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Learning from a Controversy

Jonathan Sadowsky traces the history of attitudes toward electroconvulsive therapy

By David Levin

Spring | Summer 2017

Historian at library desk

Historian of medicine Jonathan Sadowsky devoted nine years of research to his book on electroconvulsive therapy. Photo by Mike Sands.

From a pop-culture perspective, electroconvulsive therapy (ECT) doesn’t have a great reputation. Since its inception, the treatment—also called “shock therapy”—has been depicted in novels and films as psychological torture, a matter of strapping mentally ill patients onto gurneys and zapping them into submission.

There’s a grain of truth in some of these stories, says Jonathan Sadowsky, the Theodore J. Castele Professor and associate professor in the Department of History. But, he notes, the therapy has also been proven to drastically reduce symptoms of bipolar and depressive disorders and to provide some patients with instant relief from suffering.

Modern administrations of ECT are a far cry from those performed in its early days. The treatment now includes general anesthesia and medication to tame the painful seizures it causes. Yet even in this modified form, ECT remains deeply divisive, with advocates insisting on its merits and critics assailing its debilitating side effects: loss of memory and cognitive function.

For Sadowsky, this ongoing debate makes ECT fascinating. He’s been studying the history of the treatment—and of attitudes toward ECT—for nine years and has now published a book on the topic, Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy. In it, he argues that regardless of whether the treatment is inherently good or bad, the fact that it’s the center of such a powerful controversy speaks volumes about the way our society approaches psychology, medicine and the brain.

In an interview for art/sci, Sadowsky discussed the challenges of writing about such a contentious topic.

Writing a history is one thing, but tackling why a controversy arose seems like a different beast. What were some of the challenges of approaching a book that way?

I think looking at the controversy actually made it easier in some ways. I mean, a lot of historical accounts of ECT have really been briefs either for or against the treatment. But the more I looked at ECT, the more I realized that the controversy really is the story. It raises all sorts of cultural questions. What does ECT tell us about our ideas of what medicine should and can do? What does it tell us about which adverse medical effects we’re willing to endure as a culture? The debate over ECT has at times even been a proxy war about who we are as humans. Are we physiological beings that can be reduced to the electrical impulses in our brains, or something else?

Do you think ECT is unique in that regard? Or are there other treatments that share that sort of cultural baggage?

It’s certainly not unique. But its ability to bring about very dramatic effects on people in a very short amount of time brings those issues into relief. ECT is interesting culturally because there are such profound differences in how people view it. It brings out very strong passions in people, from thinking it’s something so criminal it should be banned, to thinking it’s the greatest invention in psychiatry’s history and one that should be used more widely. That is a very, very striking difference of opinion.

So in the midst of this controversy, why has ECT survived, where other controversial treatments like lobotomy—which won its creators the Nobel Prize in 1949—are now considered barbaric?

A lot of treatments were initially used because they were observed to have some clinical effect, but later they were discarded because the costs clearly outweighed the benefits. In the case of lobotomy, it took longer to recognize the magnitude of the costs, because in many patients not all of the cognitive deficits caused by the treatment were immediately apparent.

With ECT, the cost-benefit analysis has always been a little more complicated. It can cause memory loss, which is a significant cost, but not everyone experiences it. For many people, whatever memory they lose, they recover, and the demonstrated success in relieving symptoms has been dramatic.

Today, ECT is used under anesthesia, and with muscle relaxants, but in the past, those aids weren’t used, even when available. Why is that?

One reason might be that many hospitals were simply underfunded, understaffed, overcrowded, as we know they were, and so they didn’t have all the resources they should have had. But there’s also an unfortunate history in psychiatric institutions of treating the mentally ill as, frankly, less than human, even to the point of imagining that they don’t feel pain the same way.

Book coverYou mention in the book that ECT was also sometimes used as a means of control—that it was administered as punishment in some cases.

Yes. Virtually every hospital that I was able to find any data on had at least some use of ECT for disciplinary purposes. In some instances, that was the main goal, and in others, the disciplinary use was combined with therapeutic aims. Many hospitals regarded unruly or difficult behavior as an aspect of a patient’s illness.

One of the points I tried to make in the book is that some of the negative perceptions of ECT in popular culture were based in reality. On the other hand, we have to recognize that ECT advocates, people who have benefited from the treatment, are often very frustrated that those inhumane uses of ECT dominate the public consciousness. It’s important to be balanced here.

If the procedure has actually helped some patients, why do you think the image of it as barbaric has persisted?

I think that image is dominant because people had friends or family members who were subjected to unmodified ECT in its early days—that is, without anesthesia or muscle relaxants, which is very painful—or to ECT used for punitive purposes. One Flew Over the Cuckoo’s Nest, which was a sensationalist story in a lot of respects, actually wasn’t unrealistic in its depiction of ECT in the 1950s. I think that story is the biggest culprit here—I can’t think of any other piece of literature or film that so dominates public perception of a particular medical treatment. Even to this day, for younger people, their first reaction when a doctor recommends ECT is, “Wait, is that going to be like One Flew Over the Cuckoo’s Nest?”

But today, it’s done under anesthesia, so it’s a very different experience. With that in mind, are psychiatrists still as divided on the treatment as patients and the public?

There isn’t that much debate among psychiatrists about whether it’s effective. Even some of the strongest opponents of ECT concede that it’s efficacious. They simply argue that the costs are too high, in terms of cognitive deficits and memory loss, to continue using it.

If you really think, as some psychiatrists have claimed, that modern ECT is virtually harmless, then there’s really no reason not to use it as a first-line treatment for mild depression. Why allow a depressed person to suffer longer than he or she has to? But that’s not what psychiatry does. What it does is first wait and try antidepressants, or psychotherapy, or a combination of the two. And if those don’t work, then ECT is considered. Usually it’s a last resort.

At the same time, though, medications like Prozac also change the way the brain works—so where’s the line drawn between medicating a patient and using ECT?

In many cases, they do raise some of the same issues, but it’s a matter of trying to balance risk and benefit. If ECT is actually harmless, maybe it is preferable to drugs. But I happen to think that there’s too much evidence of risk of significant memory loss in some patients, and they find this loss quite disturbing. Your memory is an important part of who you are. To lose memories, to forget vacations with your spouse or not remember close acquaintances when you run into them in the supermarket—these are very upsetting experiences to have. And these are things that really don’t happen if you take Prozac or Wellbutrin.

What were some of the biggest challenges you faced while writing this book?

It’s not easy to write about something that’s controversial. I signed up for it, so I can’t really complain—but I found when I gave public talks on the subject, someone would invariably come up to me afterwards and either say, “How could you possibly defend this barbaric treatment?” or, “Why did you give so much weight to the critics when ECT is perfectly effective?” I didn’t know which one I was going to get. I could give the identical talk in two different places, and get a different response depending on who was in the audience. And to be honest, I didn’t really relish those attacks.

It’s a bit of a hornet’s nest, I imagine.

Yeah! I mean, it’s one of those topics where it’s impossible to please everybody. But I hope I’m able to show people—and I know there’s a limit to how well this can be accomplished—that we can have a more interesting conversation about ECT. Instead of polarizing between whether it’s good or bad, if we start discussing some of the subtleties and nuances of it, we might realize that, like every medical treatment, it has costs and benefits, and those are sometimes hard to weigh.

David Levin is a freelance science and technology reporter based in Boston.


Page last modified: April 27, 2017