summer 2008: volume 7: issue 3
Oxonian Review of Books

Also in this Issue:

Shock and Cure

Jamie Horder

Edward Shorter and David Healy Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness Rutgers University Press, 2007 382 pages £18.50 ISBN 978-0813541693

It was the spring of 1938 in Mussolini’s Italy, and a group of men had obtained custody of a former railway worker whom the police had recently picked up off the streets of Rome. Drawing inspiration from the apparatus used by a nearby abattoir to stun pigs before slaughter, the men shaved their subject’s head and proceeded to attach a pair of crude electrodes to either side, which were then connected to a custom-built machine designed to deliver brief but intense bursts of electricity. Experiments involving a number of unfortunate dogs had indicated that the same current applied across the heart was generally lethal, but no animals had been killed by a shock to the head. The switch was flicked; the man, hitherto fully conscious, immediately entered a tonic-clonic or grand mal seizure, akin to the most severe kind of epileptic fit. His limbs contorted wildly, his face blueing through lack of oxygen as his breathing temporarily ceased. The seizure was brief, and the man returned to consciousness a short time later. It was not long, however, before he would be shocked into convulsions again.

One could be forgiven for seeing in this sequence of events a session of torture, akin perhaps to the force-feedings with castor oil that the Fascist authorities at the time so enjoyed. Indeed, many commentators have interpreted the events of that April day and the subsequent history of what became known as electroconvulsive therapy or ECT, in just that way. For the men in Rome were a team of psychiatrists, led by a Dr. Ugo Cerletti, and the goal of their experiments with electricity was not punitive but medical. As far as Cerletti was concerned, the first trial had been a resounding success. After several sessions of the treatment, the patient, who had been living as a vagrant, speaking incoherently, and suffering from paranoid delusions, showed a dramatic improvement in his mental state and was able to return home to his wife. Psychiatrists around the world rapidly adopted ECT as a more patient-friendly alternative to the existing methods for producing therapeutic seizures, namely injections with toxic drugs or high doses of insulin. (That such seizures could produce improvements in some cases of mental illness had been known for a number of years.)

Today, to the extent that they are aware of the procedure at all, most people regard ECT as a frightening and shameful black mark on the history of medicine. Jack Nicholson’s powerful portrayal of a lovable rogue subdued and broken by the ‘shock box’ in One Flew Over the Cuckoo’s Nest is familiar to millions. How did such a once-lauded treatment fall from grace, and is its sinister reputation deserved? Edward Shorter and David Healy attempt to answer these questions in Shock Therapy, a book that combines a history of ECT’s origins and development with an enthusiastic defence of the procedure’s continued use. It is a timely book. With the safety and effectiveness of antidepressants and other psychiatric medications increasingly coming under fire (not always fairly), and with increased debate about the desirability of more psychotherapists in the NHS, it is bracing to be told that nothing works nearly so well as a few electrical shocks. According to the authors, received wisdom has been utterly wrong for the past few decades, and ECT is and has long been an underused and grossly underappreciated treatment.

As they explain, ECT was not always perceived as inhumane. During the 1930s and 1940s, shock therapy enjoyed widespread popular acclaim, with the press promoting it as a wondrous treatment for all kinds of mental ills. The media and most of the public accepted the claims of doctors quite uncritically. By the 1960s, however, lurid stories of minds shattered by shock therapy became commonplace, and a series of damaging newspaper articles, books, and movies served to erode the procedure’s reputation in the minds of the public. With surprising rapidity, the perception of shock therapy transformed from a miracle cure into a case study in medical brutality, a damaging, cruel, and useless procedure. The use of ECT declined markedly during this period, and numerous hospitals abandoned it, though its use continued in many others. In some US states and a few European countries, shock therapy even became subject to specific legislation limiting its use—something almost unprecedented for a medical procedure.

For Shorter and Healy, the campaign against ECT was a misguided and harmful deviation, a rejection of the one psychiatric treatment that really worked in severe mental illness in favour of talking cures and psychiatric medications that were less consistently beneficial. (Healy’s critical views on such drugs, especially antidepressants, are well known and forcefully expressed at several points in this book.) Many readers will react with surprise to this, for it is the critical accounts of ECT that have become fixed in the public consciousness. Some people are even surprised to learn that shock therapy is still practiced in civilised nations, yet it is used routinely in Britain and elsewhere: walking down the main corridor of Oxford’s Warneford Hospital, near Headington, visitors can see the waiting room of the ECT suite alongside the Coke machine and the toilets.

Strange as it might seem, ECT is an extremely useful means of treatment. Psychiatrists today are almost unanimous in the opinion that it is highly effective for many patients, and most would agree with Shorter and Healy that it is in fact the strongest treatment available for severe clinical depression. Study after study has shown that a course of ECT (which today most commonly involves one session every other day for an average of ten sessions) produces major improvements in at least 70 percent of such patients, with the benefits becoming apparent within days. Numerous clinical trials have shown that the effects of ECT are both more powerful and more rapid than even the most potent antidepressant drugs, and it is often effective in patients in whom several different medications have been tried and failed. In addition, many psychiatrists believe that ECT is useful in treating psychiatric conditions other than depression, such as manic excitement, though there have been few systematic studies to support such alternative applications.

When it works well, ECT can produce truly dramatic effects. For example, people who have been lying motionless in a state of catatonic depression ‘wake up’ over a matter of hours. Those who describe watching the procedure sometimes sound like believers witnessing the power of the Lord at a revival meeting: the treatment is miraculous; it restores life to the desolate; it is like raising patients from the dead. Despite a proliferation of theories, scientists are still at a loss to explain how ECT works, but that it works remains beyond serious doubt. The treatment’s major limitation is that the benefits produced are often short-lived, unless the therapy is followed by drug treatment or a continuing course of shocks.

Despite the best efforts of its detractors, shock therapy never went away because, quite simply, it is indispensable. This brings us to the central question of Shock Therapy: given that it was and remains so helpful, why did ECT become so unpopular? Opponents of the procedure would say that during the 1960s, shock therapy ‘survivors’ found their voices for the first time and made the public aware of the procedure’s dark side, that is, of the side effects. This is an issue that is, to put it lightly, controversial. On the one hand, the long-standing belief that shock produces gross ‘brain damage’ or massive mental impairments—that it destroys intellects and personalities—is certainly false. Indeed, it can and regularly does restore such faculties to people who have lost them to illness. Rather more plausible are the claims relating to memory loss: ECT has been accused of ‘wiping’ memories laid down years before the treatment and also of causing impairments in the patient’s ability to remember new material. Although there is no firm scientific evidence that such lasting damage occurs, it is well known that patients never remember the therapy procedure itself and frequently lose memories of events occurring within hours or days of the shocks. The crucial and as yet unanswered question is whether the memory losses extend beyond these periods, and it is not impossible that the absence of affirmative evidence represents researchers’ failure to measure such long-term problems.

Shock Therapy dismisses complaints of lasting damage and essentially brands them as symptoms of mental illness in patients for whom ECT did not work. This explanation is possible, and most psychiatrists agree that any lasting harms that do exist are outweighed by the proven benefits, but critics are unlikely to be satisfied with this rather glib explanation. Even most ECT practitioners say that more work is needed to investigate the consequences of the treatment. It is fair to say, however, that such side effects can hardly suffice to explain either the militancy or the success of the public anti-shock campaign. Cancer chemotherapy and other such treatments with deeply unpleasant consequences are accepted as uncontroversial by all but a fringe minority of contrarians. Hollywood does not make movies about them. Shock therapy seems to strike a nerve, but why?

Shorter and Healy’s answer is that the fall of ECT was the product of the inherently unpleasant image of the procedure combined with the intellectual climate of the 1960s. Early shock sessions were indeed traumatic to witness: the patient’s wildly contorting limbs were a sight not easily forgotten, even if one was aware that patients were quite unconscious and not in any appreciable danger. (Since the 1950s, anaesthetics and muscle relaxants have been used to ensure that patients lie motionless throughout—something ignored in most media accounts). Yet while the procedure may never have been pretty, it was not until the 1960s that it became controversial. This was the decade of dissent in the West, as generals, priests, and politicians all found their authority challenged. Psychiatrists fared no better: during the early sixties, a number of doctors, psychologists, sociologists, and writers began to rail against what they perceived as the authoritarian nature of the somatic therapies and their practitioners, and also against the whole system of diagnosing and locking up the mentally disordered.

Evaluating these ‘antipsychiatrists’ (as they became known, and sometimes called themselves) would take a book in itself, but it is certainly true that psychiatry at the time was not short of abuses, though few of these were related specifically to shock therapy. Nevertheless, ECT was sometimes used in ways that would now be recognised as quite unjustified. Shorter and Healy do not shy away from describing such practices as ‘regressive ECT’, whereby practitioners applied the treatment at far higher than the normal doses in order to provoke a state of infantile disorientation, from which, a few doctors hoped, it would be possible to ‘re-train’ the patients to become functioning members of society. In other cases, practitioners used the threat of ECT to keep unruly patients in line. The point, however, is that by focusing exclusively upon its abuses, the antipsychiatrists ignored the benefits of the procedure, and the authors are right that it is the perpetrators of such actions rather than ECT itself that should bear responsibility.

The antipsychiatrists were nevertheless remarkably successful in changing public perceptions. The whole spirit of the age was changing and suddenly, for large segments of the population, psychiatry became the enemy and ECT one of its most destructive weapons. Psychiatrists Andrew McDonald and Garry Walter’s survey of the portrayal of electroconvulsive treatments in American cinema nicely illustrates the change in attitudes. They note that early depictions were generally positive: ECT featured in only a handful of movies from the 1940s to the 1960s, but when it did, it was as a helpful therapy for distraught or traumatized protagonists, something which ‘put them back on their feet’. Yet during the sixties and early seventies, shock therapy underwent a sudden and dramatic transformation, culminating in One Flew Over The Cuckoo’s Nest (1975) and a number of similar if less well known works. Since the 1980s, the cruel nature of shock has been taken as so obvious that it has mainly played the role of a humorous or ironic source of pain or punishment in scenes set in psychiatric hospitals—its use as a weapon by a vigilante bent on revenge in the lurid Death Wish 2 (1981) being typical. As McDonald and Walter put it, ‘Having commenced its movie career as a severe but helpful remedy for personal distress, ECT on film has become a progressively more negative and cruel treatment, leaving the impression of a brutal, harmful, and abusive manoeuvre with no therapeutic benefit.’

Yet this raises a crucial point, and it is one that Shock Therapy does not fully explore. In movies since the 1970s, the question of the therapeutic benefits of ECT does not even arise: the procedure is presented not as a bad medical treatment, but rather as an effective tool of oppression, just as the antipsychiatrists had suggested. In Cuckoo’s Nest, the victims of ECT appear as sane as anyone else (‘What do you think you are, for Chrissake, crazy or somethin’? Well you’re not! You’re not! You’re no crazier than the average asshole out walkin’ around on the streets and that’s it’). Therefore to ‘treat’ them is, in itself, an absurdity. Shorter and Healy convincingly argue that the impact of popular culture on the reputation of ECT has been profound; they warn, indeed, that even today Bollywood movies are undermining the procedure’s reputation in India, a country in which shock has long been used more widely than in the West. Yet, in their focus on the portrayals of ECT, Shorter and Healy do not explore the perhaps more important issue of the portrayal of mental illness. This is central, because in claiming that shock therapy is useful, psychiatrists necessarily assume that people suffering from mental illnesses are in need of a cure. By undermining this fundamental axiom of psychiatry and presenting the people who receive shock as being anything but ‘ill’, Hollywood made ECT illegitimate regardless of what it specifically entailed: it cannot be a good treatment because there is no disease to treat.

Thus, it is hardly surprising that public opinion of ECT is so out of tune with that of psychiatrists, when the public understanding of mental illness is so often different from that of professionals. This situation cannot be blamed on Hollywood entirely. Severe psychiatric illnesses are unnerving and deeply mysterious diseases, and most people are lucky enough never to come in contact with someone in the midst of severe melancholic depression, or a full-blown manic or psychotic episode. Few people understand these conditions, yet it is just these states that ECT is used to treat. To say that electroconvulsive shock is effective is not to say that it is a useful way of keeping people compliant, but rather that it can make life bearable for people who have lost all hope. It can help restore mental equilibrium to people who have lost all contact with reality. Unless one realises the initial state of those who undergo the procedure, it is inevitable that one’s opinion of the treatment will be low. That mere electrical shocks could bring such profound benefits goes against all the dictates of common sense, but in the face of mental illness, common sense is commonly an unreliable guide.

Shock Therapy does not look beyond the ECT suite to ask what it is about psychiatry that allowed huge segments of the public to become utterly oblivious to the benefits of one of its most effective treatments. To do so would be to write an account of psychiatry itself. Yet the story of shock therapy cannot be complete outside of such a history. Perhaps the most important lesson of this book is that we are rarely more irrational than when faced with madness.

Copyright © 2008 Oxonian Review of Books