Psychiatry's Electroconvulsive SHOCK TREATMENT A Crime Against Humanity
SayNotoPsychiatry
SHOCK TREATMENT
A Crime Against Humanity
by Lawrence Stevens, J.D.
What used to be called electroshock or electric shock treatment (EST) is now
usually called "electroconvulsive therapy", often abbreviated ECT. The term
is misleading, because ECT is not a form of therapy, despite the claims of
its supporters. ECT causes brain damage, memory loss, and diminished
intelligence. An article in the March 25, 1993 New England Journal of
Medicine says "ELECTROCONVULSIVE therapy is widely used to treat certain
psychiatric disorders, particularly major depression" (p. 839). The March
26, 1990 issue of Newsweek magazine reports that "electroconvulsive therapy
(ECT) ... is enjoying a resurgence. ... an estimated 30,000 to 50,000
Americans now receive shock therapy each year" (p. 44). Other recent
estimates go as high as 100,000 per year.
In his textbook Psychiatry for Medical Students, published in
1984, Robert J. Waldinger, M.D., says "ECT's mechanism of action is not
known. ... As with the other somatic therapies in psychiatry, we do not
know the mechanism by which ECT exerts its therapeutic effects" (pp. 120 &
389). Psychiatrists claim unhappiness or so-called depression is sometimes
caused by unknown biological abnormalities in the brain. They say by some
unknown mode of action ECT cures these unknown biological abnormalities.
There is no good evidence for these claims. Other than by causing mental
disorientation and memory loss, ECT does not help eliminate the unhappy
feeling called depression. This is true even though currently unhappiness
or "depression" is the only "condition" for which ECT is a recognized
"therapy". Indeed, rather than eliminating depression, the memory loss and
lost mental ability caused by ECT has caused some subjected to ECT so much
anguish they have committed suicide after receiving the "treatment".
ECT consists of electricity being passed through the brain
with a force of from 70 to 400 volts and an amperage of from 200
milliamperes to 1.6 amperes (1600 milliamperes). The electric shock is
administered for as little as a fraction of a second to as long as several
seconds. The electrodes are placed on each side of the head at about the
temples, or sometimes on the front and back of one side of the head so the
electricity will pass through just the left or right side of the brain
(which is called "unilateral" ECT). Some psychiatrists falsely claim ECT
consists of a very small amount of electricity being passed through the
brain. In fact, the 70 to 400 volts and 200 to 1600 milliamperes used in
ECT is quite powerful. The power applied in ECT is typically as great as
that found in the wall sockets in your home. It could kill the "patient" if
the current were not limited to the head. The electricity in ECT is so
powerful it can burn the skin on the head where the electrodes are placed.
Because of this, psychiatrists use electrode jelly, also called conductive
gel, to prevent skin burns from the electricity. The electricity going
through the brain causes seizures so powerful the so-called patients
receiving this so-called therapy have broken their own bones during the
seizures. To prevent this, a muscle paralyzing drug is administered
immediately before the so-called treatment. Of course, the worst part of
ECT is brain damage, not broken bones.
Electricity is only one of several ways psychiatrists have
induced seizures in people for supposedly therapeutic purposes. According
to psychiatrists, seizures induced by chemicals or gas inhalants are just as
effective, psychiatrically speaking, as ECT. In September 1977 in the
American Journal of Psychiatry, psychiatry professor Max Fink, M.D., said:
"Seizures may also be induced by an anesthetic inhalant, flurothyl, with no
electrical currents, and these treatments are as effective as ECT" (p. 992).
On the same page he said seizures induced by injecting a drug,
pentylenetetrazol (Metrazol), into the bloodstream have therapeutic effects
equal to seizures induced with ECT.
It's interesting, to say the least, that any of these three
very different seizure producing agents - flurothyl gas inhaled through a
gas mask, Metrazol injected with a hypodermic needle, or electricity passed
through the head - could be equally psychiatrically "therapeutic".
Psychiatrists say that it is the seizure that is "therapeutic", not the
method of inducing the seizure. But why would seizures induced by any of
these three very different methods be equally "therapeutic"?
One theory is they are all equally horrifying to the victim
(the "patient") who receives the "treatment". In his book Against Therapy,
published in 1988, psychoanalyst Jeffrey Masson, Ph.D., asks: "Why do
psychiatrists torture people and call it electroshock therapy?" (p. xv). In
his book Battle for the Mind: A Physiology of Conversion and Brain-Washing,
William Sargant said "The history of psychiatric treatment shows, indeed,
that from time immemorial attempts have been made to cure mental disorders
by the use of physiological shocks, frights, and various chemical agents;
and such means have always yielded brilliant results in certain types of
patient" (p. 82). In his book Breakdown, psychologist Norman S. Sutherland
points out that in his observations ECT "was widely dreaded", and he says
"there are many reports from patients likening the atmosphere in hospital on
days when ECT was to be administered to that of a prison on the day of an
execution" (p. 196).
Defenders of ECT say that because of the addition of
anesthesia to make the procedure painless, the horribleness of ECT is
entirely a thing of the past. This argument misses the point. It is the
mental disorientation, the memory loss, the lost mental ability, the
realization after awaking from the "therapy" that the essence of one's very
self is being destroyed by the "treatment" that induces the terror - not
only or even primarily physical suffering. ECT, or electroshock, strikes to
the core personality and is terrifying for this reason. As was said by
Lothar B. Kalinowsky, M.D., and Paul H. Hoch, M.D., in their book Shock
Treatments, Psychosurgery, and Other Somatic Treatments in Psychiatry: "Fear
of ECT, however, is a greater problem than was originally realized. This
refers to a fear which develops or increases only after a certain number of
treatments. It is different than the fear which the patient, unacquainted
with the treatment, has prior to the first application. ... 'The agonizing
experience of the shattered self' is the most convincing explanation for the
late fear of the treatment" (p. 133). One way ECT achieves its effects is
the victims of this supposed therapy change their behavior, display of
emotion, and expressed ideas for the purpose of avoiding being tortured and
destroyed by the "therapy". Refusing to take ECT doesn't always work,
because ECT is often administered against the "patient's" will. In The
Powers of Psychiatry, published in 1980, Emory University Professor Jonas
Robitscher, J.D., M.D., said "Organized psychiatry continues to oppose any
restrictions by statute, regulation, or court case on its 'right' to give
shock to involuntary and unwilling patients" (p. 279). Even now in the
1990s only one state in the United States - Wisconsin - prohibits all
involuntary administration of ECT.
Since the "patient's" fear of ECT is one of the things that
makes ECT "work", psychiatrists often get results by merely threatening
people with ECT. As psychiatrist Peter R. Breggin, M.D., says in his book
Electroshock: It's Brain Disabling Effects: "For patients who witness these
[brain disabling] effects without themselves undergoing ECT, the effect of
ECT is nonetheless intimidating. They do everything in their power to
cooperate in order to avoid a similar fate" (p. 173).
Another way ECT achieves its effects is by damaging the brain.
In the words of Lee Coleman, M.D., a psychiatrist: "The rationale for
electroshock was formerly couched in psychoanalytic terms, with punitive
superegos sometimes requiring repeated shocks of 110 volts for appeasement.
Only then could guilt be assuaged and discontent be relieved. It is much
more common now to hear equally absurd neurophysiological explanations, this
time the idea being that these electrical assaults somehow rearrange brain
chemistry for the better. Most theorists readily agree, however, that these
are speculations; in fact, they seem to take a certain satisfaction in shock
treatment's supposedly unknown mode of action. ... The truth is, however,
that electroshock 'works' by a mechanism that is simple, straightforward,
and understood my many of those who have undergone it and anyone else who
truly wanted t find out. Unfortunately, the advocates of electroshock
(particularly those who administer it) refuse to recognize what it does,
because to do so would make them feel bad. Electroshock works by damaging
the brain. Proponents insist that this damage is negligible and transient -
a contention that is disputed by many who have been subjected to the
procedure. Furthermore, its advocates want to see this damage as a 'side
effect.' In fact, the changes one sees when electroshock is administered are
completely consistent with any acute brain injury, such as a blow to the
head from a hammer. In essence, what happens is that the individual is
dazed, confused, and disoriented, and therefore cannot remember or
appreciate current problems. The shocks are then continued for a few weeks
(sometimes several times a day) to make the procedure 'take,' that is, to
damage the brain sufficiently so that the individual will not remember, at
least for several months, the problems that led to his being shocked in the
first place. The greater the brain damage, the more likely that certain
memories and abilities will never return. Thus memory loss and confusion
secondary to brain injury are not side effects of electroshock; they are the
means by which families (perhaps unwittingly) and psychiatrists sometimes
choose to deal with troubled and troublesome persons. Many of us would
question such a dubious means of obliterating, rather than dealing with,
emotional distress" (From the Introduction, The History of Shock Treatment,
edited by L. R. Frank, p. xiii.)
Advocates of ECT falsely claim there is no evidence of brain
damage from ECT. For example, in his book Overcoming Depression, Dr. Andrew
Stanway, a British physician, says "People often worry that ECT might be
damaging their brain in some way but there is no evidence of this" (p.184).
In fact, it didn't take long after ECT was invented in 1938
for autopsy studies revealing ECT-caused brain damage to begin appearing in
medical journals. This brain damage includes cerebral hemorrhages (abnormal
bleeding), edema (excessive accumulation of fluid), cortical atrophy
(shrinkage of the cerebral cortex, or outer layers of the brain), dilated
perivascular spaces in the brain, fibrosis (thickening and scarring),
gliosis (growth of abnormal tissue), and rarefied and partially destroyed
brain tissue. (See Peter R. Breggin, M.D., Electroshock: It's Brain
Disabling Effects for references.) Commenting on the extent of physical
brain damage caused by electroconvulsive "therapy", Karl Pribram, Ph.D.,
head of Stanford University's Neuropsychology Laboratory, once said: "I'd
rather have a small lobotomy than a series of electroconvulsive shock. ... I
just know what the brain looks like after a series of shocks, and it's not
very pleasant to look at" (APA Monitor, Sept.-Oct. 1974, pp. 9-10). Dr.
Sidney Sament, a neurologist, describes ECT this way: "Electroconvulsive
therapy in effect may be defined as a controlled type of brain damage
produced by electrical means. No doubt some psychiatric symptoms are
eliminated ... but this is at the expense of brain damage" (Clinical
Psychiatry News, March 1983, p. 4). Although he is a defender of ECT, Duke
University psychiatry professor Richard D. Weiner, M.D., Ph.D., has admitted
that "the data as a whole must be considered consistent with the occurrence
of frontal atrophy following ECT" (Behavioral & Brain Sciences, March 1984,
p. 8). By "frontal atrophy" he means atrophy (reduced size) of the frontal
lobes of the brain, the frontal lobes being the parts believed to be
responsible for higher mental functions. The frontal lobes get most of the
electricity in ECT. Dr. Weiner also admits "Breggin's statement that ECT
always produces an acute organic brain syndrome is correct" (ibid., p. 42).
Organic brain syndrome is organic brain disease.
Psychological testing of those who have had ECT also indicates
ECT causes permanent brain damage. For example, in an article in the
British Journal of Psychiatry, three psychologists said "The ECT patients'
performance was also found to be inferior on the WAIS [Wechsler Adult
Intelligence Scale]" and "The ECT patients' inferior Bender-Gestalt
performance does suggest that ECT causes permanent brain damage" (Donald I.
Templer, Ph.D., et al., "Cognitive Functioning and Degree of Psychosis in
Schizophrenics given many Electroconvulsive Treatments" Brit. J. Psychiatry,
Vol. 123 (1973), p. 441 at pp. 442, 443).
In 1989 in his book The Exercise Prescription for Depression
and Anxiety, psychology professor Keith W. Hohnsgard, Ph.D., says "Some who
receive ECT appear to suffer both serious and permanent memory loss" (p. 88,
emphasis added). A woman who had ECT described these effects ECT had on her
memory: "I don't remember things I never wanted to forget - important
things - like my wedding day and who was there. A friend took me back to
the church where I had my wedding, and it had no meaning to me" (quoted in:
Peter R. Breggin, M.D., Electroshock: It's Brain Disabling Effects, p. 36).
Professional people who have sought treatment for depression and had ECT
have lost a lifetime of professional knowledge and skill to this so-called
therapy. (See, for example, Berton Rouche's article in Suggested Reading,
below). In one state, Texas, a state law requires those considering ECT be
warned about ECT caused memory loss. But in most states those undergoing
ECT voluntarily do so without any warning of the brain damage and associated
memory loss and intellectual impairment to which they are about to be
subjected - the psychiatrist suggesting ECT usually being the person least
likely to give this warning. [See copy of this Texas Law, below]
ECT advocates sometimes claim the addition of anesthesia, a
muscle paralyzing drug, and oxygenation (making the "patient" breath air or
100% oxygen) prevent ECT-caused brain damage. But neither anesthesia nor
muscle paralyzing drugs nor breathing oxygen stop what the electricity does
to the brain. Autopsy study, EEGs, and observation of those who have
received ECT indicate those given ECT with anesthesia, a muscle paralyzing
drug, and forced breathing of air or oxygen experience the same brain
damage, memory loss, and intellectual impairment as those given ECT without
these modifications.
Some ECT advocates say the newer brief pulse ECT devices cause
less harm than the sine-wave ECT devices that predominated until the 1980s.
In contrast, one prominent ECT supporter, psychiatry professor Richard D.
Weiner, M.D., Ph.D., cites studies that "demonstrated sine wave and
bidirectional pulse stimuli produced equivalent amnestic changes"
(Behavioral & Brain Sciences, March 1984, p. 18). According to Chicago
Medical School psychiatry professor Richard Abrams, M.D., in his textbook
Electroconvulsive Therapy, 400 volts is a typical peak voltage produced by
the newer brief-pulse ECT devices (p. 113). This is more than double the
highest voltages produced by the older sine-wave machines, suggesting the
newer brief-pulse ECT devices do greater harm.
Claims that the new "unilateral" ECT in which the electricity
is run through only one side of the head is less damaging are also false.
The idea is to spare the parts of the brain responsible for verbal and
mathematical skills (non-emotional, computer-like intellectual functions).
These functions are believed to be located in what is misleadingly called
the dominant side of the brain. One problem is the difficulty of
determining which side of the brain this is in any particular individual.
In most people it is the left side, but in some it is the right side, so
psychiatrists sometimes inadvertently shock the side of the brain they are
trying to spare. The side of the brain intended to get the electricity in
unilateral ECT is deceptively called the non-dominant side. This supposedly
non-dominant side of the brain is primarily responsible for our emotionality
and sexuality, artistic, creative, and musical ability, visual and spatial
perception, athletic ability, unconscious mental functions, and some aspects
of memory. In the words of neurology professor Oliver Sacks, it is "of the
most fundamental importance" because it provides "the physical foundations
of the persona, the self" without which "we become computer-like" (The Man
Who Mistook His Wife for a Hat and Other Clinical Tales, pp. 5, 20). The
side of the brain electroshocked in supposedly non-dominant hemisphere
unilateral ECT is at least as important to us as the other parts of our
brains.
Psychiatrists who use ECT are violating their Hippocratic oath
to not harm patients and are guilty of a form of health care quackery.
Unfortunately, most psychiatrists have administered ECT, and government has
failed to live up to its responsibility to protect us from this harmful and
irrational "treatment". It is therefore left to you to protect yourself and
your loved ones from quackery such as ECT by keeping yourself and your loved
ones away from practitioners who use it.
Suggested Reading
Peter R. Breggin, M.D., Electroshock: Its Brain Disabling Effects (Springer
Publishing Co., New York, 1979).
Peter R. Breggin, M.D., Toxic Psychiatry: Why Therapy, Empathy, and Love
Must Replace the Drugs, Electroshock, and Biochemical Theories of the "New
Psychiatry" (St. Martin's Press, New York, 1991).
Leonard Roy Frank (editor), The History of Shock Treatment (self-published,
San Francisco, 1978). Available directly from the author for $12 postpaid:
2300 Webster St., San Francisco, California 94115.
John Friedberg, M.D., "Electroshock Therapy: Let's Stop Blasting the Brain",
Psychology Today magazine, August 1975, p. 18.
John Friedberg, M.D., Shock Treatment Is Not Good For Your Brain: A
Neurologist Challenges the Psychiatric Myth (Glide Publications, San
Francisco, 1976).
John Friedberg, M.D., "Shock Treatment, Brain Damage, and Memory Loss: A
Neurological Perspective", American Journal of Psychiatry, Vol. 134, No. 9
(September 1977), p. 1010.
Berton Rouche, "Annals of Medicine - As Empty as Eve", New Yorker magazine,
September 9, 1974, p. 84. This biographical article describes in horrifying
detail the extent and permanence of memory loss caused by electroshock
"therapy".
THE AUTHOR, Lawrence Stevens, is a lawyer whose practice has included
representing psychiatric "patients". His pamphlets are not copyrighted.
You are invited to make copies for distribution to those who you think will
benefit.
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are outside the USA, see How to Contact the Antipsychiatry Coalition.
1997 UPDATE by www.antipsychiatry.org web-master Douglas A. Smith:
In the 1997 edition of his book The Essential Guide to Psychiatric Drugs,
Columbia University Professor of Psychiatry Jack M. Gorman, M.D., includes a
section titled "Electroconvulsive Therapy" in which he makes glaring
misstatements of fact about ECT, including this: "The patient must first
agree to undergo ECT, and many hospitals now require the consent of both the
patient and at least one family member. So there is no strapping of people
by force onto stretchers" (p. 116). During my own experience as a prisoner
of psychiatry with my own eyes I witnessed a fellow "patient" being forcibly
dragged off for electroconvulsive "therapy" as she pleaded with her
tormentors to stop. As they carried her away and tried to force her into
the room where she was to be given ECT, she locked her arms with one hand on
each side of the doorway in a futile effort to resist. After considerable
effort, they overcame her physical resistance and carried her feet first
into the "treatment" room. It was obviously a living nightmare for her, as
it would be for anybody. Her verbal and physical resistance and the force
being used against her by several large men left no doubt about the
involuntary nature of the so-called treatment. I felt several emotions as I
witnessed this inhumane spectacle: fear I would be the next victim of
involuntarily administered electric shock treatment; anger at those who
would be so cruel and stupid as to do this to a another person, and guilt
about doing nothing to help this unfortunate woman fight off those who were
harming her - even though I knew such resistance would be futile and might
make me more likely to become an electroshock victim and almost certainly
would have resulted in me being forcibly drugged into oblivion with
Thorazine. This was many years ago, but I continue to hear reports of
involuntary use of ECT; and even at the time I witnessed this woman's ECT
nightmare I heard denials by staff members of that very hospital who claimed
ECT was administered only with the patient's consent. Then and now, false
denials like this make it obvious nothing said by psychiatrists and
associated mental health "professionals" who use harmful "treatments" such
as ECT can be trusted.
The same is true regarding the brain damage inflicted with ECT.
In the 1997 edition of this book, Dr. Gorman denies there is any evidence of
ECT-caused brain damage. He says: "Careful neuropsychologic testing in a
number of studies has failed to show any long-lasting memory problems in
most patients who have received ECT. Sometimes, memory problems can last
longer, although six months is generally the upper limit. What about those
who insist they have 'permanent brain damage' from ECT? Once again, it must
be stated that careful scientific studies have never [emphasis added] been
able to find any [emphasis added] evidence of permanent memory loss
resulting from ECT. ... The risk of permanent memory defect from ECT seems
so remote that individual patients should probably disregard it" (pp.
117-118). Dr. Gorman limits his denials to "memory loss" and doesn't
directly address reduced intelligence and reduced ability to experience
emotions as a result of ECT, but his words are nevertheless falsely
reassuring about these effects and about ECT caused brain damage. If you
have read Mr. Stevens' article about ECT (above), you probably won't be
fooled by Dr. Gorman's or other psychiatrists' denials about the brain
damage caused by electric shock treatment.
Dr. Gorman also says: "ECT is a treatment of great effectiveness
and very small risk. Why, then, is it so controversial? First, the
treatment is admittedly mysterious. One of my colleagues, Dr. Stuart
Yudofsky, once likened it to kicking the television set when the picture is
fuzzy. We still haven't the slightest clue why it works. All that is known
is that causing a convulsion in the brain relieves depression.
Interestingly, ECT also relieves mania [extreme happiness] and reduces
psychotic symptoms..." (p. 119). Why is it so hard for Dr. Gorman and other
psychiatrists to see the obvious?: By causing brain damage, ECT reduces or
eliminates everything the brain does: unhappiness ("depression"), happiness
("mania"), irrational or strange thinking ("psychosis"), memory,
intelligence, the entire range of functions of which an undamaged brain is
capable. (Yes, in my opinion, irrational or strange thinking can come from
an undamaged human brain. The religious thinking of many "normal" people is
an illustration of this.)
Dr. Gorman's 1997 revision of his book The Essential Guide to
Psychiatric Drugs shows psychiatry's false claims about ECT (and other
aspects of psychiatry) haven't changed.
2000 UPDATES
"Although ECT is effective, it causes pronounced memory problems and its
[antidepressant] effects are transitory. Although the process of ECT is no
longer as barbaric as the image of Jack Nicholson being shocked in One Flew
over the Cuckoo's Nest, it is dehumanizing. I do not recommend ECT unless
it's a life-threatening emergency..." Edward Drummond, M.D., Associate
Medical Director at Seacoast Mental Health Center in Portsmouth, New
Hampshire, in his book The Complete Guide to Psychiatric Drugs (John Wiley &
Sons, Inc., New York, 2000), page 87. Dr. Drummond graduated from Tufts
University School of Medicine and was trained in psychiatry at Harvard
University.
Involuntarily ECT continues in the year 2000: In a Support Coalition
"Dendrite" e-mailing dated August 23, 2000, it was reported that Kathleen
Garrett, a 66 year old woman at DesPeres Hospital in St. Louis, Missouri was
given electric shock treatments against her will on Monday, August 21 and
Wednesday, August 23, 2000 and that she was scheduled for 10 to 12 more.
Both she and her son, Steve Vance, who is a social worker, opposed this
harmful treatment. Her son brought an attorney to a court hearing trying to
stop it, but a judge ordered it anyway. Her son said: "When are they going
to stop? When they've totally fried her mind?" Then, only a day later, in
another Support Coalition e-mailing dated August 24, 2000, it was reported
that in response to protests by the public, the hospital had announced it
would give Ms. Garrett no more electric shock treatments and would instead
discharge her from the hospital. This is especially good news for Ms.
Garrett and her son, and it is a victory for us in our fight against
psychiatric oppression, psychiatric assault, and violation of human rights
in the name of mental health. This victory shows that our efforts to stop
psychiatry's health care quackery like electroconvulsive "therapy" (ECT) and
its violations of human rights can succeed. It should encourage us to
continue our efforts. The American public's failure to oppose psychiatry's
harmful treatments and human rights violations is not caused by evil intent
but ignorance and - sometimes - stupidity. People understand enough about
electricity to realize how evil it was to damage this woman's brain with
electroconvulsive "therapy" (ECT), especially against her will. Most do not
know how commonplace unjustified civil commitment for supposed mental
illness is, and most do not know enough about psychiatric drugs to
understand how evil it is to force psychiatric drugs on anyone, including
supposedly mentally ill people. If we can make a large enough segment of
the public understand what is really happening, we will defeat those
promoting arbitrary imprisonment called "involuntary psychiatric
hospitalization" and psychiatry's harmful so-called therapies and make
America - and the World - a safer place for everyone.
For the full text of the August 24, 2000 "Dendrite" emailing, see the
Support Coalition website.
_________________________________
Texas legislators were not convinced by psychiatrists' false denials of
permanent memory loss caused by ECT nor their claim, like Dr. Gorman's
(above), that "ECT is a treatment of great effectiveness and very small
risk." This is indicated by their enactment of the below statute in 1993
(revised in 1997):
TEXAS LAW
Sec. 578.003. Consent to [Electroconvulsive] Therapy.
(a) The board by rule shall adopt a standard written consent form to be used
when electroconvulsive therapy is considered. The board by rule shall also
prescribe the information that must be contained in the written supplement
required under Subsection(c). In addition to the information required under
this section,the form must include the information required by the Texas
Medical Disclosure Panel for electroconvulsive therapy. In developing the
form, the board shall consider recommendations of the panel. Use of the
consent form prescribed by the board in the manner prescribed by this
section creates a rebuttable presumption that the disclosure requirements of
Sections 6.05 and 6.06, Medical Liability and Insurance Improvement Act of
Texas (Article 4590i, Vernon's Texas Civil Statutes), have been met.
(b) The written consent form must clearly and explicitly state:
(1) the nature and purpose of the procedure;
(2) the nature, degree, duration, and probability of the side effects and
significant risks of the treatment commonly known by the medical profession,
especially noting the possible degree and duration of memory loss, the
possibility of permanent irrevocable memory loss, and the possibility of
death;
(3) that there is a division of opinion as to the efficacy of the procedure;
and
(4) the probable degree and duration of improvement or remission expected
with or without the procedure.
[underline added]