Few who have seen Milos Forman’s film One Flew Over the Cuckoo’s Nest are likely to forget the scene in which its hero, Randle McMurphy, undergoes shock treatment. As a spokesman for England’s Royal College of Psychiatrists ruefully put it, the film “did for ECT what Jaws did for sharks.” ECT—electroconvulsive therapy—is what the medical profession calls shock treatment. Handcuffed and waiting on a bench with his friend Chief Bromton, McMurphy is summoned into a treatment room by a white-capped nurse. He looks around, curious but wary, as a doctor’s voice says, “This won’t hurt and it will be over in just a minute.” A nurse inserts an improbably large wooden object into his mouth—“to keep you from biting your tongue,” she explains—and places what looks like a set of cotton-covered headphones on his temples. Six young men, neatly dressed in white shirts and bow ties, hold him down as the doctor turns a knob on a machine. Then the camera focuses on McMurphy’s face as electricity surges through his brain and his entire body begins to convulse. He gasps and struggles to breathe as the nurse holds the crown of his head and his chin together to keep the enormous bit in his mouth, his body arches and shudders, the three assistants on each side press down on his thrashing legs, hips, and shoulders. The only sympathetic presence in this frightening clinical scene is McMurphy, whose character is brought to life by Jack Nicholson in one of the most memorable performances of his career. Since the camera refuses to look away, we watch the simulated effects of a grand mal seizure on a human body for thirty slow seconds.
Forman’s film was greeted with critical and popular acclaim when it premiered in 1975, and went on to win the five major Academy Awards. It has terrified many a prospective inmate of a psychiatric institution ever since. Shot on location at the Oregon State Hospital with patients and staff as extras, the film’s slippage between patient and prisoner is deliberate. Like Ken Kesey’s 1962 novel on which it is based, the film is an antipsychiatry and anti-authoritarian polemic, and portrays the men on the ward as prisoners of a repressive social machine. They are all in some way deviant, and they will be held until they become the conformist, emasculated, deadened individuals that American society demands. McMurphy is a gambler, a Korean War veteran (with a dishonorable discharge for insubordination), and an all-around hell-raiser who has gotten into trouble with the law yet again, this time for statutory rape. He decides to avoid the hard labor of a prison farm by pretending to be psychotic. “If it gets me outta those damned pea fields,” he says, “I’ll be whatever their little heart desires, be it psychopath or mad dog or werewolf.” He moves into the psychiatric hospital and becomes the rebel-hero who urges the broken men of the ward to rise up against the sadistic and man-hating Nurse Ratched, called “Big Nurse” by her patients.
Because McMurphy has challenged her regime in outrageous ways, Big Nurse has a plan in store for him: “The Shock Shop, Mr. McMurphy, might be said to do the work of the sleeping pill, the electric chair and the torture rack. It’s a clever little procedure, simple, quick, nearly painless it happens so fast, but no one ever wants another one. Ever.” The Shock Shop is the threat that ensures compliance. Chief Bromden describes how a character named Ruckly looks upon returning from “that filthy brain-murdering room”: “You can see by his eyes how they burned him out over there; his eyes are all smoked up and gray and deserted inside like blown fuses.” McMurphy emerges from the Shock Shop unbroken, much to the amazement of his weaker comrades. He jokes that his electrified body can only enhance his sexual magnetism: “When I get out of here the first woman that takes on ol’ Red McMurphy the 10,000 watt psychopath, she’s gonna light up like a pinball machine and pay off in silver dollars!” But after he nearly strangles her to death, Nurse Ratched destroys McMurphy with the deadliest weapon in her arsenal: a lobotomy. In an off-camera surgical procedure that the novel refers to as a “frontal lobe castration,” the nerves to the frontal lobes of his brain are severed. We see him afterwards, head lolling, eyes vacant, two incision marks on his forehead. Chief recognizes that his friend is gone, though his body is still living. He suffocates McMurphy with a pillow, throws a massive marble hydrotherapy machine through a window, and makes his escape from the hospital. In the film, shock treatment and lobotomy are two instruments of the same soul-killing institutional practice. In reality, lobotomy was an irreversible mutilation of the brain’s frontal lobes, while ECT is often a life-saving intervention in the worst cases of drug-resistant depression, especially when the threat of suicide makes the situation urgent.
Kesey’s novel was inspired by his experience as a night-shift aide at the Veteran’s Hospital in Menlo Park, California, where he had volunteered to test the effects of hallucinogenic drugs. He didn’t know that in doing so he was contributing to a clandestine CIA program called MK Ultra, whose purpose was to find drugs and mind-control techniques that could be useful in interrogation. The novel’s central ideas—that people labeled with mental illness were just people who didn’t or couldn’t conform, and that those who did submit to psychiatric treatment were betraying their authentic selves—did not originate with Kesey. Several books of the early 1960s presented challenges to psychiatric diagnosis, treatment, and confinement, including The Myth of Mental Illness, by the Hungarian émigré psychiatrist Thomas Szasz; The Divided Self, by the Scottish psychiatrist R. D. Laing; and Asylums and Stigma, both by the Canadian sociologist Erving Goffman. The works of Szasz, in particular, provided the intellectual basis for a patients’ rights movement. In the San Francisco Bay Area, a group of activists, including people calling themselves survivors of psychiatric commitment, issued a quarterly journal called Madness Network News, printing testimonies from people who had been denied “even the most basic aspects of personal choice, self-determination and human rights.” One issue included an article called “Tom Szasz, Freedom Fighter,” and another included one called “R. D. Laing, Superstar.” Laing’s position on insanity was that it was a rational response to an insane world. Other articles focused on the horrors of shock treatment. In 1982 the residents of Berkeley, California, voted to criminalize ECT, although the ban was soon overturned.
As a psychiatrist who had turned against his profession while holding a tenured position at SUNY Upstate Medical University from 1956 until 1990, Szasz became a leading voice in the American antipsychiatry movement. He taught psychiatry, he said, as an atheist would teach theology. In 1969 he joined forces with the Church of Scientology to create the Citizen’s Commission for Human Rights, which still commands a highly visible position on the Internet to oppose psychiatric treatment of all kinds. Szasz’s attacks came at a bad time for psychiatry. His central claim, that there was no such thing as mental illness, dovetailed with an ongoing problem for the profession: the lack of clear physiological evidence for the psychiatric illnesses. Szasz argued in book after book that mental illness cannot exist because the mind is not a physical organ. His final book argues against psychiatric treatment for the prevention of suicide because to end one’s life is a voluntary act, the right of every human being. He refused to countenance the idea that mental illnesses result from pathology of the brain and nervous system, and his primary concern was to oppose diagnostic labeling, coercion, and confinement by what he called “the therapeutic state.”
Many viewers of Forman’s film and readers of Kesey’s novel would have been aware that in real life, the mentally ill were sometimes abused instead of helped. One Flew Over the Cuckoo’s Nest raised an undeniable truth: shock treatment had been used as a form of punishment in state hospitals that warehoused helpless mentally ill patients. ECT was introduced to the seven-thousand-bed Georgia State Sanatorium in 1942, where it was called “the Georgia Power cocktail” by patients and staff. Peter Cranford, who worked as a psychologist there, remembered, “The words ‘punish’ and ‘shock treatment’ were often synonymous to the disturbed.” Abuse by attendants was common in large institutions like this one, where the doctor-patient ratio was less than one to one hundred. In a 1985 report for the National Institutes of Health, the medical historian David Rothman wrote, “ECT stands practically alone among the medical/surgical interventions in that misuse was not the goal of curing but of controlling the patients for the benefits of the hospital staff.” So it is with McMurphy and the men on the ward; shock and other therapies are used solely to intimidate or punish.
Szasz was delighted that One Flew Over the Cuckoo’s Nest aligned with his philosophical position. He even wrote a letter to Kesey asking permission to quote from the novel, which he commended as a “tremendous achievement.” Kesey replied,
Mr. Szasz: I took your letter to my next door neighbor, who is getting his Doctorate in Psychology, and he was much impressed: “Oh, man, Szasz? Yeah. This book of his [The Myth of Mental Illness] is the Catch 22 of the syke world!” Just to give you some idea of your impact in these distant parts. Certainly you may quote my book. I would consider it an honor.
Kesey explained to Szasz that he wrote the entire novel while working night shifts at the VA hospital, except for the shock treatment scene: “I did that scene after, the day after, in fact, I took a treatment with an apparatus that a friend of mine had rigged up for me.” It’s unclear why Kesey felt the need to have a friend give him a makeshift treatment, but the detail underscores just how bold he could be in experimenting on himself. Elsewhere Kesey wrote, “Peyote . . . inspired my chief narrator”—the paranoid, visionary Chief Bromden—“because it was after choking down eight of the little cactus plants that I wrote the first three pages.” In a 1990 interview, Kesey speculated on the harm he might have done himself in his long love affair with hallucinogens: “If I could go back in time and trade in certain experiences I’ve had for the brain cells presumably burned up, it would be a tough decision.”
Psychiatrists who tried to recommend ECT to frightened patients in the wake of One Flew Over the Cuckoo’s Nest faced the task of convincing them that neither the film nor the novel conveyed an accurate representation of the treatment. The audiences flocking to see Cuckoo’s Nest in 1975 witnessed a scene of shock treatment given without the anesthesia and the muscle relaxant that were both used routinely from the mid-1950s onward, and many viewers assumed that it was always given that way. These modifications had been put into use as soon as they became available, because when ECT was given without muscle relaxant, compression fractures of the patient’s vertebrae sometimes resulted from the body’s violent movement during the seizure. These could occur even when the patient was lying on a padded table and held down by leather restraints.
Sylvia Plath’s autobiographical novel The Bell Jar draws on her experience of a suicidal depression in the summer of 1953 and includes a memorable passage in which the protagonist, Esther Greenwood, receives shock treatment without being anesthetized: “Then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant. I wondered what terrible thing it was that I had done.” The inexperienced young psychiatrist to whom Plath’s family doctor had sent her gave her ECT as an outpatient, without anesthesia and without her informed consent. Gordon Lameyer, Plath’s boyfriend at the time, wrote, “Sylvia felt so traumatized . . . that she felt, not so irrationally, as if she were being electrocuted for some unknown crime.” From the novel’s opening sentence, Esther is preoccupied with the imminent execution of Julius and Ethel Rosenberg—“It was a queer, sultry summer, the summer they electrocuted the Rosenbergs”—and Esther’s traumatic experience of ECT blurs the distinction between electrocution and shock treatment.
The vivid account in The Bell Jar, with its great jolts and crackling blue light, is often cited on anti-ECT websites, useful in its description of the treatment as a form of electrical torture. But Plath’s novel also includes a rarely cited fictional reference to the much more successful round of ECT that she received at McLean Hospital later the same year, after which she returned to complete her final year at Smith College: “All the heat and fear had purged itself. I felt surprisingly at peace. The bell jar hung suspended a few feet above my head. I was open to the circulating air.” While this sense of relief has been felt and recorded by many people who have emerged from suicidal depression after just a few ECT sessions, the public perception of shock treatment continues to be fed by images in film and on television that are jarringly at odds with the experience of people who have been helped by it.
Contrast Plath’s description or the scene of McMurphy’s torment with what ECT looks like when given with the muscle relaxant, anesthesia, and oxygen that are now standard components of the procedure. Here psychiatrist Daniel Carlat describes what happens once these preparations are in place for his patient Michael, who is unconscious:
“Treatment!” I called out, and pushed the red button.
After one or two seconds the machine had drawn the necessary voltage and let out a loud beeeeeeep, signaling that current was now flowing. Michael’s jaw clenched, and I soon noticed a very fine tremor of his right arm. I looked at the brain wave tracing to confirm that he was having a seizure, and indeed, Michael’s brain waves [were] indicating rhythmic activity of large swaths of the brain—in other words—a seizure.
Emphasizing the ordinary medical aspect of modern-day shock treatment, one practitioner said, “We like to keep it as boring as possible.” A patient concurred: “It is a nonentity, a nothing. You go to sleep, and when you wake up, it is all over. It is easier to take than going to the dentist.” The undramatic nature of present-day ECT can be seen on YouTube in short explanatory videos posted by people who hope to defuse the stigma surrounding the treatment. Since the seizure is notable only by the slight tremor, there is almost nothing to see, which is probably why movies and television dramas don’t represent it realistically.
This was brought home in the popular television series Homeland, whose bipolar heroine, Carrie Mathison, looks like she is undergoing something dreadful when, in the finale of the first season, she lies on an ECT treatment table and, once the anesthetist has inserted the IV drip, begins counting backwards from one hundred. Suddenly she awakens, her descent into unconsciousness having been interrupted by the memory of a critical plot detail, and she fears she will forget it. Then she lapses into sleep once again, but as the doctor’s latex-gloved hands place the electrodes on her temples and the machine releases its electrical pulse, Carrie’s whole face clenches as if she is suffering and her body shudders violently until the screen blacks out for a season-ending cliffhanger. While one of the show’s producers, whose sister has bipolar disorder, has said that she wanted to show the illness realistically, the scene of Carrie’s treatment bends to the drama’s demands, showing ECT as more nightmarish than benign.
MELODRAMATIC SCENES of shock treatment like the one in Homeland continue to appear in television and in movies, and elicit in audiences a frisson of horror that can be traced back to Mary Wollstonecraft Shelley’s 1818 gothic thriller Frankenstein. Shelley’s novel reflects popular interest in the relatively new science of electricity. It also features both electricity and a convulsion, just as ECT does. In Shelley’s tale, the scientist Victor Frankenstein hopes that an electrical charge will “infuse a spark of being” into a human-like form he has made from body parts stolen from graveyards. The monster’s moment of awakening, narrated by his creator, is marked by a dramatic convulsion: “It was already one in the morning; the rain pattered dismally against the panes, and my candle was nearly burnt out, when, by the glimmer of the half-extinguished light, I saw the dull yellow eye of the creature open; it breathed hard, and a convulsive motion agitated its limbs.”
At the time, people were fascinated with the question of whether the dead could be reanimated. Shelley took her inspiration from Giovanni Aldini, who carried out experiments based on the discovery in 1791 by his uncle, Luigi Galvani, that muscles and nerves communicated through electrical signals. Seeking a way to revive those who had been drowned or asphyxiated, Aldini conducted electrical experiments in 1803 in London’s Newgate Prison on the body of a man who had been hanged for the murder of his wife and child. During Aldini’s macabre public demonstration, onlookers reported that “Forster’s eye opened, his right hand was raised and clenched, and his legs moved.” To some, it appeared that the dead man “was on the eve of being restored to life.” Aldini also reported some success with the trial of his electrical apparatus on the head of a farmer suffering from “melancholy madness”—a use for electrical shocks that had been suggested by Benjamin Franklin and his friend the Dutch physician Jan Ingenhousz. ECT is a later refinement of these early hunches that electricity could have an enlivening effect. If severe depression is a kind of living death, ECT can return the dead to life. After his first session of shock treatment, the talk show host Dick Cavett sat up in his hospital bed when his wife walked into his room and said to her, “Look who’s back among the living.”
Aldini, with his uncanny effects upon the body of a murderer, was just one of several scientists who contributed to the rapid development of electrotherapy in the nineteenth century. Electrical stimulation became a standard treatment in private clinics for those suffering from nervous illnesses, and continues today in such technologies as the pacemaker, cardiac defibrillation, and ECT. Yet ECT alone among these medical innovations retains an aura of stigma. It is curious that ECT provokes such horror while television shows like ER and Grey’s Anatomy routinely feature the dramatic effect of electricity when applied to a heart in cardiac arrest. We’ve all seen it again and again: a doctor places the paddles on the patient’s chest and calls “Clear!” The patient’s body visibly receives the jolt, while everyone glances anxiously at the monitor for the return of the regular waves of the heartbeat. First used during an open-heart surgery in 1947 by Claude Beck, defibrillation can restore a stopped or arrhythmic heart to its normal rhythm. The amount of current sent through the heart is much greater than what is sent through the brain in ECT. Nonetheless, a jolt of electricity comes across as heroic and lifesaving when used in a medical emergency room—at least in the movies and on TV—and no one questions the need for it.
The two treatments were not always viewed in such opposite ways. In 1952, Time and Newsweek underscored that the new technology used to shock the heart was essentially the same as the one already in use for the brain: “Electric shock, which has brought back to sanity hundreds of bewildered psychotics, has saved the life of a pretty Chicago nurse whose heart had stopped beating.” But it is not precisely true that the technologies are alike. ECT uses electricity to induce a therapeutic brain seizure, and it is the seizure, not the shock, that is the crucial element (thus, although colloquially useful, the term “shock treatment” is inaccurate).
Several plausible theories have emerged as to how ECT may work. It appears that severe depression results from a lack of connectivity in some areas of the brain and hyper-connectivity in others, particularly in an area called the left dorsolateral prefrontal cortex (DLPFC). ECT decreases connectivity in the DLPFC, which is associated with negative emotion. Bilateral seizures may address an imbalance of connectivity across the brain’s two hemispheres. ECT has been found to trigger a surge of hormones that alleviates the dysfunction along the HPA axis and halts the overproduction of cortisol. In animal studies, seizures enhance neurogenesis—the generation of new neurons—in the hippocampus.
The history of what would emerge as electroconvulsive therapy, like so many advances in medicine, can make for disturbing reading. During the first half of the twentieth century, scientists made dramatic experiments on the bodies of the mentally ill as they tried to heal disordered minds. Some of these methods were based on the observations of doctors over the centuries that high fevers, seizures, and even comas could bring about positive changes. In 1917 Julius Wagner-Jauregg injected malaria-infected blood into a patient suffering from dementia paralytica, a condition caused by syphilis, to bring on a high fever. Wagner-Jauregg won the Nobel Prize for medicine in 1927, despite the fact that his treatment killed 15 percent of his patients.
During the 1930s, Manfred Sakel experimented with rendering patients comatose with overdoses of insulin, sending their bodies into insulin shock and often into seizures as well. Sakel would revive them with an injection of glucose, repeating the process daily for weeks. Both coma and seizure appeared to have a calming effect on schizophrenics, sometimes returning a psychotic patient to a state of lucidity. The treatment was widely used through the 1940s and ’50s before it was finally acknowledged that insulin shock and glucose injections were doing more harm than good. An American psychiatrist remarked on his experience of the insulin treatment ward, “With all these people—tossing, moaning, twitching, shouting, grasping—I felt as though I were in the midst of Hell as drawn by Gustave Doré for Dante’s Divine Comedy.”
Psychiatry’s enthusiastic adoption of therapies later proven to have no benefit is no different from what has happened in other branches of medicine. Innovation is born from the desire to find a cure. Until the mid-twentieth century when effective antipsychotic and antidepressant drugs became available, psychiatrists were the helpless caretakers of patients who were psychotic, catatonic, or immobilized by profound depression, and who spent years wasting away in asylums. The resistance of the major mental illnesses to any treatment at all made doctors willing to use desperate measures to bring about even temporary improvement. Only in light of what historian of psychiatry Edward Shorter has called “half a century of nihilistic hopelessness” do experiments with fever, coma, and seizures make sense as bold, if dangerous, measures.
IN 1932, A YOUNG NEUROPSYCHIATRIST named Ladislas Meduna sat before a microscope in Budapest, comparing fine slices from the postmortem brains of epileptics and schizophrenics under a microscope. Meduna was a pathologist by training, but he was soon to find himself attending patients in a psychiatric clinic. Looking through his microscope, he noticed a striking contrast in the respective density and scarcity of glial cells, which form connective and insulating tissue for neurons. Because epilepsy appeared to be uncommon in schizophrenics, doctors had long suspected a biological antagonism between epilepsy and schizophrenia, and hence between seizures and psychosis. As early as the sixteenth century, the Swiss physician Paracelsus had used camphor to produce epileptic convulsions in so-called lunatics. Working from the antagonism hypothesis, two Hungarian doctors that Meduna knew had recently tried injecting epileptics with the blood of psychotic patients, with no success. Reversing that logic, Meduna wanted to find a safe way to induce seizures in schizophrenics, and began his experiments using camphor injections in guinea pigs.
Since October of 1930, a thirty-three-year-old electrician whose name was Zoltan L. had been living in the Royal Hungarian State Psychiatric Institute where Meduna was working. Zoltan was brought to the hospital because he had been trying to strangle his wife, although he didn’t remember having done so. His diagnosis on admission was schizophrenia, and his preoccupations centered upon jealousy of his wife and his doubt that he was the father of their young daughter. He sometimes heard voices coming from his stomach, he sometimes perceived people passing in front of his face, and sometimes animals “sneaking” in front of his feet. Four weeks before his admission he had asked his wife for some poison so that he could kill himself. After his admission, during which time he was mute and motionless, the doctors treated him for several months with opium, and later for a couple of weeks with strychnine, which was then used as a stimulant. Neither approach had the desired effect.
On January 23, 1934, Meduna was ready to try inducing a seizure in a patient. He chose Zoltan, who since his admission over three years earlier had stopped eating, was fed through a tube, and was in a continuously catatonic state. Before an audience of his colleagues, Meduna injected Zoltan with a solution of camphor and oil and, according to Meduna’s autobiography, “after forty-five minutes of anxious and fearful waiting the patient suddenly had a classical epileptic attack that lasted sixty seconds.” As Zoltan returned to consciousness, Meduna nearly collapsed in anxiety: “My body began to tremble, a profuse sweat almost drenched me, and, as I later heard, my face was ash gray.” At the time, physicians could experiment on disabled patients without their permission, so it’s reassuring to know that Meduna was himself frightened during the seizure, and relieved that Zoltan was apparently unharmed.
Each injection Zoltan received resulted, after a long delay, in a seizure. But there was no change in his condition until the fifth when, according to Meduna, “He spontaneously arises from bed, is lively, and asks for something to eat. . . . He is interested in everything going on about him, asks about his illness and realizes he has been sick. He asks how long he has been in the hospital, and when we tell him that he has already been there four years he cannot believe it.” Meduna’s autobiography presents Zoltan’s case as an unqualified success, and punctuates it with a memorable anecdote. When one morning Meduna asked the nurse how his patient was doing, she replied, “We had quite a time with him. He escaped last night from the institution, went home and found out that the ‘cousin’ living with his wife was not a relation at all but a lover of his wife.” After beating his wife’s lover and then beating his wife, Zoltan returned to the hospital, saying he preferred living there rather than in the “crazy world.” Meduna’s autobiography then closes the case of Zoltan: “From then on I considered this patient cured, and he remained well at the time I left Europe in 1939.”
Medical historians have accepted this version of events, with Zoltan miraculously well, the first patient to prove the success of Meduna’s innovative convulsive treatment. When he published the results of his trial in a medical journal, Meduna reported that of twenty-six patients, thirteen had remarkably improved or recovered. By 1938, his technique for the induction of seizures was adopted in European and American psychiatric hospitals, and Meduna himself emigrated to America in 1939, taking a position at Loyola University in Chicago.
While doctors adopted the treatment enthusiastically, it was harrowing for patients. Early on, Meduna had switched from camphor to a faster acting chemical agent called metrazol, but even then a delay of about a minute remained between the injection and the onset of the seizure, a delay filled with extreme anxiety for the patient. American psychiatrist Solomon Katzenelbogen reported in 1940, when metrazol convulsive therapy was being used for schizophrenia, mania, depression, and even alcoholism, that “while the patients’ statements obviously reflect some of the content of their basic psychotic conditions, they contain nevertheless one common and outstanding feature, namely, the feeling of being tortured, and of intense fear of imminent death.”
And what became of Zoltan? It seems odd that a fully recovered patient would be allowed to continue living in a state institution. Recently, several Hungarian scholars unearthed Meduna’s case notes in the archives of the Institute, which closed in 2007. They found that Meduna treated Zoltan over a longer period than had been thought, from 1934 through 1937, and that after his brief remission in 1934, Zoltan was never well and could never be discharged. He died in the Institute in 1945.
IN 1938, JUST FOUR YEARS AFTER Zoltan was subjected to Meduna’s convulsive therapy in Budapest, the Italian police picked up a man who had been wandering in Rome’s train station. He couldn’t tell them his name, nor where he lived. Since the man was speaking incoherently and seemed to be hallucinating, the police took him to the university’s psychiatric clinic. It happened that the head of the clinic was Ugo Cerletti, who had been working for several years to develop a method of using electricity to induce seizures. A neuropsychiatrist born in 1877, Cerletti had studied with some of the leading figures in biological psychiatry, including Emil Kraepelin and Alois Alzheimer. In the early 1930s, Cerletti began investigating what happened to the brain during epileptic seizures, based on an observation that the mood of epileptic patients who were also depressed seemed to improve after a period of frequent convulsions.
Cerletti was sensitive to the moral revulsion people would feel about his research, and wrote that “the idea of submitting a man to convulsant electric discharges was considered as utopian, barbaric, and dangerous; in everyone’s mind was the specter of the electric chair.” Nonetheless, he proceeded. For two years Cerletti and his assistants experimented with inducing seizures in dogs, and found that by placing the electrodes on the temples, they could induce convulsions without killing the animal. Seeking a safe method to deliver electrical current to a human brain, they carried out further experiments at Rome’s slaughterhouse, where pigs were stunned with electricity before being killed.
Cerletti’s colleague Lucio Bini built a small box that would transmit the current. The challenge was to find the proper variables of voltage and duration that were strong enough to cause a seizure, and not so strong as to cause death. Once they determined that the gap between a seizure-inducing dose and a lethal dose of electricity was wide, they felt it would be safe to take their experiment to the next level. The police had just unwittingly delivered them their first human subject. At the clinic, the man from the railway station had been diagnosed with schizophrenia. Cerletti wrote, “He expressed himself exclusively in an incomprehensible gibberish made up of odd neologisms and, since his arrival from Milan by train without a ticket, not a thing had been ascertainable about his identity.” One of Cerletti’s assistants, Ferdinando Accornero, described the patient as “unemotional, living passively, like a tree that does not give fruit.” He felt that the man’s mind “had completely unraveled,” and there was little hope of his recovery.
On the eleventh of April, they were ready to proceed. They put a gauze-covered rubber tube between the man’s teeth and placed electrodes, moistened with saline solution, on his temples. Bini flicked the switch, and 80 volts of current ran for a quarter of a second. The man’s body jumped, and he cried out. With the next pulse, he sat up and began to sing a bawdy popular song. Another slightly longer pulse still didn’t produce a seizure, but the patient protested in perfectly clear Italian, “Che cazzo fai?” or, “What the fuck are you doing?” Cerletti was pleased that the man’s speech was no longer incoherent. One more attempt, and the patient cried out that another would be deadly (“Non una seconda! mortifera!”). Now the doctors looked at each other nervously, fearful of proceeding. Cerletti nodded, Bini gave the pulse, and since the patient still did not have a full seizure, Cerletti ended the trial for that day, heartened that the patient was unharmed and speaking.
They tried again with this same patient nine days later (these first two trials, on two separate days, were combined in Cerletti’s record to make for a more dramatic story of immediate success). This time, Bini applied enough current to send the man into a full epileptic seizure, and the doctors looked on as he violently convulsed, turned blue, and stopped breathing for forty-eight seconds. Much like Meduna during Zoltan’s first seizure, they were terrified that they might kill the patient. According to Cerletti, when the seizure ended, “The patient sat up of his own accord, looked about him calmly with a vague smile, as though asking what was expected of him. I asked him, ‘What has been happening to you?’ He answered, with no more gibberish: ‘I don’t know, perhaps I have been asleep.’ ”
The man—his name was Enrico, as he now remembered—received several more treatments and was discharged, “thought and memory unimpaired,” according to Cerletti, and aware that his paranoia and hallucinations were symptoms of an illness from which he had recovered. However, his wife wrote to Bini nearly two years later to report that her husband’s illness had returned, and that he had been admitted to a psychiatric hospital in Milan. She asked that Bini contact the doctor there. Bini forwarded the letter to Cerletti, but Cerletti never responded. In this disappointing detail Bini and Cerletti seem less interested in patients than in their larger project. Having served his purpose as the first human subject of a pathbreaking medical technology, was Enrico now to be ignored because his relapse would not be convenient for Cerletti to acknowledge? Like Meduna, whose narrative of Zoltan’s recovery was misleading, Cerletti allowed the story of his first cure to go untainted by the disease’s recurrence. Cerletti was widely praised for the breakthrough therapy he called l’elettroshock, which was soon adopted in European hospitals. He had proven that placing electrodes on the patient’s temples and giving an electrical stimulus produced an immediate seizure, and was far more efficient than Meduna’s slower and more painful chemical induction method, which Cerletti’s method now superseded.
Lothar Kalinowsky, a German psychiatrist who had been present at Cerletti’s first treatments in Rome, brought the method to the New York State Psychiatric Institute in 1940. The use of ECT in American psychiatric hospitals didn’t become widespread until the 1950s, however, for two reasons. First, psychoanalytically minded psychiatrists were opposed to it because an intervention on the physical brain didn’t support their theory that the causes of mental illness were psychogenic. Second, the possibility of broken bones (especially in frailer patients) was a powerful disincentive. When the muscle relaxant succinylcholine began to be used in 1952, ECT became a highly effective treatment for melancholic depression, mania, and for catatonia and depression in schizophrenia. By 1959, it was considered such an acceptable procedure that Group Health Insurance of New York City allowed coverage for up to ten electroshock treatments annually for each subscriber.
Even as the treatment was gaining widespread acceptance, the forces of antipsychiatry were gathering. Very soon, activists would work to brand ECT with the mark of shame—even to associate it with Nazi torture techniques—and to force it out of use alongside the abandoned, harmful practices of lobotomy and insulin coma treatment. In the 1960s and ’70s, shock treatment came to be associated with coercion, mind control, and “all that was brutal and inhumane in clinical medicine.” These negative associations were powerfully reinforced for the many people who saw One Flew Over the Cuckoo’s Nest. In the wake of the film, one psychiatrist complained in a letter to the British Medical Journal: “What to me is inexplicable is that no responsible medical body appears to have made any effort to allay the fear engendered among filmgoers by the demonstration of punitive, unmodified ECT in ‘One Flew Over the Cuckoo’s Nest.’ ” Even worldly and well-educated people continue to associate ECT with mind control and punishment. The film contributed to a steep decline in the use of ECT during a period when new and effective antipsychotic and antidepressant drugs had already reduced the numbers of patients in need of the treatment. Data gathered by the National Institute of Mental Health shows that between 1975—the year Cuckoo’s Nest premiered—and 1980, ECT use fell by a remarkable 46 percent. Still, the opposition continued.
In 1985, the National Institutes of Health held a conference on ECT. Max Fink, an early practitioner of the treatment who has long been a devoted advocate, recalled that activists interrupted his presentation, shouting, “Everybody who does electroshock should be in jail!” By this time, the NIH reported that, far from being a treatment used on nonconsenting involuntary patients, those patients that the antipsychiatry movement felt needed protecting, ECT was used overwhelmingly “for patients who are white, voluntary, and paying their way in private institutions.” Seventy percent of them were women. The downward trend in the use of ECT only began to reverse itself in the late 1980s, with numbers rising through the 1990s. Today, roughly 100,000 people receive ECT annually, nearly triple the number cited for 1980 in the NIMH study, though in some parts of the country it remains under legal restriction. The lack of treatment centers and skilled psychiatrists continues to limit access for many people.
DURING THE 1980S, in the aftermath of Cuckoo’s Nest, clinicians were reluctant to suggest ECT and more likely to face opposition by the patient’s family if they did. Most medical schools, and even most psychiatry residency programs, didn’t include electroconvulsive therapy in their curricula. In the hospitals that still did provide ECT, it was often used only after a long drug trial had failed.
Take, for example, a young psychiatrist in 1984, whose female patient remained suicidal after four weeks on an antidepressant. Having seen One Flew Over the Cuckoo’s Nest, her husband was alarmed when the doctor suggested ECT. But he acquiesced when told that if he resisted, the hospital would seek a court order to overrule him. So the psychiatrist jotted down the new plan: “In this acutely suicidal patient, bilateral ECT is felt to be the modality of choice with the highest potential for rapid clinical improvement. Projected number of ECT treatments is 7–10 with hope of response evidencing around 4th-5th treatment.”
I was that patient. When I first stepped into the treatment room four days after the shower incident, the use of ECT was in the trough of its long decline, while in the wider culture it carried a powerful stigma. The antipsychiatry backlash meant that progress in refining the techniques had drastically slowed. In the trial-and-error approach that my hospital record reflects, certain aspects of the treatment were not so distant from the experimental early days of Meduna and Cerletti, despite the four and a half decades that had passed.
It was late morning when one of the aides came for me, and we walked through long, polished corridors to another part of the hospital. A nurse and two doctors—an anesthesiologist and the resident who would perform the procedure—were waiting in a large tiled room. They were kind and reassuring, and although I was anxious about what was now going to happen, I felt that I had nothing to lose. I lay down on a gurney and the nurse started an IV for the anesthetic. Behind me was the ECT machine, a small electrical box with knobs and switches. The nurse placed an oxygen mask over my face and told me to count backwards from one hundred. I don’t think I ever got further than ninety-seven. The next thing I remember, someone helped me off the table and walked me back up to my room.
There was more going on before and during the treatment than these few details that I recall. Bilateral ECT means that the current passes between electrodes placed on both sides of the head, and the resulting seizure affects both sides of the brain. This was considered the most effective treatment for someone in the terrible shape that I was in. It causes greater temporary cognitive deficits than unilateral placement because the current passes through the brain’s speech and memory centers, but is more efficient in bringing about a recovery. The memory loss is usually temporary, though this is a matter of contention and an issue that still gives pause to potential patients. The electrodes would have been moistened with conductant gel, positioned over my temples, and held in place with a rubber headband. My pulse, blood pressure, and brain waves would have been monitored. The muscle relaxant succinylcholine was given through the IV to keep my body from moving during the seizure. Because the diaphragm is temporarily paralyzed by the muscle relaxant and cannot expand and contract the lungs, oxygen is necessary. Today, a nurse or doctor manually ventilates the lungs because the anesthetized body’s inability to actively take in oxygen means the brain is not getting enough, and this increases the cognitive side effects. According to the record, they also gave me atropine. Seizures can cause a temporary interruption or slowing of the heart’s rhythm, and atropine was used to prevent that. The fast-acting sedative that sent me to sleep in three seconds was pentobarbital. ECT is a simple procedure, but many precautionary measures must be taken before the pulse of electricity can be given to produce the seizure.
For the first few treatments, given the settings he marked down, it seems that the doctor was working with the variables of current and voltage in order to induce a seizure of adequate strength and duration. Seizure thresholds vary according to the patient’s age, gender, medications, and other factors, and the current can be impeded by faulty contact of the electrodes and other issues. He would have needed to begin with a setting based on given parameters and modify according to the results.
ECT seizures should end without intervention, but my first two seizures lasted more than two minutes, and the doctor stopped them with additional pentobarbital. After the third treatment he seems to have arrived at the result he was seeking, and from then on most seizures were in the range of forty-five to sixty-five seconds. Because I knew he would have been familiar with the treatment protocols of the mid-1980s, I consulted ECT expert Max Fink, who told me that notations on my treatment record indicate the use of a then recently introduced machine that delivered a brief-pulse current, as opposed to the sine-wave current of earlier machines. Since the early 1980s, brief-pulse machines have replaced the earlier sine-wave ones. After the fourth session a nurse reported, “Patient talks about feeling like she is cured, that she would never hurt herself again, is in good spirits and talking to patients and staff.” (I found this hospital euphemism “to hurt oneself” annoying, since I had never been interested in hurting myself. I had only been interested in dying, as quickly as possible.) Dr. Young, too, noted my brighter mood. He raised my observation status so that I was no longer being watched twenty-four hours a day.
Side effects were troublesome. In the aftermath of anesthesia came headache, nausea, and vomiting, sometimes into the next day. Another problem appears in the notes: they suspected that one of the drugs used during ECT was exacerbating a rash I’d had for several weeks. It began as a reaction to the antidepressant imipramine, which gave me hives. Although that drug had been tapered quickly before the ECT began, a very itchy, angry rash was now spreading up my back and neck. I was taken to a medical clinic in another wing of the hospital, where a blood test indicated a strong allergic reaction. They discontinued the atropine, which can cause a rash in some people, and gave me Benadryl, which eventually solved the problem. Much of the physical discomfort I had with ECT treatment resulted from complications of drug sensitivity, and these diminished with adjustments in the first couple of weeks.
Immediately after each treatment I had some loss of memory, which cleared as the hours passed. As the number of treatments mounted, the amnesia increased. This aspect of the bilateral ECT I was receiving was very strange, since it separated me from the feelings that had brought me to the hospital. On the day of the third session Dr. Young wrote, “Patient has been disoriented and confused with treatments. As yet this pseudo-dementia is transient though will become a more persistent feature with bilateral treatments. Patient showing some early improvement but unable to recognize this herself as her cognitive features of depression persist and are severe.” “Pseudo-dementia” was a term then used in psychiatry to refer to problems with memory, concentration, and attention that are reversible but similar to those of dementia. Prolonged severe depression causes cognitive symptoms too, which result from a loss of neural connections in the brain. That day, I couldn’t remember why I was in the hospital. A nurse wrote in my chart, “She says something happened to her although she doesn’t know what it is. Confused after ECT and not really understanding what has happened to her or what she is doing here.” I had forgotten about Anna’s death and all that followed. I was still having melancholia’s variation in mood, feeling very dark in the morning and better as the day wore on. Dr. Young commented on how this diurnal mood shift made it hard for me to hold on to feeling better: “It is difficult for her to experience subjective improvements and be confronted soon after with these renewed feelings of hopelessness.”
Whatever mild improvement Dr. Young had noticed then reversed itself, and I entered a state of true depressive psychosis. He put me back on twenty-four-hour surveillance. Now I was talking freely about my terrible thoughts: “Patient had a talk with nursing staff member and explained her problem as a ‘moral illness.’ She feels disloyal to husband and family in wanting to kill herself. She has been suicidal for a long time and has prayed but her prayers were not answered so she feels she’s evil and full of sin and can’t change. She feels suicide is inevitable and has no desire to live.” The next day I was begging to be allowed to go home, since I believed that there was nothing more they could do to help me. Dr. Young noted my “significant loss of reality testing,” and added the antipsychotic Haldol to my regimen. The next day he wrote, “Patient currently firmly believes that she is ‘not human,’ is not depressed but rather ‘depraved,’ ‘evil,’ and would like ‘a brain transplant.’ ” I could feel and express nothing but guilt, hopelessness, and self-condemnation. He increased the dose of Haldol.
How much more disastrous could things get? My parents, too, had had enough: during visiting hours one day, a nurse wrote, they were asking me to “snap out of it.” It was unbearably frightening for them. Jake was bringing books from the library and reading to me about patients having the same delusional thoughts I was having. But I continued to believe, he says, that I was evil, not depressed. In psychiatry there is a term for this: I lacked “insight” into my state of mind. Like so many people in the state of what used to be called madness, I believed in the truth of my delusions.
On the day of the eighth ECT treatment Dr. Young wrote, “Patient continues to be markedly delusional—today unhappily is her birthday, and she is involved with the fact that it is Friday the 13th, as it was on her actual day of birth.” Recent events had proven that I was very unlucky indeed, and I now believed it was no coincidence that I’d been born on that particular day. Dr. Young noted that the treatment plan was to be re-evaluated, since the ECT didn’t appear to be making any difference in my condition. They had abandoned the antidepressant trial, and now they were considering abandoning ECT for a new medication trial combining an antipsychotic and an antidepressant. Jake remembers feeling that the doctors were “grasping at straws,” since none of their proposed treatments were helping. He worried that I was having too much shock treatment: “Your short term memory got bad and you continued to be depressed. . . . The ECT continued well beyond the half dozen sessions that had been proposed. It was spring and getting quite nice out. You weren’t allowed out of the ward. I wanted them to take you outside.” I had been indoors continuously for over three weeks. So many aspects of our life had become very strange, and to Jake my situation seemed too much like imprisonment. The doctors then decided to press on with more ECT: “Patient continues not to show any clinical improvement with this treatment but nonetheless a full course of ECT will be pursued.” They added a drug called Cogentin, which was supposed to protect against the neurological side effects, like rigidity and muscle spasms, that could result from prolonged exposure to the anti-psychotic Haldol.
Over the next ten days or so my condition continued unchanged as the number of ECT treatments mounted. The cognitive side effects of the shock treatment were taking a toll. A nurse asked me to recite my home phone number one day, and I couldn’t. I had been writing occasionally in a notebook, and Dr. Young suggested that given the increasing short-term memory loss, I record what feeling better was like so that I could read it when I felt hopeless. In one such lucid moment I wrote, “Feeling hopeful again today that there must be some way to recover from this and return to my old, better self. There is so much to live for, if only I can convince the doctors here that I’m capable of it.” At other times, Dr. Young observed, I seemed detached, lethargic, “generally blunted affectively”—possibly Haldol side effects—and worried about what would happen when they finally realized that they couldn’t help me.
In my guilty frame of mind, the anxiety was overwhelming. I was tormented by the seeming inevitability of suicide. I was unable to reverse the mental process that had brought me so low, and now the experts, too, were stymied in their efforts to reverse it. I worried about how my suicide would affect Jake and my family. I felt responsible for the crime of not being able to carry the burden of my own life, and thereby transferring the burden of my death to the people who loved me. My trouble seemed to me unnatural and perverse: everyone should be able to stay alive, at the very least. I couldn’t see that illness was driving me to suicide, and not my own moral failing or weakness of character.
By the third week of April I’d been in the hospital for a month, and Dr. Young put in a transfer request to longer term care. He was ready to give up on ECT, noting that after the twelfth treatment I would be considered “ECT nonresponsive,” and they’d have to try another plan. After the twelfth treatment, the nurse noted that I was “extremely confused, disoriented, babbling.” She did neurological checks throughout the evening as these cognitive and speech disturbances gradually cleared. But cumulative exposure to bilateral treatments and a daily antipsychotic grew more and more debilitating.
Instead of switching to an antipsychotic/antidepressant combination for the next phase of treatment, they again decided to press on with ECT. Today the number of treatments in an effective sequence can range from four up to twenty or so, but because these are usually unilateral—given on the right side of the head only—or with ultrabrief pulses of current, they don’t cause the degree of memory loss that I experienced. They took me off the antipsychotic and switched to an older-style ECT machine that used sine-wave current (the kind of current in wall outlets). For whatever reason, my recovery began with the use of this more primitive machine. It may be a coincidence, but within two treatments there was noticeable improvement. According to a National Institutes of Health study on ECT from 2007, the treatment I had would not now be recommended because of its heavy toll in cognitive side effects: “Sine wave stimulation, for the use of which there is no justification at this point, and bilateral electrode placement, produced the most persistent long-term deficits.”
I did lose memories, but most of what I forgot I eventually remembered. Episodes from my childhood and my more recent past were inaccessible for quite a while, though after the treatments were over I had no trouble retaining new information, and I started graduate school the following year. What happened while the treatments were ongoing remains mostly a blank. My older brother visited and gave me a dress for my birthday, but when I got home I had no idea where the dress came from. Friends wrote letters I have no memory of receiving. What I do remember about the time during treatments, I’ve been able to retrieve because the hospital record jogged the memory, or because I wrote it down in the notebook at the time.
The problem of memory loss remains the most contentious issue with ECT. Some people refuse treatment for fear of it, while others agree to treatment despite the chance of it. It all depends on what you’re willing to lose: your memory or your life. Ernest Hemingway protested, shortly before his suicide, that shock treatment had destroyed him: “What these shock doctors don’t know is about writers . . . What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient.” Hemingway’s alcoholism and his very severe depression could also have impaired his memory, but it was simpler to blame ECT. A very different perspective on ECT and writers comes from David Foster Wallace, whose friend Donald Antrim was in the depths of a suicidal depression. Antrim’s doctor told him, “You’re very sick, and you’re very psychotic, and we can take care of you.” They told him he should have ECT. Antrim was terrified, “because he believed it would mean the end of him as a writer. That his talent would be scattered. His brains scrambled. The mechanism disassembled.” Wallace, having been in these circumstances himself, called Antrim at the hospital. He said, speaking writer to writer, “I’m calling to tell you that if they offer you ECT, you should do it. You’ll be all right.” For the great majority of people, any lingering amnesia clears as the brain heals in the months after treatment, but a small and vocal group claims that important moments in their lives—the birth of a child, a wedding, the death of a parent—are lost forever.
By the end of April, after seventeen treatments over a period of six weeks, the worst was over. The nursing notes are studded with a new, positive language: “Patient seems brighter, alert and motivated, interacting with staff and peers”; “Status raised to CS. This made her very happy”; “Patient able to concentrate long enough to play chess”; “Patient continues in great spirits, smiling and verbal”; “Patient socializing with peers. In good spirits. Affect brighter. Pleasant.” Dr. Young wrote, “Affect is bright and full-range. Patient continues to have euthymic mood, punctuated with mild persistence of diurnal mood variation. Denies suicidal ideation, no longer expressing hopelessness and worthlessness, no evidence of psychotic thought process”; “Patient to receive 14th ECT today. Plan is to administer additional 2–3 more ECT treatments to consolidate response”; “Socializing appropriately with other patients. Went outside to courtyard and played volleyball.” Volleyball? Chess? Great spirits? Even now I can feel the relief and happiness conveyed by these words and what they meant for me, for my family, and for my doctor, who had been expecting improvement much earlier.
Suicidal depression is difficult to treat, and I imagine it can be nearly as distressing for the doctor as for the patient. For some reason, I didn’t get better as quickly as Dr. Young’s optimistic projection suggested I would. I assume that psychiatrists will think it unfair of me to look back and question the technique or the experience of the resident who performed the ECT, and to wonder whether it might have been more quickly effective with another person in charge. The truth is, I just don’t know whether the treatment could have, or should have, gone better at the time. Certainly it is much better for the majority of people having ECT today. The American Psychiatric Association claims that ECT can bring about a dramatic improvement in 80 to 90 percent of patients with mood disorders. The improvement is not necessarily permanent; these are relapsing and recurrent illnesses. But because of continuing stigma and fear, ECT is often not suggested until a lengthy course of medication has failed to bring relief. Some people kill themselves in this interim. In my case it’s easy to recognize some of what went wrong: the belated realization that I was ill and not merely grief-stricken, the belated diagnosis and prescription of medication, the switch from medication to ECT only after a nearly lethal suicide attempt. Lithium could have been given as soon as I arrived in the hospital, since it has a proven record of reducing suicidal impulses.
Despite the discomfort and the temporary memory loss it caused, I would have ECT again without hesitation. People voluntarily undergo much more invasive and damaging medical interventions to save or to prolong their lives—chemotherapy, radiation, open-heart surgery, blood transfusions, bone marrow transplants—and speak freely about those experiences, but continue to think about cancer and heart disease differently from mood disorders that can be equally deadly. In telling my own less than ideal story thirty years after the fact, I don’t want to discourage anyone from having this potentially life-saving treatment. What was difficult in my experience would now be unusual because the treatment protocol has improved over the years to greatly reduce the side effects. And my situation was extreme not only because of the perilous condition of my mind, but because my body was already hypersensitive and aggravated by drug allergies.
But now ECT was behind me. The serious work of returning to life could begin.