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Shock and Disbelief - Page 2
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A Patient's Complaint
inda Andre, a tall, attractive woman in her early forties, is the director of the Committee for Truth in Psychiatry, a loose-knit organization of 500 former ECT patients. I was directed to CTIP by Max Fink, who has had numerous run-ins with Andre. At a talk Fink gave some years ago in New York, Andre stood up in the audience and loudly protested his association with Somatics, one of the two largest U.S. manufacturers of ECT devices. (Fink says he has no financial links with any ECT-device manufacturer.) Andre has been to many psychiatric conferences. She is hardly ever afforded official time to speak. More often she simply rises from the crowd.
When Andre and I met recently, I mentioned Fink, and she shook her head. "Ah, Max Fink, my dear friend. Oh, that man. That man. Not an honest and ethical individual, shall we say? I cannot believe that the scientific press lets the stuff he says get through. I'm sure he told you that no one ever had memory loss from ECT, except maybe around the time of ECT itself, and that they don't want to remember. He probably told you that we're just exaggerating. And everybody has some memory loss. He keeps these positions because he can. Shock is his baby. He's been associated with it longer than anyone." Fink, it became clear, represents for Andre the epitome of psychiatric deception. In an unpublished article on ECT, Andre has written,
After 50 years of giving electroshock, I can't believe Fink knows any less about the extent of permanent memory loss and disability than I do. I believe he and his fellow apologists are making a value judgment about the worth of their patients' memories and lives, and deciding on that basis to essentially trade brain damage for temporary relief of depression.
Andre has been the director of CTIP since 1992. She told me she first became involved in the organization in 1985, several months after she received fifteen "shock" treatments at the Payne Whitney Psychiatric Clinic, in New York City. Andre takes exception to the term "ECT," dismissing "electroconvulsive therapy" as "the elegant new PR-conscious name for 'electroshock.'" She says that she doesn't remember anything about her treatments, and that she was committed to the clinic against her will.
"Everything I know about getting electroshock is what I've been told," she says. "I don't remember anything about it. From what I understand, my brother basically tricked me into going into the hospital at a time when I was going through a lot of problems and had become a pain in the ass to him." Andre says she escaped from the hospital several times before her treatment began, and that each time her brother recommitted her. When she was finally released, she says, she had both retrograde and anterograde amnesia: she couldn't remember much of the previous four years, and she had difficulty creating memories of new events. One day, at home, she heard a woman named Marilyn Rice talking on the radio about ECT.
Rice is something of a legend in the world of ECT. In 1974 the distinguished medical writer Berton Roueché published an article about her in The New Yorker, disguising Rice, who had received ECT to treat a serious bout of depression, as "Natalie Parker." The article, titled "As Empty as Eve," depicted Rice's experience as a nightmarish erasure of memory. "There is a harrowing sense of confusion," Roueché wrote, "and then a full awakening in the midnight dark of total amnesia." Her sense of purpose bolstered by the article, Rice formed CTIP and began accumulating documentation that ECT causes, as she put it, "psychiatrically-induced brain damage." She wrote letters to psychiatrists, government officials, newspapers and magazines, and other potential allies, and created a small network of ECT "survivors," as she called them. To one doctor she wrote, "I could easily set up a psychiatric hospital as good as yours. I would just put the patients down on the sidewalk and interfere with their cerebral function by dropping flower pots on their heads."
Andre got Rice's phone number from the radio station and called her. The two became very close, and when Rice died, of heart failure, in 1992, Andre took over as director.
Can ECT cause a complete erasure of memory, as Andre claims? Most psychiatrists insist that it can't, and that side effects are usually slight. Roland Kohloff, the principal tympanist for the New York Philharmonic, was treated several times with ECT after slipping into severe depression. Each time he quickly rebounded and went back to work. "After you get a series," he told me recently, "there will be for a while some short-term-memory problems. I might not remember something I had done a couple of weeks before, or somebody called and I don't remember that they called. But nothing major; and then, as time goes on, it gets better. Look at Vladimir Horowitz"—the concert pianist, who has also been treated with ECT. "He was able to play billions of notes: Chopin, Tchaikovsky. The worst for me was that I'd forget something and my wife would say, 'Oh, I told you a couple of weeks ago but you didn't remember: you had the ECT.'"
What patients like Andre are complaining about is something more serious. They argue that ECT can result in wholesale amnesia, along with a steep decline in IQ. At the age of twenty, Andre says, her IQ was 156. Three years after her ECT it was around 112, and it does not appear to have increased since. Whether or not this is a result of ECT is hard to determine. Norman Endler, a psychologist who was himself treated with ECT, and Emmanuel Persad, a psychiatrist, wrote in their book Electroconvulsive Therapy: The Myths and the Realities (1988), "There is no conclusive proof that ECT causes permanent brain damage." What muddies the issue is that mental illness itself can cause cognitive defects, including a drop in IQ and in the ability to retain new memories. The informed-consent document for ECT used by Charles Kellner, a professor of psychiatry at the Medical University of South Carolina and the editor of The Journal of ECT, although scrupulous in its delineation of even the most severe side effects, states, "In part because psychiatric conditions themselves produce impairments in learning and memory, many patients actually report that their learning and memory functioning is improved after ECT."
In some cases a profound deterioration of cognitive ability is clearly the result of mental illness. Harold Sackeim, the chief of biological psychiatry at the New York State Psychiatric Institute, in New York City, and probably the most prolific ECT researcher in the world, told me about a colleague whose son had a psychotic break while a student at Harvard and now can't hold down a job at a fast-food restaurant.
Andre, Sackeim says, has shown him her medical records; he says that she may have experienced a similar breakdown. But there is no way to know for sure whether ECT was the culprit in Andre's loss of IQ and memory. "In very rare cases," Sackeim acknowledges, "there will be profound memory loss. People can lose years of their lives."
Jeremy Coplan, a professor of psychiatry at suny Downstate Medical Center, in Brooklyn, who, like many other psychiatrists, doesn't actively treat with ECT but does refer patients for it, told me that the issue of memory loss is, unfortunately, often downplayed by psychiatrists. "For instance, someone may forget where the bathroom is in their house—at least temporarily," he said. "There can be a profound disruption of memory—not a minor thing if you put yourself in the patient's shoes." But, he said, it's a matter of risk versus benefit. "It's better that the patient is temporarily disoriented than seriously depressed for years."
The effect that ECT has on memory has been notoriously hard for ECT practitioners to concede. "The field has been under attack for such a long period of time," Sackeim says, "that a defensive posture was developed where limitations of the treatment were not acknowledged. So people complained of profound cognitive effects, and [those effects] were attributed to an ongoing psychopathology and essentially dismissed. I think that hurt the field of ECT."
Lately doctors have been taking special pains to spell out the risks that patients face. "I tell all my patients that they are going to have memory loss," Sackeim says. "In the vast, vast majority of patients that will be limited to a few months surrounding the course of treatment. There will not be a blank slate. But there will be gaps in memory. And the vast majority of patients say that's a small price to pay for getting well. It's not really a big deal to them. But I also tell them that in very rare instances it can be more extensive, and that no one can tell for certain who is going to experience that and who is not."
It has taken some time for a full disclosure to seep into the official literature. The report published this year by the APA Committee on ECT contains that organization's first substantial discussion of the possibility of serious memory problems.
A Doctor's Complaint
here was a moment at the 1985 NIH conference, Peter Breggin recalls, when patients who had had positive experiences with ECT were asked to step up to the lectern and tell about their illness and recovery. Breggin, who is the director of the International Center for the Study of Psychiatry and Psychology, in Bethesda, Maryland, had already delivered a lecture titled "Neuro-pathology and Cognitive Dysfunction From ECT," and he listened intently as the patients spoke. Afterward one of them pressed a note into his hand, thanking him for speaking out about the side effects of ECT. "This was one of the pro-ECT people," Breggin told me when we spoke recently. "They were up there to tell people that ECT works, and here this person was thanking me for providing a dissenting opinion."
For Breggin, the experience epitomized ECT's ability to reduce patients to docility—to the point where they are willing to praise a treatment they feel has done them harm. In his view, ECT is a purposeful assault on the brain. He has been publicizing this opinion since 1979, when his first book, Electroshock: Its Brain-Disabling Effects, was published. Since then Breggin, a psychiatrist by training, has made a career out of attacking psychiatry and its methods. He has written several books arguing against the use of medication to treat mental illness, and he claims to be responsible for quashing the resurgence of lobotomy. His most recent efforts have been directed at establishing a link between antidepressants and the Columbine massacre. When Breggin discusses psychiatry, it is in the brusque manner of an aggressive debater.
Though Breggin has waged many campaigns, he has attacked ECT particularly vehemently, arguing that it causes "severe brain dysfunction" and that it creates in patients profound feelings of apathy or delirium. Psychiatrists welcome either outcome, he told me, because they can note with satisfaction on their charts that the patient is "complaining less" or has "an elevated mood." In this way, he says, psychiatrists fool themselves into believing that they are helping a patient when they are really doing harm. In his book Toxic Psychiatry (1991), Breggin wrote,
If a woman received an accidental shock in her kitchen, perhaps from touching her forehead against a short-circuited refrigerator, and fell to the floor convulsing, she'd be rushed to the local ER and treated as an acute medical emergency. If she awoke the way a shock patient does—dazed, confused, disoriented, and suffering from a headache, stiff neck, and nausea—she'd be hospitalized for careful observation and probably put on anticonvulsants for months to prevent another convulsion. But on a psychiatric ward she'd be told she was doing fine and "not to worry," while the electrical closed-head injury was inflicted again and again.
Breggin first encountered ECT in the 1950s, when, as an undergraduate at Harvard, he volunteered at a state psychiatric hospital. He was horrified, he recalls, at the conditions on the hospital's "back wards." Schizophrenic patients were left mumbling and rocking back and forth, without any human contact. They were led, zombie-like, to be treated with insulin coma or ECT. Breggin believed that if the patients were exposed to a more empathic environment, and one that provided for their basic needs, they would get better, so he persuaded the hospital administration to start a program of "love and care." He contends that plain old kindness worked. Later, as a resident in psychiatry and a teaching fellow at Harvard Medical School, Breggin observed firsthand the trend in psychiatry away from psychotherapy and toward physiological treatment, and he found it very disturbing.
"Mental illness," he says, "is a metaphor. It's not reality. When patients come into my office and say that they're depressed, I don't give them medication. I ask questions: What is their life like? What is their story? Where are they from? How did they get depressed? Why do they call it depression? Depression isn't caused by some mythical biochemical imbalance. It's another word for hopelessness."
Elsewhere on the Web
Links to related material on other Web sites.
"Curing the Therapeutic State: Thomas Szasz on the Medicalization of American Life" (Reason, July 2000)
The transcript of an interview with Szasz in a libertarian publication.
This is a philosophy that Breggin absorbed from his training under Thomas Szasz, one of the forerunners of the "anti-psychiatry" movement. In the 1960s—along with Erving Goffman, R. D. Laing, and Michel Foucault—Szasz, a refugee from Nazi-era Hungary and a psychiatrist, promoted the view that mental illness is a social construct. Breggin's language is taken straight from his teacher. In the revised edition of his 1961 book The Myth of Mental Illness, Szasz wrote, "'Mental illness' is a metaphor. Minds can be 'sick' only in the sense that jokes are 'sick' or economies are 'sick.'"
Breggin is scorned by mainstream psychiatrists for his links to Szasz and for his contemptuous attitude toward physiological psychiatry. "Lots of fields have splinter groups," Harold Sackeim says. "Increasingly the dominant perspective in psychiatry is a biochemical one. There are people who, on ideological grounds, feel that this shouldn't be the case. They think psychotherapy should be the first line of treatment." But, he says, this opinion isn't necessarily benign. "Breggin will argue that a cup of tea, chicken soup, and a lot of hugging will get a psychotically depressed patient well. And he'll kill a lot of patients that way. That's why he doesn't have hospital privileges."
Still, Breggin has hit a nerve. Patients who have had negative experiences with ECT restate his arguments almost verbatim. By demonizing psychiatrists, by "exposing" their claims, Breggin has suggested answers to patients seeking to understand why they continue to suffer.
Scientology Versus Psychiatry
f practitioners of ECT tolerate "survivor" groups and disdain dissenting psychiatrists, they actively loathe the Citizens Commission on Human Rights. The inside of the pamphlet I have—one of many published and disseminated by CCHR—is an indication of why. A quick sampling of chapter headings: "Perpetuating Cruelty," "Therapy or Torture?," "The Nazi Heritage" ("electroshock's development ... traces back to a dark alliance between psychiatry and the Nazi concentration camps"), "Apartheid and ECT," "ECT Promotes Breast Cancer," "Shock From Birth to Grave." Bolts of electricity in vivid neon colors provide visual unity here, emanating from the heads of pregnant women, fetuses, piglets. CCHR does not believe in subtlety.
The commission maintains offices in forty states and chapters in thirty other countries. It has used its branches in part to lobby for legislation against ECT. In 1974 it worked to get the California legislature to prohibit ECT for patients under the age of twelve. It has several times been instrumental in introducing legislation in Texas to ban ECT altogether. Although the legislation has failed, Texas is now, owing in large part to CCHR's efforts, the state in which it is the most difficult to get the treatment. Recently CCHR supported a bill in the Italian region of Piedmont which succeeded in banning ECT for children, the elderly, and, in most cases, pregnant women. That CCHR has effectively and perhaps permanently damaged the public image of ECT is one of the few things about which the commission and psychiatrists agree.
CCHR was founded in 1969 by the Church of Scientology, which by now has a fashionable Hollywood aura— John Travolta, Tom Cruise, and Nicole Kidman are all members. Scientology, "an applied religious philosophy," seeks to change the world through a system known as Dianetics, a term made familiar by a series of TV commercials for a book of the same name by the late L. Ron Hubbard, Scientology's founder and a science-fiction writer. Through Dianetics, Scientologists hope, according to the church's Web site, to create a utopia "without insanity, without criminals and without war, where the able can prosper and honest beings can have rights, and where man is free to rise to greater heights." In CCHR's view, one of the greatest threats to this vision is abuses inherent in psychiatry, which damages the mind instead of soothing the soul. "For more than 115 years, psychiatrists have treated man as an animal," CCHR's Web site states. "They have assaulted, sexually abused, irreversibly damaged, drugged or killed, all under the guise of 'mental healing.'"
CCHR was co-founded by Thomas Szasz, and its members take pains to emphasize this fact. Their connection to "the Church," as they call it, is spoken of less frequently. CCHR is separately incorporated, and although virtually every CCHR member worldwide also happens to be a member of the Church of Scientology, this is by choice, the organization says, not by compulsion. Rather than promote Scientology, CCHR seeks to lay out the evidence of psychiatry's misdeeds through the use of statistics, anecdotes, journal articles, news accounts, and hospital records.
The most voluminous resource for anti-ECT information within CCHR is Jerry Boswell, the director of the commission's Texas branch and the man most responsible for the state's stringent ECT laws. Boswell is patient and even-tempered, and his voice—soft and deep, with a heavy drawl—conjures the image of a large man in boots and a cowboy hat. At one point in a recent phone conversation with him I mentioned the TV personality Dick Cavett, who has very publicly and very positively spoken about how ECT helped him out of a terrible depression. "With ECT you have to ask the question of how much electricity was used," Boswell said. "Let's say you have Dick Cavett on your couch. Are you going to shock him at three hundred percent above the seizure threshold, or are you going to give him less electricity? You're going to give him less, because he's a public figure."
CCHR continually alleges that ECT uses "too high" a level of electricity. This has been difficult for psychiatrists to counter, because the very concept of "too high" leads immediately into contentious terrain. Dozens of studies have been done to determine how much electricity produces the most-therapeutic seizures. On the basis of these studies some researchers have recommended that ECT devices be equipped to deliver more electricity. A 1991 paper by Harold Sackeim, "Are ECT Devices Underpowered?," published in The Journal of ECT (then called Convulsive Therapy), questioned the ability of contemporary devices to stimulate an ideally therapeutic seizure.
Whatever damage CCHR may have done to ECT, the organization has unquestionably improved the gathering of statistics regarding the treatment. The results, however, have not been advantageous to CCHR's cause. Several years ago CCHR lobbied successfully for compulsory reporting of ECT cases in Texas. William Reid, a clinical professor of psychiatry at the University of Texas Health Science Center, in San Antonio, and three other authors recently published in the Journal of Clinical Psychiatry all of the center's available data from September of 1993 to April of 1995. The article reported that 97.5 percent of all admissions were wholly voluntary; that the percentage of patients exhibiting "severe" symptoms was reduced from 70.7 prior to ECT to 2.4 afterward; that the percentage of patients with "moderate," "severe," or "extreme" memory dysfunction decreased after ECT; and that no bone fractures, heart attacks, or deaths occurred during treatment. Of the 2,583 patients described by the data, eight died within two weeks of their last treatment, but only two of these deaths may have been related in any way to ECT. The authors write,
We are aware that anti-ECT groups have used the publicly available ... data to support their contentions that ECT is dangerous and unnecessary and to campaign in the Texas legislature to ban the treatment altogether. We believe that those groups have often misinterpreted and/or misused the ... data. We hope that this paper promotes objective discussion among clinicians, patients, families, and those who influence patients' access to this important treatment modality.
Photograph by Arthur Tress.
Copyright © 2001 by The Atlantic Monthly Group. All rights reserved.
The Atlantic Monthly; February 2001; Shock and Disbelief - 01.02; Volume 287, No. 2; page 79-90.