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.

Jamie Horder is reading for a DPhil in psychiatry at St John’s College, Oxford.

Steven Pinker
The Stuff of Thought:
Language as a Window into Human Nature
Allen Lane, 2007
512 pages
£25.00
ISBN 978-0713997415

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Steven Pinker likes language.  He has, after all, built a career on the study of it, and he confesses that he is perhaps a little too fond of obscure verbs.  Language, it seems, also likes Steven Pinker, at least judging by his justly famous ability as a master of English prose.  Given this mutual appreciation, it is perhaps somewhat surprising that one of the arguments of Pinker’s latest book, The Stuff of Thought, is that the place of language in the human mind is not nearly so central as many have claimed.  Although he spends plenty of entertaining pages discussing the grammar and semantics of profanity (When I exclaim ‘Screw you!’, what exactly am I saying?) and explaining why so many of his generation are called Steve, the focus of the book lies in exploring why language is not the master of the mind and what, in fact, is.

The anthropologist and linguist Benjamin Whorf lent his name to the hypothesis that the particular language which one is raised to speak has a profound influence on the way in which one perceives and conceives of the world.  In its strong form, Whorfianism holds that certain thoughts and ideas are literally inconceivable to those who do not speak the appropriate tongue.  In other words, the language we use to communicate with other people is the same language which we use, in our heads, for thinking and reasoning: the unspeakable is also the unthinkable.  To take a well-worn example, Eskimos supposedly have a great many different words for the various kinds of what English simply calls ‘snow’.  Surely, this means that Eskimos think about and even see the powdery white stuff differently?  (Whorf himself even went as far as to claim that the Hopi, a Native American people, actually have no concept of time, or at least not as we know it, on the grounds that their language has no tenses and has, in general, a poverty of time-related terms.)

Pinker thinks little of such arguments.  As he points out, if Eskimos have no shortage of words for water in its solid form, this is presumably because they spend their lives working on and with it.  Their numerous words for snow are the consequence, not the cause, of the Eskimo’s intimate knowledge of it, and even the most parochial English speaker will quickly come to appreciate the subtleties of snow once they find themselves knee-deep in it.  Depending upon how you count them, Pinker says, we in fact probably have just as many words for snow as the Eskimos anyway.  Likewise, although different languages deal with time in numerous ways, closer anthropological inspection shows that all peoples do understand and work within it (how indeed could they survive if they didn’t?).  Of course, it remains possible that the language we speak determines not what we can and cannot think but what we habitually tend to think, conditioning the kind of things we pay attention to, and the implicit assumptions we are prone to make.  Pinker is willing to admit that there may be something in this weaker (or as he puts it, less interesting) theory.

Whorf’s is not the only theory of ‘linguistic determinism’ that Pinker is determined to lay to rest.  The cognitive scientist and Democratic Party activist George Lakoff also draws fire for his theory that our abstract thoughts are necessarily structured by linguistic metaphors.  Lakoff points out that almost all of our discourse either concerns concrete objects and occurrences, or refers to abstract concepts as if they were such concretes.  It is indeed remarkable that we talk nonchalantly about the stick that props up Sam’s garden shed and the argument that props up Kant’s theory of transcendental idealism; of the passing-by of the 10.30 train to Bristol and of the passing-by of time (or its flowing, etc.)  For Lakoff, these are not ‘mere’ metaphors, but evidence that our minds actually cannot deal with abstract concepts except by representing them as concrete things.  It follows that the particular metaphor which we adopt in regard to a situation dictates the whole way in which we think about an issue—a conclusion with important practical implications for politicians, among others.  Pinker, however, says that we can, and indeed often do, point out the ways in which a given metaphor is valid or invalid.  Rather than being slaves to metaphors, we seem to have a genuine abstract reasoning ability, independent of language, which stands aloft from them.  Again, this is not to deny that analogies can be important tools of thought, especially when it comes to helping us to formulate novel ideas.  Nor is it to deny that the way an issue is framed can shape our conceptions of it.  Pinker’s point is that, even if influenced by language, thought does not rely upon it—we can go beyond metaphor, indeed beyond words, even if we often do not.  As he points out, this is probably most people’s ‘common sense’ view, although of course, this does not mean it is true.

If, then, Pinker is so fond of language, why is he so eager to put it in its place?  One clue is in the subtitle of the book, ‘language as a window into human nature’.  For Pinker holds a very specific theory of human nature and, in one way or another, all of his several popular books have been dedicated to expounded and defending it.  In The Stuff of Thought, he aims to show how our ways of speaking shed light on human psychology, but for this to be more than a circular exercise, our psychology has to exist independently of, and be reflected in, the structure of language, rather than the other way around.  If Whorf and his friends had their way, it would be psychology which reflected linguistics, and human nature would vanish in a puff of pronouns.

Pinker’s interest in human nature is long-standing.  He is a founding member of the school of thought known as Evolutionary Psychology, a movement which originated in the late 1980s as a conscious reaction against the prevailing climate in the social sciences, where culture was everything and man was a ‘blank slate’ whose mind and behaviour were socially constructed.  Evolutionary Psychologists believe that just as the human body has been shaped by the process of evolution, giving us the distinct anatomy with which we are all so familiar, natural selection has also provided us with a mental architecture—a set of ways of thinking, feeling and perceiving shared by all normal human beings, regardless of the language we speak or the culture in which we are socialised, and ultimately the product of the genetically determined structure of our brains.  This cognitive toolbox is human nature, man’s common inheritance.  Pinker is one of the most influential proponents of this view; he was a contributor to the classic The Adapted Mind (1992), while in his book The Language Instinct (1995), he described language as one of Man’s evolved mental faculties.  In How the Mind Works (1997)he presented a layman’s account of human nature as Evolutionary Psychologists see it.  Such ideas have proven attractive to many experimental psychologists and neuroscientists—among other things, Darwinism offers what the behavioural sciences have long lacked, a unifying paradigm.  There have, however, been vocal critics—the philosopher Jerry Fodor, for example, left no doubt over which side he was on by publishing a book entitled The Mind Doesn’t Work That Way.

So, for Pinker, the stuff of thought is not language.  On the contrary, it is our built-in cognitive machinery: a triumph of evolution which effortlessly performs the mind-boggling task of taking our raw sensory data and constructing a model of the world ordered according to the categories of space, time, and causation, populated by other people whose minds we understand in terms of intentions, beliefs and desires.  We are so familiar with these mental scaffolds that they can easily go unnoticed, but if we look closely we can see evidence of them in our language.  Take causation: the way we think about cause-and-effect is not derived from anything we know about physics, Pinker claims, but rather relies upon a simple mental model.  Certain objects or actors have ‘intrinsic’ tendencies to do or act in certain ways and other objects can prevent, allow or help them to do this—like little balls pushing each other around.  Accordingly we distinguish between scenarios which are, nevertheless, logically equivalent: if I were to throw a marble at a coin which was about to fall heads, pushing it over onto tails instead, we say that I ‘caused’ it to end up tails, but we do not say this, although it is hard to justify why, if I intercept a marble which is threatening to do the opposite.  We also talk about certain objects (often people) as being uncaused causes—John broke the lamp—implicitly affirming our belief in free will.  Pinker provides a similar analysis of the cognitive scaffolding behind our talk about space and time, ethics and more.

Some might detect echoes of Sigmund Freud in all of this, perhaps comparing it unfavourably with the psychoanalytic theory of unconscious desires which reveal themselves cryptically in dreams and slips of the tongue.  Yet there are fundamental differences.  For one thing, Pinker does not rely purely on the analysis of language, since he also quotes experimental evidence in support of his positions.  The analogy with Freud is also tenuous, for he claimed to have identified long-buried ideas which were quite inaccessible to normal consciousness; only with the help of a trained psychoanalyst could such gloomy realms be charted.  By contrast, what Pinker is doing is pointing us towards aspects of our thinking which normally escape our attention. The point is that they are just that—aspects of our own minds, not of reality out there.  In other words, he is inviting us to see as merely psychology things which we otherwise take for granted. Our brains impose the concepts of causality, space, and time, and human agency, upon the world, rather than reading them off from it—and this is surely a fascinating thought, not to mention a disturbing one.

There’s nothing especially new in all this.  Anyone familiar with Western philosophy will recognise that Pinker is providing a modern treatment of issues centuries old, and, to his credit, he briefly discusses thinkers such as Hume who, more than two centuries ago, provided arguments against the objective validity of, for example, our conception of causality.  In particular, the theory that our minds produce a picture of reality structured around innate mental concepts of space and time strongly recalls Immanuel Kant, as Pinker himself points out.  Yet what is more original about The Stuff of Thought, apart from its accessibility (one certainly feels that Kant could have used a couple more Dilbert cartoons, and I’m sure Plato would have appreciated Pinker’s characterisation of his Cave as a ‘movie theatre out of the Flintstones’), is that it provides a firmly scientific approach to these quintessential philosophical questions.  Our minds work in certain ways because these ways proved to be useful during the evolutionary time over which our species was formed: there is no real mystery about why we conceive of the world in the way in which we do, and some day, we may even come to understand how our brains do it.

Yet Pinker shies away from some of the more radical interpretations that could be drawn from this picture.  Our concepts of free will, moral responsibility, cause-and-effect, and objects-in-space may indeed be mere phantoms of the human brain, he says, but they are useful ones, and it is not as if we have any practical alternatives for our day-to-day lives.  Disappointingly, while he may well be justified in this pragmatic conservativism,  he gives very little attention to the issue, and one is left feeling that there is much more to be said about this.  Philosophers, for example, have long used their intuitions as a window into the nature of the moral and physical worlds.  If Pinker is right, then this whole enterprise seems in danger of being reduced to a branch of cognitive science: the study of how we have evolved to think about the world, rather than how the world really is.  (Indeed, although Pinker does not mention them, a number of philosophers, such as Shaun Nichols, have begun to argue along these lines and have proposed that the future should belong to an ‘experimental philosophy’ which adopts scientific methods.  Of course, not everyone is happy about this threatened annexation by science.)

The Stuff of Thought concludes on a hopeful note with a chapter called ‘Out of the Cave’.  Pinker says that while evolution has given our minds a distinct architecture, it has also made them flexible.  We are vassals neither of language, nor culture, nor natural selection, and with the proper education we can come to think, and talk, in ways which go far beyond what nature intended.  While the ways our minds have evolved may not be ideally suited to the challenges of the modern world, and while, as Pinker notes, ‘Left to our own devices, we are apt to backslide into our instinctive conceptual ways’ we also find ourselves with the capacity for genuine reasoning.  Reading this book along with his others, one senses that Pinker is interested in more than just language and psychology.  What he is really concerned with is defending the possibility of human knowledge and progress against the threat of post-modern relativism.  Thus his rejection of Whorf and Lakoff’s attempts to reduce the mind’s working to linguistic puppetry.

With his common-sense view of cognition, his confident belief in a universal human nature, and his enthusiasm for natural science, Pinker resembles the philosophes of the 18th century Enlightenment.  Like them, he is no professional philosopher, but seeks, with more than a little mischievousness, to overturn what he sees as an outdated orthodoxy, in this case the prevailing cultural relativism of the social sciences.  Those on the receiving end—those for whom the Enlightenment is something which our post-modern world has rightly moved beyond—are likely to be less than enthusiastic about The Stuff of Thought’s message.  Were Voltaire in a position to comment, however, he would, I feel, approve.

Jamie Horder is reading for a DPhil in Psychiatry at St John’s College, Oxford.

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