Ray Sandford doesn't want to do this.
On a sunny yet cool mid-April morning, the pear-shaped 54-year-old emerges from the front door of his ranch-style group home in Columbia Heights. Wearing a black windbreaker and gray sweatpants, he grips the handle of his four-pronged cane and plods begrudgingly toward the street. One of Sandford's caretakers, a large woman wearing all purple, follows perfunctorily behind to see him to his destination.
He's told them repeatedly he doesn't want to do this.
He ambles forward. There's nothing he can do now. No sense in fighting it. Not now.
A 20-passenger Anoka transit bus idles along the curb awaiting his arrival. A short, swarthy driver assists Sandford. The bus slowly pulls away and embarks on the 12-mile ride to Mercy Medical Clinic in Coon Rapids.
Upon arrival, Sandford walks through the automatic sliding doors and assumes his position in a wheelchair. He's whisked to a room on the fifth floor where nurses poke an IV through his fleshy forearm. He's given a muscle relaxant and general anesthesia. Within 30 seconds, the room dissolves. He's out cold.
Assistants lay him out on his back. A doctor places electrodes on either side of Sandford's cranium. Cords extend from the electrodes, connecting to what appears to be an antiquated stereo set. A couple of dials protrude from the machine's display. A physician flips an unassuming switch.
A three-second burst of 140 volts blasts through Sandford's brain. While he's totally unconscious, Sandford's torso jerks up and down. His arms and legs writhe only slightly, steadied by muscle relaxants coursing through his veins. Sandford's toes curl downward, as if his feet were trying ball up into fists. He's experiencing a grand mal seizure.
Two minutes later, it's over. Sandford will feel a bit woozy the rest of the day, but there'll be no lasting pain. His short-term memory is the only thing that will suffer.
But he'll still remember quite clearly that he never wanted to do this.
"They can literally tie me up, put me in ambulance, and bring me in to get shock treatments," he says. "I don't fight it, because there's nothing I can do by that time. You want to know how I feel? I don't like it at all."
INTRODUCED TO AMERICA in 1939, electroconvulsive therapy is one of the most controversial medical procedures still in practice. Not much is known about how or why it works. Even so, by the end of World War II, every reputable hospital in the world performed the procedure.
"It was a very useful treatment because there was no treatment like it before," says ECT proponent Dr. Max Fink, widely regarded as the grandfather of American ECT and a professor of psychiatry at Stony Brook University in New York. "At the time, every state was troubled by the fact that they were building bigger and bigger hospitals for the mentally ill. Once ECT caught on, the number of hospital beds for mental illness was reduced sharply."
After the advent of psychotropic drugs in the 1950s, however, ECT appeared to be going the way of the lobotomy. Prescription meds were suddenly viewed as a more reliable and humane alternative.
But by the early '80s, something unexpected happened: antidepressants and other psychotropics turned out not to be the panacea everyone hoped they would be.
"Many doctors had patients who had been given the best care in the major centers of the world with pills, but they still had patients who were very, very sick," says Dr. Fink. "So they turned to doctors who were using ECT devices, and one by one, hospital by hospital, ECT was reintroduced. Most of the reintroduction occurred at the end of the 1980s and beginning of the 1990s. By now, there aren't many psychiatric hospitals that don't have ECT."
Today, between 100,000 and 200,000 Americans undergo the procedure each year. But not everyone is convinced that's a good thing.
"When you induce a grand mal convulsion by sending 100-plus volts of electricity in the brain, you're going to create damage," says Dr. John Breeding, an Austin, Texas-based psychologist and self-described ECT abolitionist. "This is most easily seen with memory loss that many patients experience. You're talking major voltage directly into the temporal lobes of the brain. And the data is very clear that there's close to a 100 percent relapse rate, which means patients have to keep coming back and suffer further brain damage. This is referred to as 'maintenance ECT,' rather than as a failed treatment, which is what it really is."
Even more controversial is the practice of forced, court-ordered electroconvulsive treatment. Neither the American Psychiatric Association nor activist groups have estimates on how many Americans undergo forced ECT annually, but there were 41 cases in Hennepin County last year.
Ray Sandford was one of them. But unlike the others, he's not going quietly, opting instead to take his fight to the public arena. A small army of mental-health activists has now taken up a national-scale PR campaign on his behalf, painting him as something of a real-life R.P. McMurphy from One Flew Over the Cuckoo's Nest.
"This case is particularly egregious," says Dr. Breeding. "Ray Sandford was really the first I heard of somebody being shocked on an outpatient basis."
MARILYN SANDFORD had particularly high hopes for her eldest son. When her three boys, along with their neighborhood friends, would play in a vast sandpit on the far side of their two-acre estate in Eagan, it was clear, even from a distance, that Raymond was in charge.
"He was exceptionally bright and had a real gift for verbal persuasion," says Marilyn. "Those boys were a pack, and he was the leader of the pack. We assumed he'd make an excellent salesman."
Ray's father, a contractor by trade, built the family's blue two-story home himself, outfitting the stately split-level with a cathedral ceiling and spiral staircase. With no mortgage to pay and the postwar housing boom providing lucrative work for her husband, Marilyn was able to quit her job as a polio nurse and devote her time to raising the boys.
As Ray entered adolescence, he grew enamored of real estate, memorizing local lot prices and market fluctuations. His goal, he told his parents matter-of-factly, was to be a millionaire by the age of 21.
Shortly after Ray's 17th birthday, it became clear that something was wrong with him. Ray, who had always gotten exceptional grades at Sibley High in Mendota Heights, suddenly dropped out his senior year. He emptied his college fund—about $3,000 his parents had saved up—and bought his own lot in a trailer park in Lilydale, eight miles north.
At first, Marilyn chalked up her son's bizarre behavior to adolescent angst.
"It's very hard to come to terms with the fact that your eldest and very promising child is mentally ill," she says. "That's not something you're ever ready for."
But as Ray's recklessness continued to escalate, Marilyn was forced to confront reality. Out to run some errands, Marilyn glanced in her rearview mirror to see Ray following close behind in his '63 Impala—too close. He whizzed past her, then abruptly stopped. He peeled out around her, nearly smashing into oncoming traffic, then stopped again.
Ray's thoughts and speech, meanwhile, grew more and more disjointed. When Ray was 19, Marilyn's father, a country doctor, visited the family. After supper, he took Marilyn aside and told her what she already knew: "You need to get that boy checked out."
She brought her son to Hastings Mental Hospital. After observing Ray and hearing Marilyn's account of his behavior, the doctors gave Marilyn a grim prognosis: "Your son suffers from severe manic depression. We recommend he be institutionalized."
Ray's new home would be Hastings Mental Hospital, an austere brick building.
"Now his brother is a doctor, his sister is a doctor, another brother is a successful engineer, and then another brother owns and manages property," Marilyn says ruefully. "They're all doing very well and here he is, the leader—and each hospitalization leaves him a little less well-off financially. So now he really has nothing."
In 2005, Marilyn, then 76 and eying her own mortality, contacted Lutheran Social Services, the state's largest nonprofit provider of health care, and asked them to act as legal guardian and caretaker for Ray. She would no longer have any legal say in his future. For Marilyn, it was a difficult but necessary decision.
"I have high blood pressure; I could die tomorrow," she says. "It's ridiculous to assume I could be responsible for someone else's life at this point. I knew we needed to find him a conservator."
By 2006, Ray Sandford had transferred to Community Behavioral Health Hospital in Willmar. Shortly after the move, his manic spells worsened. Sandford grew frustrated with the confines, which only exacerbated his psychosis. According to a report later submitted to a mental court, Sandford was "grossly psychotic, yelling violently and smearing feces all over, urinating wherever and whenever he felt like it."
The meds weren't working. The time had come for an alternative.
In January 2008, staff at Willmar approached Dr. Kevin Turnquist, a psychiatrist who specializes in schizophrenia. Four months after meeting Ray, the doctor petitioned to impose electroconvulsive therapy on the 54-year-old.
At the May 13 hearing in the basement of St. Paul's Regions Hospital, Ramsey County District Judge Teresa R. Warner heard from Dr. Turnquist, as well as from two court-appointed medical examiners who testified that Ray was "not in a position to weigh the benefits versus the risks of ECT treatment."
The hearing was quick, lasting barely a half-hour.
"The Court considered the respondent's family and community, as well as his moral, religious, and social values," ruled Judge Warner. "Based on these considerations, a reasonable person would authorize treatment with electroconvulsive therapy."
THE RITUAL always begins the same.
Just after 6 p.m. Sandford hears a knock at the door. It's his caretakers. They've come to raid his refrigerator.
"No more food for the rest of the night, Ray. Doctor's orders."
After purging the fridge of sandwich meat and the shelves of Doritos, they march upstairs and stash the provisions in a padlocked compartment.
It's not a cruel trick; if Sandford ever succumbed to a midnight hankering for a bologna sandwich, it might very well prove to be his last. That's because, should any food still be sloshing around his stomach during next morning's ECT-induced seizure, there's a good chance he'd vomit and choke to death on the table.
Which is why he doesn't utter a word of protest as they carry his groceries away, or when his stomach starts growling at 10 p.m.
"There's nothing fun about it," he says of the fasting, and leaves it at that.
Of greater concern to him is the procedure itself. He knows he'll be unconscious during the ordeal, that it will be painless. Still, he's a bit anxious.
"You don't know if you're going to wake up," he says, his eyes widening as he confronts his own mortality. "It's not very likely, but it's still possible. When I did the first couple of them, I was a lot more scared than I am now."
He did those first few willingly—anything to get out of the hospital, which he found to be oppressive. It seemed like a fair trade-off.
But on June 10, 2008, he once again found himself in the basement courtroom of Regions Hospital listening to important strangers explain to other important strangers why it's in society's best interest to blast 140 volts of electricity through his cranium at regularly scheduled intervals. Today's hearing would decide whether the month-long court order should be allowed to expire.
One of the strangers, Dr. Peter Myers, whom Sandford had met only briefly, testified that Sandford had shown "noted improvement" since beginning ECT, in the sense that Sandford "now has the ability to remain calm." Dr. Myers also commended him for "exhibiting more organized thought patterns." However, continued the doctor, "he still remains a danger to himself and is in need of continued commitment and treatment with neuroleptic medication and electroconvulsive therapy."
Judge Warner agreed. She gave the go-ahead for three ECTs a week for up to four weeks, followed by one treatment per week for one year thereafter.
The ruling was based on solid precedent. In 1976, just as ECT was at the nadir of its popularity, a 14-year-old Minnesota boy was shocked against his and his mother's objections. The mother filed suit and went before the Minnesota Supreme Court. The resulting decision held that legally competent patients were immune from being shocked against their stated objections. Moreover, the case made clear that even incompetent patients were entitled to a court proceeding before being administered electroconvulsive therapy.
On its face, the Price-Sheppard decision appeared to bolster patients' self-determination—after all, the requirement for guardians to get court-approval before administering the volts is one that didn't exist before.
But in practice, court-ordered ECT has been on the rise since the ruling, for a number of reasons. The ruling assumed that a committed person is—by very virtue of being committed—incompetent. Second, attaining the court order is more of a bureaucratic formality than a serious deliberation.
"I would say the court grants the order for ECT in well over 90 percent of the cases," says Doug McGuire, of the Hennepin County Commitment Defense Panel, which represents patients in the proceedings. "It's very unusual for the court not to grant the ECT request."
Mental health courts require a lower standard to the petitioner ("clear and convincing evidence") than do criminal courts ("beyond a reasonable doubt"), but more importantly, the petitioner—almost invariably a doctor, as in Sandford's case—naturally wields more credibility than a person deemed unfit to care for himself.
"One of the issues that comes up is how vigorously the person's court-appointed attorney puts forth their objections to the ECT," notes Pamela Hoopes, the lead attorney for the Minnesota Disability Law Center.
ON OCTOBER 22, David Oaks was sitting in his office in Eugene, Oregon, when his phone rang.
As director of MindFreedom International, a coalition of self-described "mental human rights organizations" advocating what they call "a nonviolent revolution in mental health care," Oaks has fielded his share of strange calls. But Oaks had never heard a story like this before.
"My name is Ray Sandford," said the man on the phone. "I live in a group home in suburban Minneapolis. I'm getting electroshock treatment against my will. What do I do?"
Oaks dialed Lutheran Social Services to confirm the story. A worker familiar with Sandford's case verified that Sandford was indeed receiving court-ordered electroshock treatments. A copy of the court order confirmed it.
"I get calls all the time from people who are frightened, who are being pushed around and bullied by the mental health system," says Oaks. "But this guy has made sense the whole time. His was an extremely human response: 'I don't want it.'"
Taking up the cause, MindFreedom launched an online Campaign for Ray, with a website detailing Sandford's predicament. Oaks compiled a list of caretakers associated with Sandford—from doctors to judges to lawyers—along with their contact information, encouraging visitors to call them and demand they put an end to the treatment. In addition, MindFreedom sent out mass emails to its network of activists who, in turn, inundated the governor's office with phone calls.
The tactic seemed to be working. On April 15, Dr. Dean Knutson stepped aside as Sandford's psychiatrist. Eight days later, Lutheran Social Services submitted to the Ramsey County probate court a petition to resign as Sandford's guardian.
But on May 12, a knock sounded outside Sandford's door. It was his caretakers. They had come to raid his refrigerator.
THE NEXT DAY, Sandford emerges from his front door to a familiar sight: an idling white bus. He slowly steps forward, his four-pronged cane gripping warm asphalt.
He doesn't want to do this. He's told them repeatedly he doesn't want to do this.
He climbs inside the bus and takes a seat. A hiss sounds as the bus's brakes release.
He arrives at Mercy Medical Clinic and is taken to the fifth floor. An IV is inserted. Sandford is less than two minutes from undergoing his 43rd ECT when a doctor approaches him.
"Mr. Sandford, it looks like we're going to postpone today's treatment," he says. "Sorry for the inconvenience."
Unbeknownst to Sandford, his mother had, for the past 48 hours, placed dozens of calls to Mercy's ECT Unit. Her words were concise and persuasive.
"His doctor has given up on him," she told anyone who would listen. "I'm a retired nurse. And I know for a fact you cannot give ECT without a doctor's order."
It's unclear whether Sandford will have to go through with more ECT or who his new doctor will be. Marilyn and a friend are in the process of finding a psychiatrist.
As for Ray Sandford, his appraisal of last week's surprising turn is characteristically nonchalant.
"I felt a whole lot better after they told me I wouldn't have to go through with it," he says. "But I wish they would have told me earlier, instead of having to go through all the trouble. They knew I didn't want to do this."