Rebecca* remembers fighting her clinical team all the way to the theatre, shouting the electroconvulsive therapy she was about to receive was against her will.
"I felt completely helpless, that my body wasn’t my own. I felt like I was in a movie," she said.
"I was shocked they could actually administer it against my will."
Health authorities describe electroconvulsive therapy (colloquially known as shock therapy or ECT) as a safe procedure, in which electrodes are placed on the head and seizures induced in the brain under general anaesthetic.
Royal Australian and New Zealand College of Psychiatrists spokesman Dr Neil Coventry said ECT was one of the most effective treatments for severe depression and other serious mental illnesses, and modern ECT was delivered with precision and constantly monitored.
"For people who are suffering and where nothing else has worked, ECT can quite literally save a life,” he said.
Months on from her treatment, Rebecca is happier than before, and doesn't discount that ECT, as well medication or personal changes, may have benefited her.
However, she describes the experience of having it forced upon her differently: "Invasive, old-fashioned, and frightening," she said.
Rebecca was admitted to hospital voluntarily last year after experiencing periods of delusion, which included attempting to take a holiday without any identification or tickets.
"I probably wasn't very well, but I'd never been like that before," she said.
Shortly after admission, she was placed under a treatment order and told she would receive ECT.
Hundreds ordered to have ECT
In the 2023/24 year, at least 1,700 mandatory ECT orders were approved in Australia, with courses usually lasting eight to 12 sessions.
The true number was likely substantially higher, with some states not measuring or reporting approvals.
In Victoria, a patient must lack capacity to give informed consent before they can be ordered to have ECT — a bar Rebecca said was never passed.
"I have always been aware of what ECT is, and it is certainly something I would never have agreed to," she said.
"I think it's an infringement on human rights."
With the help of Victoria Legal Aid, she appealed the mandatory order, which the Victorian Civil and Administrative Tribunal (VCAT) overturned, ruling she had capacity and the ECT was scrapped.
She had already received a number of ECT treatments, which she said left her foggy and with muscle pain.
She also attributes ongoing memory loss that sometimes leaves her disorientated in the suburb where she’s lived for a decade to the treatment.
Her experience is illustrative of an issue reported by advocacy groups and contained in tribunal and court cases from around the country, which suggested rules surrounding mandatory ECT were often misunderstood or not adhered to.
National Mental Health Consumer Alliance (NMHCA) chief executive Priscilla Brice said the number of people receiving ECT against their will was likely far higher than order numbers suggested, because data didn't identify recipients on guardianship orders.
Feedback from NMHCA's partners across Australia identified "systemic risks" under many state and territory frameworks, Mx Brice said, including its use to enable coercive practices that violated human rights principles.
Mx Brice called for the elimination of involuntary ECT.
The rules governing ECT without consent
Each state had different rules, but most required a tribunal to approve clinicians' applications for involuntary ECT.
Tribunals usually required a patient to be unable to give informed consent and be admitted to hospital involuntarily.
Less restrictive treatments were usually required to have been tried first, and ECT had to be clinically appropriate.
Tasmania was an outlier, with ECT not subject to any special regulation, although tribunal approval was still required. The state also didn’t record data on orders the number of orders it was making.
Although rules differ from state to state, insights from those tribunals tracking the data suggested the majority of applications for involuntary ECT were approved.
Independent mental health advocate Simon Katterl, who worked at the Victorian Equal Opportunity and Human Rights Commission, said tribunals were often criticised for "rubber stamping" ECT orders.
His criticisms are echoed by Victorian Mental Illness Awareness Council chief executive Vrinda Edan.
"I only know of one or two cases where the tribunal has not agreed," she said.
In the 2023/24 year, New South Wales Mental Health Review Tribunal (MHRT) approved 95 per cent of the 749 ECT orders considered.
A MHRT spokesperson said decision-making panels included a lawyer, psychiatrist, and a third qualified member, and all decisions were made according to the law.
"Often the patient has a legal representative who takes instruction from the patient," the spokesperson said.
ECT order approval rates were similarly high in other states that monitor them.
In Queensland, 92 per cent of applications for ordered or emergency ECT that made it to decision were approved.
In Victoria, 87 per cent of applications were approved, as were all 18 in the Northern Territory.
Dr Colleen Loo, a psychiatrist and former president of the International Society for ECT and Neurostimulation, said the high rate of approvals reflected clinicians' training and awareness of the rules, rather than rubber-stamping.
Dr Loo said ECT was more beneficial for patients who lack capacity, pointing to a Singaporean study of 175 recipients with schizophrenia, depression and bipolar mania.
It found those lacking capacity showed greater improvements in mood, functioning, and cognition, although patients were only monitored one to two days after treatment.
Similar studies had not been conducted in Australia, Loo said, because research on those unable to consent would "be a nightmare to get any ethics committee to ever agree".
Mistakes in orders
Victoria Legal Aid fought more than 85 ECT orders in 2023/24 at the Mental Health Tribunal (MHT) and challenged other existing orders at VCAT, with some success, according to its associate director of mental health and disability law, Catherine Leslie.
She said mental health issues and distress could be inappropriately used to argue a person lacked capacity, and clinicians at times confused least restrictive treatment with optimal treatment, focusing too much on what might be quickest.
"Treating teams aren't necessarily getting it right," Ms Leslie said.
The issues highlighted by advocacy groups like Ms Leslie’s often formed the basis of legal challenges to mandatory ECT orders, and resulted in orders being overturned.
Data from VCAT showed 19 of 24 challenges since April 2023 resulted in ECT being stopped.
And in a recent Tasmanian case, a tribunal heard ECT treatment for a patient was cancelled just hours before she was due to undergo it, as clinicians realised she was not subject to a valid treatment order.
“It is clear from reviewing previous reported determinations of the Tribunal on reviews of assessment orders that there has been ongoing confusion and error arising in the use of the prescribed forms … over the last 12 months,” the TASCAT said in a decision published in December.
“[This has resulted] in invalid orders being made and the detainment, assessment and treatment of patients, without legal authority.”
TASCAT ordered a copy of the decision be issued to the Chief Civil Psychiatrist and Statewide Speciality Director to consider if further training was needed.
A Tasmanian Department of Health spokesperson said an education and training program had been introduced, and forms revised to ensure risk of errors was minimised.
"Revision of provisions around ECT will be included as part of the wider review," the spokesperson said.
In another decision, this time at the Queensland Mental Health Court, a woman had 12 ECT treatments overturned after a judge determined less restrictive medication options had not been exhausted.
Out of step with the WHO
Some advocacy groups believe Australia had to shift from a paternalistic approach, where clinicians ordered ECT because they felt it was in the patient's best interest, to an approach that prioritised human rights and self-determination.
Queensland Advocacy for Inclusion (QAI) chief executive Matilda Alexander said Australia's approach should be brought in line with the World Health Organisation's (WHO) stance on ECT.
The WHO and the United Nations issued a guidance and practice document in 2023 that stated: “International human rights standards clarify that ECT without consent violates the right to physical and mental integrity and may constitute torture and ill-treatment".
It also said ECT was "not recommended for children" and "this should be prohibited through legislation".
Only Western Australia and the ACT have banned ECT for minors, prohibiting its use on children aged under 14 and 12 respectively.
However, treatment of under 18s with ECT usually required tribunal approval.
The guidance also addressed the fact there is "significant controversy” surrounding ECT, noting the treatment could result in memory loss and brain damage and its use “dramatically declined” in countries around the world.
There is some debate about the risks and benefits of ECT in the medical community but both supporters and opponents acknowledge that adverse event can occur.
The Western Australian Chief Psychiatrist monitored for a range of adverse events during ECT, including premature consciousness, anaesthetic complications (including cardiac arrhythmia), muscle tears, vertebral column damage, severe headaches, and persistent memory deficit.
It found that an adverse event occurred in nearly 13 per cent of ECT courses in 2023/24.
The ABC approached health authorities in Victoria, Queensland, NSW and Tasmania with questions about each state’s regulation of ECT. All defended their approach to involuntary ECT and the effectiveness of the treatment.
A Victorian Government spokesperson said it had introduced legislation to reinforce an individual’s rights in 2022 in response to a royal commission into the state's mental health system.
Safer Care Victoria's Mental Health Improvement Program had also been set up to strengthen supported decision making.
For Rebecca, that autonomy is key.
"It felt unbelievable, getting my body back, getting my mind back."
*Rebecca's name has been changed to protect her identity and ensure coherence to the Mental Health and Wellbeing Act
