If there is one thing that the general public seems to know about psychiatry it is that shock therapy is a very bad thing. It is, if the popular conception is to be believed, nasty brutish and not always short. It is barbaric and unscientific. It is also very cinematic, a point that comes up frequently in an attempt to understand the public image.
However, in Shorter and Healy's estimation, it is much misunderstood, much maligned and very much underestimated. This book, chronicling what the authors call the not-so-civil war of shock therapy, is a reconsideration of the evidence and a defense of ECT and its practice, and in that the two well-credentialed authors look to counter the case against ECT and also provide evidence for its use.
Shorter (well known for his historical work) and Healy (respected for his clinical research) take aim not only at the public constructions of ECT (and who among us cannot but think of One Flew Over the Cuckoo's Nest?), but also what they see as the irrational aspects of the debate (they note somewhat wryly in the final sentence that medicine is not vacuum sealed against irrationality). They are clearly aware that the book will be controversial; they deliberately chose a title that would instantly bring strong feelings to the fore and might even be seen to be deliberately provocative. And yet, their argument suggests that the evidence for the efficacy and safety of ECT is so strong that there should be little controversy over its use.
Although, as they correctly assert, ECT can be said to have begun in 1938 with the work of Ugo Cerletti, it is important to note that the ideas of using electricity in the treatment of mental illness, or using shocks, or inducing seizures did not materialize out of thin air. There was a clear line of therapeutic hypothesizing, and this worked in concepts of neurological function as well as psychological processing. It would have been interesting to explore the historical roots of the shock in shock therapy a little more. We have, after all, seen patients placed in ice baths, douched with cold showers, put under a barrel of water emptied from a great height, spun round and round so fast as to disorientate, and so on, almost endlessly. There is, almost in common parlance, a feeling that people can be shocked to their senses. In a similar vein, electricity has been seen as a miracle cure in numerous disorders, even the very stuff of life itself, and so it seems that the historical context of the meaning as well as practice of ECT is highly significant.
However, even when seemingly positive results came through, no-one was ever quite sure how it worked. Did it some way, reset the brain's wiring -- a bit like thumping the television when the picture isn't quite clear? Did it effect a psychological punishment, thereby expiating a patient's guilt and allowing a recovery to happen? Persuasive theories came and went, but none really answered the central question. This, alongside the debate concerning memory loss often seems to be at the crux of the matter.
The position of Healy and Shorter is that evidence is now convincing enough to put an end to the debate, and that the opposition to ECT, while having some foundation in the past in procedures and practice such as unmodified seizures and no anaesthesia, has somehow shifted into entrenched positions that encompass ethical issues as well.
ECT has also become a touchstone in the psychiatric survivors' movement -- and again it is instructive to consider the language. It only takes a moment to search for related web-sites and to see how accusations of bias are flung back and forth by proponents and opponents of ECT. Evidence of whatever character is debunked, challenged, accused of bias and it is perhaps that each interest group spends its energy primarily preaching to the choir. Each group accuses the other of being in the thrall, and sometimes the pay, of enigmatic and nefarious pressure groups or conspiracies. It all becomes very tangled, and the real question can be forgotten.
But it is also interesting to note how ECT has begun to be considered by mental health legislation around the world. It is not seen as a standard treatment; there is something different about it. It often requires extra consultations and informed consent. And whether this is due to the very nature of the treatment or a result of its public construction is still not really clear.
So, if a book such as this cannot expect to change entrenched positions, what can it do? It may be noted that Shorter and Healy call the book 'a' history, and not 'the' history; there is an acknowledged authorial bias. It is also reasonable to assume that the two authors are not shy of any debate. However, a naїve reader may find this aspect difficult to extract, and may not be able to make unbiased sense of the material and the way it is presented. It comes across as self-confident, and perhaps even dismissive of other opinions.
There is a little doubt that the book is thoroughly referenced, but it may be that the methodological biases show through. Questions of patient testimony or patient choice could well be developed further. There may be those who suggest that just because something is rational, does not mean that everyone will agree that it is the right thing to do; it is possible that our actions are determined by irrationalism and image rather than the cold, hard facts. Furthermore, there is the question of "just because we can, does that mean we should?"; ECT may well be effective, it may well bring about a more rapid recovery from depression and save people from suicide, but is that all we need to know or consider. A reader would suspect that Shorter and Healy would say that if it works it is unethical not to use it while opponents may be saying that this is not always the case.
The strengths of the book are in the wealth of detail that it marshals, although as has been indicated there are certain areas and perspectives that could be developed more. It does include a final chapter on new initiatives such as magnetic seizure therapy and transcranial stimulation, and of course it may be that as neuroimaging becomes ever more sophisticated some of the mechanisms will become clear. However that is in the future. The weak points of the present text may be that it can be interpreted as overly dogmatic, and perhaps too aggressive in its argument for a history.
Nevertheless, it is an intriguing read. It may not be entirely satisfactory for those who do not have some prior sense of the debates and controversies, but for those who want to inquire into the subject in more detail, it is well worth the time. No one should be afraid of the debate, and no one should be unable to defend a particular stance unchallenged. Separating facts (if there are unbiased facts) and opinions (if there are informed opinions) in this issue may not always be really possible at this stage. The process of the debate may be the key, and in that this book, whether you agree with its premise or not, certainly makes a contribution.
© 2010 Mark Welch
Mark Welch, Ph.D., British Columbia