanding of this issue.
Moving forward, it is critical for research to explore not just the efficacy but also the ethical dimensions of treatments like electric shock therapy. The voices of those undergoing these treatments, as well as their guardians and caretakers, must also be included in this important conversation. More comprehensive studies comparing electric shock therapy with alternative treatments could provide valuable data to inform future legal and ethical discussions.
In wrapping up this exhaustive exploration, it's necessary to pull back the curtain and face the astonishing reality: In 2023, we are still debating the ethics of delivering electric shocks to children. Pause for a moment and let that sink in. In an era where self-driving cars are navigating our streets, virtual reality can transport us to imagined worlds, and medical science offers solutions once deemed miraculous, we are sanctioning the use of archaic and potentially traumatizing methods on our most vulnerable: children.
The very fact that this topic requires debate is bewildering. No matter the legalities, no matter the intricacies of dyscontrol, the underlying question remains alarmingly simple: Why, in a society so advanced, is there even a sliver of acceptance towards a method that seems ripped out of a grim history textbook?
It's time we take a collective step back and ask ourselves some fundamental questions. Is this the legacy we want to leave behind? Are we so ensnared in legal and ethical knots that we overlook the straightforward human principle of not causing harm, especially to children? The year is 2023, and it's high time we replace shocking with seeking – seeking more compassionate, innovative, and humane solutions that don't belong in the annals of dark history.
Kaufman, L. (2007, December 25). Parents defend school’s use of shock therapy. The New York Times. https://www.nytimes.com/2007/12/25/nyregion/25shock.html
Naguy, A. (2017). Successful use of sertindole for severe behavioral dyscontrol in a pediatric case of syndromic autism spectrum disorder. Journal of Child and Adolescent Psychopharmacology, 27(5), 471–472. https://doi.org/10.1089/cap.2016.0182
Ollendick, T. H., Vasey, M. W., & King, N. J. (2001). Operant conditioning influences in childhood anxiety. In M. W. Vasey & M. R. Dadds (Eds.), The developmental psychopathology of anxiety (pp. 253-277). Oxford University Press.
Pierson, B. (2021, July 7). D.C. Circuit overturns FDA ban on shock device for disabled students. Reuters. https://www.reuters.com/legal/litigation/dc-circuit-overturns-fda-ban-shock-device-disabled-students-2021-07-06/
Weiss, D. (2023, September 11). Top court in Massachusetts permits use of shock devices on institutionalized patients. ABA Journal. https://www.abajournal.com/web/article/top-court-in-massachusetts-permits-use-of-shock-devices-on-institutionalized-patients
Widiger, T. A. (2016). Classification and diagnosis; Historical development and contemporary issues. In J. E. Maddux & B. A. Winstead (Eds.), Psychopathology: Foundations for a contemporary understanding (pp. 97-110). Routledge.